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.
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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.
ahmed abdallah says
what the maximum dose of adrenaline during CPR ?
Jeff with admin. 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
Jessica says
Hi, I am a student. In a situation when a patient experienced shortness of breath following ingestion of seafood, she was placed on supplemental oxygen and a 0.5 mg (1:1000) dose of
epinephrine was ordered. But she complained about chest pain and tingling. ECG also showed ST elevation and her rise in serum creatinine kinase levels. Investigation furthers showed that wrong IV route is used instead of IM. What could be the reasons behind this wrong route? Why IV infusion route cannot be used?
Thanks.
Jeff with admin. says
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.
Article 1
Article 2
Pubert says
Sometimes the doc wants partial doses, why? How do I know when to recommend a partial dose?
Jeff with admin. says
I’m not sure why a physician would order a partial dose of epinephrine. This makes no sense to me.
Kind regards, Jeff
Sarah Shuller says
How many times can epinephrine be given during a code?
Thanks!
Jeff with admin. says
There is no limit on the number of doses that can be given.
Kind regards,
Jeff
peggy says
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?
Jeff with admin. says
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
Jeju Nath Pokharel says
Jeju N Pokharel
Shahid Gangalal National Heart Centre , Kathmandu Nepal
There is no harm, but absorption may not be possible because there is no circulation in the tissue during arrest. Once the circulation is resumed the drug will be absorbed and may cause sometimes problems like tachycardia, arrhythmia and high blood pressure
dmusson says
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?
Jeff with admin. says
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
Sarah veuleman says
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.
Elizabeth McLaren says
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.
Meribah says
Thanks . That was a re read for me . We have a cardiac events scenarios CME in the A/E where I work , tomorrow morning .
karin klouman says
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.
Jeff with admin. says
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
Rama Krishna says
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.
BeeHite says
I did have a reaction like this to an injection into my tongue to prep for a tongue biopsy. I had another reaction with novocaine and epi with a tooth filling. Both Dr. told me that I was hyper-sensitive to epi and that in the future not to have them add this to the novocaine. They might have to use something else to counteract if this is the case. But agree with Jeff, to contact the physician on what he would suggest. I ended having to take a migraine tablet and they counteracted with outside relief; ice to back of neck and cool cloth on the forehead and monitored the blood pressures. Interestingly enough, after I called my mother, she stated that her physician told her she was essentially allergic to epi. That is a scary thought if you needed it in an emergency. Not sure what they would use for a parallel med.
Phil says
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?
Jeff with admin. says
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
BelleCheri says
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?
Cindy Warren says
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?
Jeff with admin. says
You would use the injectable epinephrine. Flush endotracheal tube dose with 5ml of NS and then give 5 ventilations.
Kind regards,
Jeff
Katrina says
What is the pediatric dose of epinephrine during code blue? Thanks
Jeff with admin. says
The pediatric dose of epinephrine during cardiac arrest is 0.01mg/kg IV push every 3-5 minutes.
Kind regards,
Jeff
markdanej says
for pedia via ETT 0.1mg/kg (0.1ml/kg) 1:1000 undiluted right?
Jeff with admin. says
Correct.
For epinephrine, a dose ten times the intravenous dose (0.1 mg/kg or 0.1 mL/kg of 1:1000 concentration) is recommended.
Kind regards,
Jeff
Sarah veuleman says
You would flush with 5ml, not 10?
Jeff with admin. says
10 ml
Sean says
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?
Jeff with admin. says
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
peter says
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
Mueanthep Chomvilailuk says
You mean we have to dilute 1:1000 to 1:10000 in cardiac arrest event also?
Jeff with admin. says
Yes, that is correct. Epi must be diluted to 1:10,000. That is 1mg/10ml.
Kind regards,
Jeff
Sarah says
The 1:1000 concentration is used when giving IM for anaphylaxis. 🙂
kim tane says
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?
Jeff with admin. says
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
dr. omar says
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 ????
Jeff with admin. says
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
ma says
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.
Jeff with admin. says
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
anna says
Can you tell me the appropriate concentration of epinephrine for acls protocol ie: 1:1,000 or 1:10,000
Jeff with admin. says
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