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ACLS and Epinephrine

 

ACLS and Epinephrine

Epinephrine is the primary drug used in the pulseless arrest algorithm. It is used for its potent vasoconstrictive effects and also for its ability to increase cardiac output. Epinephrine is considered a vasopressor.

Indications for ACLS

  1. Vasoconstriction effects: epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels (arteries and veins) causing direct vasoconstriction, thus, improving perfusion pressure to the brain and heart.
  2. Cardiac Output: epinephrine also binds to beta-1-adrenergic receptors of the heart. This indirectly improves cardiac output by:
    • Increasing heart rate
    • Increasing heart muscle contractility
    • Increasing conductivity through the AV node

Epinephrine is used in the pulseless arrest algorithm as a direct IV push and also in the bradycardia algorithm as an infusion. See the respective algorithm pages for more information about their use in each.

Routes

During ACLS, epinephrine can be given 3 ways: intravenous; intraosseous, and endotracheal tube

Dosing

  • Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes.
  • IV infusion for bradycardia: 1mg epinephrine is mixed with 500ml of NS or D5W. The infusion should run at 2-10 micrograms/min (titrated to effect).
  • IV infusion for post-cardiac arrest hypotension: The dosing is 0.1-0.5 mcg/kg/min (for example a 70kg adult: 7-35 mcg/min would be given).
  • Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube.

Epinephrine should be used with caution in patients suffering from myocardial infarction since epinephrine increases heart rate and raises blood pressure. This increase in HR and BP can increase myocardial oxygen demand and worsen ischemia.

Note: There is no clinical evidence that the use of epinephrine, when used during cardiac arrest, increases rates of survival to discharge from the hospital. However, studies have shown that epinephrine and vasopressin improve rates of ROSC (return of spontaneous circulation).

Return to main ACLS Pharmacology page.

  122 Responses to “ACLS and Epinephrine”

  1. I work in a situation where I only have access to IM epi (for anaphylaxis). Is there any benefit to or harm in giving IM epi while waiting for EMS to arrive in case of cardiac arrest?

    • Giving IM Epinephrine would not do any harm, but it would not help in the situation of cardiac arrest. Focus on high quality chest compressions, early defibrillation, and early activation of EMS.

      Kind regards,
      Jeff

  2. I am a MRI tech that recently got ACLS certified with the help of your site…thank you!! There seems to be some confusion as to who can push meds. during a code. Does ACLS certification qualify you? Is an M.D. order is still neccessary?

    • During any code, there should be a physician who is in charge and giving instructions to the team. Every code that I have participated in had a physician who was giving instructions. Every facility should have policies as to who is allowed to push IV medications. This is usually RN’s and physicians. Having ACLS certification does not qualify a person to push IV medications. A verbal order during the code is sufficient for an RN to push IV medications. There may be other situations where someone other than an RN could push an IV medication, but I would clarify with your facility.
      Kind regards,
      Jeff

      • Where I am employed, only nursing staff (RNs) can push IV meds during a code, with the exception of an MD of course. The only exception to that would be RT, and only very specific meds. Imagining would be able to push certain dyes, however, I have never seen a code with that happen.

      • During and in-house code, ACLS for non-nurse/physicians should focus on high quality chest compressions. The code team should arrive soon enough to push any meds needed.

  3. Thanks . That was a re read for me . We have a cardiac events scenarios CME in the A/E where I work , tomorrow morning .

  4. I was given 2.5 mg of IV epinephrine today, as I was having an acute allergic reaction to an infusion of IV antibiotics that I have normally tolerated ( have a history of anaphylaxis to penicillin , however). this Iv injection caused an exceedingly high and pounding heart rate with angina-like- pains, immediately followed by an unbelievably excruciating headache . this subsided enough so that i could be coherent and able to talk , after a brief but what felt like an unbelievable long 10 minutes . afterwards I have had a significant and unusually extreme migraine ( 12 hours post injection). is this anything to be concerned about? please advice.
    thanks for any input.

    • I’m not a physician, so please do not consider this as advise. The symptoms that you experienced are fairly normal for the medication that you received. Epinephrine is a potent vasoconstrictor and chronotropic agent. This means that it significantly increases heart rate and causes the blood vessels to contract. In your case, the health care providers gave you the epinephrine because of it’s bronchodilation effects. Epinephrine also causes the lungs to open up and allow for ease of breathing.
      The symptoms you experiences should subside. If they last longer than 24 hours, you might give your physician a call. If it were me, I would not be to worried. The migraine may be due to the blood vessels going back to there normal dilated size. This dilation may have caused the migraine.
      Again, don’t consider this advice, but just what I know about the effects of epinephrine.

