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.
dr.satish says
how can you give adrenaline by
Infusion pump
1mg diluted with 50cc NS give dilution of 20 mcg/ mk
ACLS says
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).
Kind regards,
Jeff
Zack says
In my place, Epi is 1mg/ml (1:1000). Do I have to dilute it to 1:10.000 before infusion with AHA recommended dose which is ( 0,1-0,5 ug/kg/min) If i want to use Epi for hypotension??
ACLS says
Typical dilution for continuous infusion would be 1 mg of epinephrine in 250 mL NS this would give you 4 mcg/mL.
Kind regards, Jeff
Edem says
Please am a bit confused,in my place I always have adrenaline of 1mg per ml ,how can I constitute it to 1:10,000?
Thanks
ACLS says
1mg/ml epi is 1:1,000 and should be diluted as follows to achieve 1:10,000. Dilute 1 ml of 1mg/ml epi in 9 ml of Normal Saline to get 1:10,000 which equals 0.1mg/ml or 1mg/10ml.
Hope that makes sense.
Kind regards, Jeff
Alice Dunn says
Hi Jeff,
I know epinephrine is a beta-1, beta-2, and alpha stimulant, why does it decrease SVR if given in a dose less than 2mcg/min? I thought that it would increase SVR.
Thank you,
ACLS says
At low plasma levels, epinephrine preferentially binds to high affinity vascular β2-adrenoceptors and causes vasdilation, which results in a fall in systemic vascular resistance.
This article explains circulating catecholamines
Kind regards, Jeff
Somaia says
If the patient is monitored and rhythm shows ventricular fibrillation, do we need to check the pulse in the first confirmation
Thank you
ACLS says
If the patient is unresponsive and it was not witnessed then you should check for a pulse. This would be a formality, and you definitely should take only a very short time (in 10 seconds) to assess.
If this is witnessed ventricular fibrillation where the conversion to VF, and the subsequent unresponsiveness is witnessed then you could disregard the pulse check and provide defibrillation as soon as possible.
Kind regards,
Jeff
Saida says
No
Mustafa says
Hi Jeff
There any reason will give epi. after 2nd shock and why will not give after first shock …??
In unshakable rhythm immediately will give epi.
ACLS says
The main point of giving epinephrine after the second shock rather than as soon as possible is to ensure that there is no delay in initiation of chest compressions and the use of electricity.
That being said, if you have plenty of staff available and someone can provide the epinephrine earlier it would be OK to do that. The AHA Cardiac arrest algorithm is a rigid set of rules to follow that can be deviated from in given individual situations and depending on the physician/team discretion.
Kind regards,
Jeff
SOMAIA says
May i ask
During cardiac arrest patient initially has PEA ,epinephrine given every 3 minutes .In the third cycle he had Ventricular fibrillation can we give epinephrine after the first shock or we have to wait for the second shock
Thank you
ACLS says
You can continue on the every three minute timeline that has already been started. This is because you are dealing with the half-life of epinephrine and not just a step-by-step algorithm.
Kind regards,
Jeff
Greg says
Does epi increase or decrease the defibrillation aka shock threshold
ACLS says
Studies indicate epinephrine has no effect on shock dose threshold for defibrillation.
One Such Study
Kind regards,
Jeff
Terry Lyster says
Hi Jeff,
Thanks for all of your help. Question on Push Epi. The Journal of Emergency Medical Services is discussing this in great detail and now our hospitalists are doing this on the floor for hypotension. I do not see this in the ACLS guidelines anywhere. Taking the 1:10,000 dose 0.1mg/ml and diluting this further to 0.01mg/ml (10mcg/ml) by drawing out one ml from this syringe and adding 9ml of normal saline to it. They then give “push doses” one ml at a time for hypotension. Thoughts?
Jeff with admin. says
The only recommendation for epinephrine for hypotension is by infusion. There is no recommendation for intermittent pushes of epinephrine.
The protocols that you are using have not been guided by any American heart Association guidelines at this point.
Kind regards,
Jeff
Kristin says
Isn’t the half life of epi too short to even make a big difference if you push 10mcg PRN hypotension? Seems like even if the epi does help in this case, it would not help for long due to the short half like. If you are treating hypotension with epi it should always be an infusion are my thoughts.
ACLS says
You are correct. I have not seen any literature that supports the regular use of IV push epinephrine for the treatment of hypotension. For hypotension, epinephrine should be given as an infusion.
Kind regards,
Jeff
Jan says
Hey Jeff, I am so frustrated trying to complete my ACS online, with these buttons and patient scenerios. I very rarely am involved in a code, because the code team arrives after the code begins. I have two patients to go, that begin with bradycardia-Atropine given,etc…, then goes to cardiac arrest, code team called, CPR, shock,.. etc. on AHA site. I have done fine so far, but maybe a dumb question, but I know epi is given for cardiac arrest-with no specific amount that I can give, however when I read, I don’t see Lidocaine mentioned very much anymore. If you can help, thanks, if now, thanks anyway.
Jeff with admin. says
I don’t quite understand your question. If you would like to discuss this, you may call the technical support line at 316-243-7096. It would be easier for me to help this way. Kind regards, Jeff
J says
Here is my question. Post arrest, if you have a 110kg patient and my Epi drip at .1-.5 mcg /Kg/min. How much Epi in mg’s will you put into 500 ml of saline and what is my yield? I came up with 27.5mg in 500 so my high end would 55mcg at 60gtt and low end would be 11 mcg.
