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.

Comments

  1. sam delarosa says

    Dear Jeff

    Its me again.
    The ACLS protocol is to give 1:10000 dilution (1mg) of epi.
    During cardiac arrest (the patient is dead) why can not we just push the 1:1000 dilution
    and just followed up with 20mls normal saline?

    is there any difference?

    Thanks Jeff
    Sam

    • says

      The patient is dead, but you want them alive.

      Epinephrine 1:1000 (1mg/ml) is a concentrated form of epinephrine that can be fatal when administered IV without being diluted to 1:10,000 (0.1mg/ml). If epinephrine is administered IV, it should always be diluted to 1:10,000 which equals 0.1mg/ml or 1mg/10ml. Below are a couple of articles that review several deaths that have occurred when 1:1,000 epinephrine was administered IV.
      http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3%283%29/Pages/16.aspx
      http://www.medicscribe.com/2010/05/24/medication-errors-epinephrine/

      Kind regards,
      Jeff

      • jette123 says

        Jeff,

        How do you dilute 1:1000 epi to 1:10,000 epi? How much normal saline would I use?

        Thanks,

        Chris

      • says

        When diluting 1:1000 epinephrine to get 1:10,000, 1mg (1ml) can be diluted with 9 ml of NS to obtain the concentration of 0.1mg/ml or 1:10,000. Care must be taken that the epinephrine vial is not racemic epinephrine (inhailed epi) or epinipherine/lido 1% (used for injection for numbing agent)
        1:1000 amp of epinephrine can be diluted to be given in a code but is usually avoided due to a high potential for error.
        Kind regards,
        Jeff

      • says

        When diluting 1:1000 epinephrine, 1 mg (1ml) can be diluted with 9 mL of normal saline to obtain the concentration of 0.1 mg/mL or 1:10,000. Care must be taken that the epinephrine is I’ll is not racemic epinephrine (inhaled epi) or epinephrine/lidocaine 1% (used for injection of you numbing agent).

        1:1000 ampule of epinephrine can be given in a code but is usually avoided due to a high potential for error.
        Kind regards, Jeff

  2. says

    Giving Epinephrine by continuous infusion is like liquid pacemaker, While not recommended anymore by American Heart in the algorythms, It is still used by many old school E.R. Docs with great results. But I am just a doppie Paramedic, So the AHA wont listen to me. When the AHA did at least give it mention, we ignored the recommended dose. We put 30 Ml of 1:000 EPI. in 500 Ml saline and ran it at 125 an hour, (AHA Recommended) which gives you your 1mg. every 5 minutes. However, When we put the same 30 ml.Epi in a 250 bag and ran it nearly wide open, we were turning Asystole into V-Fib shockable rythyms. The one catch is once you get a rythym, shut the drip off or it will put them back into V-Fib. My partner and I had the highest save rate in our county. We finally admitted to our Medical Control Physician after him pestering us what we were doing. We told him the first aspect is that we better pick whom we were going to work, then explained our EPI theory. Out of 200 arrests we saved 192. He also began using it in the E.R. with similar results.A few of the other E.R. Docs began using with great results as well. However, the AHA conventions are sponsored for each aspect of ACLS a hard to get into with information, and are financially funded. Ask your Medical Control Authority to at least perform a field study of this dosing regiment for condideration in your protocols. Remember ACLS are gudelines not a bible for cardiac care……

      • says

        I was referring to.continuous infusion during a cardia arrest. Either asystole or v-fib responds well to the infusion. The use of Bicarb earlier than suggested by the AHA is also excellent prior to the infusion. Even the AHA won’t deny that giving a catecholomine in an acidotic body witll most likely show futile results. The AHA needs to open up for suggestions by the people that handle arrests every day in the field.

    • says

      I am wondering about a few things that you mentioned:
      192/200 saves, what does that mean?
      that you brought them somehow “alive” to the ER (with rosc or still under compressions?)
      and do you know the hospital discharge rate?
      there is some evidence that the 1mg/4min is already generally much too high because it causes a lot of problems in the rosc phase and patient care afterwards/long-term and also worsens longer term outcome.

      If your saverate is true, then I wonder if the endpoint of hospital discharge with good neurologic outcome is also above average.
      192/200 is like 10000% above americas and europes positive outcome rate of cardiac arrest.

      Also, did you count ALL cardiac arrest, or just those where immediate good quality bystander compressions were made?
      I am sceptic that of your 200 cases all of them were witnessed arrests with immediate compressions.
      Or if not, that even those patients that had no chest compressions for 5-10 minutes for example, still had a good outcome in like 90% of the time, by your courageous secretly change of dosing, not backed up by any literature.

      Please let us know those details, I am very curious.
      cheers

      • says

        I wanted to add that there is enough evidence that EPI increases ROSC, but actually worsens long term outcome. I can give you the references if you want. Have you looked into all the literature before trying your strategy (which is actually giving more epi than the guideline, right?)

        best wishes,
        cheers
        Alexander

  3. says

    Can Respiratory give Epi down the ET / Trach tube during a code. I was advised it wasnt in my scope of practice but have for years.

    • says

      This can be give by an RT with a written or verbal order the same way as when you follow an order to give other medications like Albuterol, Atrovent, or NAC. Kind regards, Jeff

    • says

      This can be given by an RT with a written or verbal order the same way as when you follow an order to give other medications like Albuterol, Atrovent, or NAC.
      Kind regards,
      Jeff

    • says

      If you mean maximum cumulative dose there is not a max cumulative dose. 1mg have be given every 3-5 minutes as long as necessary.

      If you mean maximum single dose then that would be 1mg per dose.

      Kind regards,
      Jeff

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