      Kind regards,
      Jeff

    • The epinephrine dose that u mentioned was very high, normal dose for anaphylaxis is 0.3 to 0.5 mg and that to should be given IM/SC. I think the dose u mentioned is wrong, or other wise u are very lucky to escape the dangerous arrhythmia s with d dose u have mentioned.

  5. I am a little confused on when it is acceptable to administer epinephrine in regards to the administration of other medications. Specifically, for the VF/Pulseless VT algorithm: after you shock twice, you resume CPR and give epi during this CPR cycle (once this first epi dose is given, epi is on it’s own timetable and can be given q3-5min). After 2 min of CPR, another shock is given followed by amiodarone 300mg (per the algorithm). What if the timetable for the next epi dose lines up with the need for amiodarone according to the algorithm? Are epi and amiodarone both administered at the same time? Basically, is epi given q3-5min regardless of what other medications are indicated at that time/point in the algorithm? Also, if the timetable for epi indicates that it be given immediately preceding or following another medication, is it allowable to administer this dose of epi?

    • Let me answer each question one-by-one. My answers are in bold.
      “After 2 min of CPR, another shock is given followed by amiodarone 300mg (per the algorithm). What if the timetable for the next epi dose lines up with the need for amiodarone according to the algorithm?” Yes, the person administering medications can give them both one after the other.

      Are epi and amiodarone both administered at the same time? Yes, that is correct.

      Basically, is epi given q3-5min regardless of what other medications are indicated at that time/point in the algorithm? Yes, that is correct.

      Also, if the timetable for epi indicates that it be given immediately preceding or following another medication, is it allowable to administer this dose of epi? Yes, this is allowable.

      You are on the right track.
      Kind regards,
      Jeff

      • Thank you, Jeff. Let’s resuscitate correctly, for our patient’s sake.

        Also note, Vasopressin 40 can follow Epi 1 mg, followed by EP 1 mg 3 min later. Also the regular Epi 1 mg follows the Vasopressin 40, just as the Epi 1 mg went before Vasopressin 40. Vasopressin 40 is simply a substitute for Epi 1 mg. Follow?

  6. For a pediatric Crash cart the Broslow states a 1:1000 concentration in the ET tube. Is this the injectable or the topical that is used?

  7. What is the pediatric dose of epinephrine during code blue? Thanks

  8. Is there any different effect between epinephrine of 1:1000 and 1:10000 when I give 1mg IV push for CPR ? If not ,why should epinephrine be diluted for IV form? Is it just preventing dispensing error due to the lower dosage of anaphylactic shock?

    • Epinephrine should not be given undiluted 1:1000, it can be fatal when given IV. Epinephrine 1:1,000 should always be diluted to 1:10,000 prior to administration. Epinephrine 1:10,000 = 1mg/10ml.
      Most crash carts in the United States now come with pre-made 1:10,000 (1mg/10ml) syringes of epinephrine to help reduce the error of giving undiluted epinephrine. The concentration ratio of 1:1,000 is to high for the medication to be given undiluted IV.
      Kind regards,
      Jeff

      • Around the world the thoughts behind 1:100 and 1:10000 vary some what.
        Yes 1:1000 for IM doses 0.3 to 0.5
        Yes 1:10000 for the little ones
        There are few studies that I can find, stating why in cardiac arrest there is a difference between 1:000 and 1:10000 apart from ease of use in a prefilled syringe and vasoconstriction.
        Point me in the right direction!
        I have only used 1:1000 in cardiac arrest for 25 years and still do today, using 1:10000 only for paediatric patients.
        I thought when they talked about large doses they were talking about 3mg IV push like we did 20 years ago.

        Thanks

    • The 1:1000 concentration is used when giving IM for anaphylaxis. :)

  9. say if u used 2.5mg via ETT, do i mix that only with a total amount of 10mls N/S? whats the effect in the lungs having that much fluid given down ETT? I’m thinking if working remote and for some unknown reason ya can’t get iv access and say did this twice – thats a lot of fluid to go down the ETT?

    • Placing an excess volume of solution into the ET tree may cause hypoxia or respiratory acidosis. This is one complication that may occur. At least 30 ml can be safely instilled into the bronchial tree with minimal negative effect. Always ensure adequate ventilation after instillation.
      If you are instilling 10ml (epinephrine every 3-5 minutes), I think this would be safe for at least 5 doses. Personally, I have not had much experience with the use of emergency medications via ET tube.

      Kind regards,
      Jeff

  10. can i ask please if i only have the 1.10000 adrenaline I.V. IN some rural area and i have a case with anaphylaxis can i give 5 cc IM ????