Jeff with admin. says
Standard concentration for mixing epinephrine for a drip is 3 mg in 250 ml of D5W or 6mg in 500 ml of D5W.
That equals 12 mcg/ml. Here’s the math:
3mg/250ml = 0.012mg/ml = 12mcg/ml
The dosing will be strictly weight based and you will need to know the weight before you can calculate a rate.
Kind regards,
Jeff
Michael Safian says
What would happen if epinephrine 1mg/ml (1:1,000) was given IVP, without dilution, during cardiac arrest?
Jeff with admin. says
In all likelihood, the patient would not survive. When 1:1000 epinephrine is injected intravenously, this causes profound vasoconstriction. This profound vasoconstriction can significantly compromise cardiac perfusion.
Other complications of intravenous injection of 1:1000 epinephrine are cerebrovascular hemorrhage, pulmonary edema, and a drastic increase in systolic and diastolic blood pressure.
Kind regards,
Jeff
Daniel says
This is not correct. The amount of drug given remains unchanged. The single milligram of epinephrine would dilute in the blood as it is circulated throughout the body. If 1mg epinephrine 1:1000, were given IVP via a Y-port, and flushed simultaneously or after being pushed, the difference in outcome compared with 1:10,000 would be immeasurable and neglibale. If 1mg epinephrine 1:1,000 were given IVP during cardiac arrest and not followed by a flush then the systemic effects would not happen as the drug would not circulate as well as it would if it were given with more volume, such as 1:10,000.
Jeff with admin. says
When you bolus a medication into the central circulation through the venous system, the venous system will return this medication to the heart fairly undiluted as a bolus. Once the medication enters the heart, it will enter the myocardial circulation where it will cause profound myocardial vasoconstriction and possibly worsen myocardial ischemia. This is the case even if a 20 mL flush is provided after the bolus. The 20 mL flush simply pushes the bolus further into the venous system toward the heart in the same way that it would have pushed it through any tube.
Of course, some dilution does occur, but there is no way to gauge how much and how long it will take to dilute to a safe concentration.
There is also a reason why epinephrine is to be given for cardiac arrest as a 1:10,000 concentration. The 1:1,000 concentration has been deemed to be unsafe and can bring potential harm to the patient when given intravenously.
The logical and obvious conclusion is to give the medication as advised by the manufacturer. Any epinephrine that is given intravenously is advised and should be diluted to 1:10,000 prior to intravenous injection.
Kind regards,
Jeff
Fikri says
Should we mix epinephrine with NS or D5 solution or not?
Jeff with admin. says
For cardiac arrest, epinephrine is administered IV, it should always be diluted to 1:10,000 which equals 0.1mg/ml or 1mg/10ml. 1:1000 and Epinephrine = 1mg/ml so 1ml of 1:1000 epi would need to be diluted with 9 mL NS or D5W.
Epinephrine can be safely deluded with normal saline or D5W.
Many emergency facilities and hospitals provide ready to inject syringes of epinephrine that are already diluted to 1:10,000.
Kind regards,
Jeff
Dy says
Hi jeff. How many epinephrine should be given for those patients suffering cardiac arrest..thankyou
Jeff with admin. says
There’s no maximum limit for the number of doses that can be given. 1mg of Epinephrine can be given every 3 to 5 minutes.
Kind regards,
Jeff
Dr sidra says
HI Jeff!
Which inotropic support is best for hypovolemic shock?
Jeff with admin. says
For inotropic support there’s not one that is any better than another. In this situation the problem is depleted volume. Increase volume. Give fluids.
Kind regards,
Jeff
april says
how many cycles of CPR should be given before administering Epinephrine?
Jeff with admin. says
For the left branch of the cardiac arrest algorithm while treating ventricular fibrillation or pulseless ventricular tachycardia, epinephrine is given after the second shock during CPR.
For the right branch of the cardiac arrest algorithm while treating PEA or asystole, epinephrine can be given as soon as possible as long as it does not delay high-quality chest compressions.
Kind regards,
Jeff
Sherry in Reno says
Hi Jeff. Can you help me understand why epi is held until after the 2nd defibrillation? If I already have IV access in place, why would I wait until 2 shocks? I understand Amiodorone is for shock-refractory VFib, but what about epi? Thanks
Jeff with admin. says
Hi Sherry,
Thank you for the question. You asked:
“Can you help me understand why epi is held until after the 2nd defibrillation? If I already have IV access in place, why would I wait until 2 shocks? I understand Amiodorone is for shock-refractory VFib, but what about epi?”
Reply:
For the left branch of the cardiac arrest algorithm, American heart Association has placed the first dose of epinephrine after the second defibrillation in a effort to deemphasize the administration of medications.
This was done because there is no evidence that the administration of epinephrine improves survival to hospital discharge. There is evidence that there is an increase in the chances of ROSC But not survival to hospital discharge.
In light of this, there is a demphasis on the administration of medications. That said, I do think that if you have IV access and staff available epinephrine can be given as soon as possible. American heart Association allows for the tailoring of rescue actions based upon the situation you have available.
Kind regards,
Jeff