Epinephrine is the primary drug used in the cardiac 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
- 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.
- 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
- 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 2 to 10 micrograms/min.
- Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube.
-
Epinephrine is used in the cardiac 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
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 ACLS Drugs Main Page.
Ednel says
I’m so confused..
A.
If 1: 1,000 means 1 cc of epi and mixed with 9 cc of NS? DO u draw up NS first then Epi last, so Epi is injected through the vein first?
B.
If 1:10,000 means drawing up 0.1 mg of epi, that means we don’t use 1:10,000 during ACLS since it calls for 1 mg of epi..
Do I make any sense?
Jeff with admin. says
You can use either concentration in ACLS but you must be aware of the concentration ration so that you don’t give to much or to little. If you are using 1:10,000 and you need to give 1mg then you would administer 10 ml. If you are using 1:1,000 and you need to give 1mg, you would administer 1 ml. (see the concentration ration below in bold)
Epinephrine vials are also labeled by concentration of a ratio of medication per mL.
CONCENTRATION
1:1,000=1mg/ml
1:10,000=0.1mg/ml
Personally, I prefer to use single dose injectors of 1mg epinephrine in a code rather than mixing. It saves time and reduces errors.
Kind regards,
Jeff
Andrea says
Is it o.k. to give epi before the first shock in v-fib/pulseless v-tach if an iv access is available?
Jeff with admin. says
AHA states “give epinephrine after the second shock.” The main reason is that AHA wants to deemphasize the use of medications because there is no clinical evidence that shows that they are effective for increasing survival rates.
AHA wants to emphasize high quality chest compressions and early defibrillation because there is clinical evidence that shows increased positive outcomes with the use of high quality chest compressions and early defibrillation.
Most of the codes, I have participated in, we give epinephrine as soon as we have IV access. If we already have IV access, we give it right away.
For continuity at the site in following the AHA ACLS guidelines, I try to go strictly by the book which says give the first dose of epinephrine after the 2nd shock.
If you are performing high quality chest compressions and are attempting defibrillation as early as possible, I see no good reason why a physician would delay the use of the epinephrine.
Regards,
Jeff
rexy says
whats the max dose of epinephrine that can be given through ET?
Jeff with admin. says
Hi Rexy,
Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube.
This may be given as many times as necessary. There is no maximum dose.
Kind regards,
Jeff
monica Barba says
so when explaining how to do the epi drip , i think it would be a good idea to also state what you are using epi 1:1,000=1mg/ml or 1:10,000=0.1mg/ml
Jeff with admin. says
1 mg of epinephrine is given. Whether you are giving 1:10,000 or 1:1,000 you are still giving 1 mg.
The AHA ACLS provider manual does not differentiate. 1 mg is 1 mg.
Kind regards,
Jeff
Dee says
Question..Our Standing orders state after 1mg 1:10,000 EPI, IV, follow with 1minute of CPR to circulate drug. Is this still the idea and if so is this the same for IO, or has this changed?
Jeff with admin. says
IV and IO administration should have the same instruction. You should ensure that at least one minute of CPR is given after the medication. Preferably, it would be given at the beginning of the round of CPR. This would give the drug about 2 minutes to circulate and have full effect.
I would add to your standing order something about following the medication with 20 ml of NS and elevating the arm if possible.
Kind regards,
Jeff
Donna Baldwin says
Hi Jeff
If I take 1:1000 epinephrine and dilute in 10cc NS, is this the correct dilution for 1mg epinephrine or do we use 1:10,000 diluted in 10cc in VF etc? The ACLS book I have says “10ml of 1:10,000 IV” …big difference and we dont have many codes here so want to be clear !
Jeff with admin. says
When diluting 1:1000 epinephrine, 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 epinepherine vial is not racemic epinepherine (inhailed epi) or epinipherine/lido 1% (used for injection for numbing agent)
1:1000 amp of epinepherine can be diluted to be given in a code but is usually avoided due to a high potential for error.
Kind regards,
Jeff
Kristin says
Can you explain the difference in uses for 1:10,000 and 1:1,000 concentrations of epinephrine?
Jeff with admin. says
Epinephrine vials are labeled by concentration of a ratio of medication per mL.
CONCENTRATION
1:1,000=1mg/ml
1:10,000=0.1mg/ml
1:1000 is for SQ/IM since the volume is less. If you had too this one is for ET administration
1:10,000 normally for IV/IO use.
The 1:1,000 is easier to use when preparing an epinephrine drip.
Kind regards,
Jeff
jporter says
How come epi’ s dose is not wt based on this page?
Jeff with admin. says
If you look under the subheading of “dosing,” you will see all of the different methods of dosing within ACLS protocol which includes weight based dosing for bradycardia.
Kind regards,
Jeff
mae says
thank a lot 🙂
Vicki says
So Amiodarone needs to be given with D5W flushes, it seems most of what I have read is you hang NS or LR as a fluid. So you have to use only D5 with amiodarone? Would LR work?
Jeff with admin. says
D5W should be used if you are Diluting amiodarone. You may follow amiodarone with NS flush or LR flush. Flushing with either one of these is not a problem.
Kind regards,
Jeff
nor says
So you mean it can only be diluted with D5W? Or I can still use the NS as diluting agent?
Jeff with admin. says
Amiodarone is incompatible with NS. As far as I know, Amiodarone is only to be diluted with D5W.
Kind regards,
Jeff
MeLisa says
My 18yr old son was in cardiac arrest. I was doing CPR when paramedics arrived. I was made to stop and help carry him to liv room floor. it was 4 mins before I was asked to leave so
my son could have their full attention. I never seen ne1 take my place with CPR the whole time I was inside. He was given epinephrine and vasopressin via IV at the ankle two minutes before receiving stop order for a total of 11 minutes of CPR. My question is…Is two minutes long enuff for the meds to reach his heart from his ankle when asystole and have time to be effective? oh and why would they stop after such short time?
Jeff with admin. says
2 minutes may not have been long enough for the epinephrine to be fully circulated. If the arrest was witnessed there are termination of CPR rules that emergency personnel follow. Emergency personnel must receive instructions to stop CPR based upon what the dispatch tells them to do. Every situation is different and even in some areas they have different CPR termination rules.
Kind regards.,
My prayers are with your family,
Jeff
revjill says
Thank you, Jeff. The review of calculations was very helpful.
revjill says
I have been out of active practice for a while and never an ICU nurse. How does one calculate the 2-10 mcg/min Epi gtt?
Jeff with admin. says
The standard concentration for an epinephrine drip is 3mg in 250 ml D5W or 3000 mcg/250 ml = 12 mcg/ml. So if you want your epinephrine infusion to run at 6 mcg/min then you would calculate it as follows. First, to simplify the drip calculation for any drug ordered as mcg/minute calculate the infusion rate for 1 mcg/minute of 3000 mcg/250 ml solution (12 mcg/ml) as shown here:
1 mcg x 60 min
———————— = 5 ml/hour (infusion rate)
12 mcg/ml (drug concentration)
Once you’ve calculated the infusion rate for 1 mcg/min which is 5 ml/hour, you can
easily determine the titration rates, as shown below:
2 mcg x 5 = 10 ml/hour (2 mcg/minute)
3 mcg x 5 = 15 ml/hour (3 mcg/minute)
4 mcg x 5 = 20 ml/hour (4 mcg/minute)
5 mcg x 5 = 25 ml/hour (5 mcg/minute)
Kind regards,
Jeff
raed says
thank y sir
ksanders says
Happy to have found some help.