    • 1:10,000 dilution of epinephrine is meant for IV use. Anaphylaxis treatment is beyond the scope of ACLS, however, here is what would be recommended: The following regimen is reasonable: 1:10,000 (100 mcg per mL) epinephrine at 1 mcg per minute, increased to 10 mcg per minute as needed. Patients receiving intravenous epinephrine require cardiac monitoring because of potential arrhythmias and ischemia.
      ANGELA W. TANG, M.D., University of California, Los Angeles, UCLA School of Medicine
      Am Fam Physician. 2003 Oct 1;68(7):1325-1333.
      Kind regards, Jeff

      • Anaphylaxis is not beyond the scope of ACLS. the dose is 0.3 mg IM of Epi 1:1000. And if cardiac arrest is imminent the dose is 0.5 of 1 in 10,000 I.V.
        It’s written in the protocol book that I ( the paramedic ) operate under.
        It is also taught nationally as a treatment in the scope of a paramedic.
        However as a practicing paramedic you operate within the Protocols of your individual county.

      • Thank for for the input. To clarify, anaphylaxis is not covered in the AHA provider manual and students taking ACLS (advanced cardiac life support) are not tested on this.
        Thank you for the clarification on the dosing.
        Kind regards,
        Jeff

  11. Can you tell me the appropriate concentration of epinephrine for acls protocol ie: 1:1,000 or 1:10,000

    • Epinephrine should not be given undiluted 1:1000, it can be fatal when given IV. Epinephrine 1:1,000 should always be diluted to 1:10,000 prior to administration. Epinephrine 1:10,000 = 1mg/10ml.
      Most crash carts in the United States now come with pre-made 1:10,000 (1mg/10ml) syringes of epinephrine to help reduce the error of giving undiluted epinephrine. The concentration ratio of 1:1,000 is to high for the medication to be given undiluted IV.

      Kind regards,
      Jeff

  12. I would like to know the effect on the patient if receive 1mg epinephrine iv within 2 minutes interval instead of 3-5minutes.

    • If epinephrine was given at a 2 minute interval, it probably would not make that much of a difference. The effect would be that you would have a higher degree of vasoconstriction.

      The main reason for the epinephrine given every 3-5 minutes is because the half-life of epinephrine is 2-3 minutes and therefore you would still have circulating epinephrine if you gave it every 2 minutes.

      Kind regards,
      Jeff

  13. Does it make any difference if you push this medication through a extension set, followed by a 20 ml pre-filled syring, or .. does it have to be pushed through an iv line with followed by a pre-filled syringe, and followed with say a bag of NS, to keep vein open? Could you do the push with out the tkvo solution? Rookie questiong. Thanks.

    • The medication should be pushed into the circulatory system through the port that is closest to the body. You can do the push without the tkvo solution just make sure to follow the medication with 20ml of NS rapid IV bolus.

      Kind regards,
      Jeff

  14. can epinephrine be given during a patient’s arrest through infusion? example, 10 ampules of epinephrine in 100ml NS for 3 doses 20 minutes interval. is that a correct intervention? because i have encountered this and am really doubtful with the order. and how many maximum doses of epi should be given?

    • This would not be considered within standard ACLS protocol for cardiac arrest. Epinephrine should be given rapid IV push in 1 mg doses every 3-5 minutes. It should also be followed by 20ml NS rapid IV push to flush into the central circulation as quickly as possible.
      Kind regards,
      Jeff

  15. Is there a max dose of Epi that can be given IV?

  16. Jeff – I am confused as to the dosing parameters on the main frame of Epinephrine: specifically, the dosing for post-arrest hypotension where the drug is said to be dosed at mcg/kg/min. I have always used Epi @ mcg/min, not per kgm, for continuous infusion for hypotension. Please clarify, as I missed a test question on your sample tests, as I am not famililar with inclusion of kgm as part of the equation. THANKS!

    • Your facility may have it’s own protocol for dosing of epinephrine that comes up with numbers that are close to the same dosing. AHA uses weight based dosing for the control of post-arrest hypotension because epinephrine used for post arrest hypotenstion is a much higher dose than that used for pacing in symptomatic bradycardia.
      For instance, if you are treating a 70 kg adult for hypotension post arrest the dose of 0.1-0.5 mcg/kg/min will be 7-35 mcg per minute.
      If you are treating any adult for symptomatic bradycardia with epinephrine your dose will be 2-10 mcg/min.
      This is a big difference in dosing especially at the higher end.
      Kind regards,
      Jeff

  17. When giving drugs through a PICC/central line, is 10cc flush enough? What about if a patient has a dialysis cath, can this be used to push drugs if necessary?

    • During cardiac arrest, all medications are supposed to be followed by a 20ml push of NS. 10ml is not enough to get the medications deep into the central circulatory system.

      I have not heard of a dialysis cath being used for anything except dialysis. I would opt for a peripheral cath. Also, many dialysis caths are loaded with heparin that can have a high concentration. This requires certain procedures for removing the heparin before use of the catheter.
      I don’t think that anyone not experienced with use of a dialysis cath should attempt to use the cath.

      Kind regards,
      Jeff

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