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.
Marwa says
Can we give epinephrin push dose 1mg in bradycardia pre arrest
ACLS says
That would not be what is recommended in the ACLS Bradycardia Algorithm. 1 mg epi IV push is used for the cardiac arrest algorithm.
Kind regards,
Jeff
camilla says
Hi! When do you stop administering epinephrine to a patient who’s coding?
ACLS says
Epinephrine may be continued throughout the code until the patient is pronounced deceased. Epinephrine is given every 3 to 5 minutes. Kind regards, Jeff
Sophie says
I understand that it’s not recommended to dilute Epinephrine with D5W or DNS as it’s incompatible . Epinephrine also induces hyperglycemia… Can you clarify..?
ACLS says
The typical solution that epinephrine is diluted with is normal saline. For the purposes of ACLS hyperglycemia would not be a consideration with regard to the administration of Epi. I’m not sure what else you would like me to clarify. If there is something further that you’re wondering about please rephrase the question so that I can better understand what you’re asking.
Kind regards,
Jeff
Casilda says
What is the max dose of Epinephrine 1mg?
ACLS says
The maximum dose for epinephrine in the cardiac arrest algorithm is 1 mg.
I have never seen a higher dose recommended.
Kind regards,
Jeff
Jill says
In a skilled nursing home setting, do you need to have special certification to administer epi during a code? I see that it is not recommended in every code situation so how do you qualify to make that call.
Thank you,
ACLS says
You would need to be a registered nurse and he would most likely have procedures and protocols that were approved by your facility.
If these medications are available to you in a crash cart you need to make sure that you are authorized by you were facility to administer in emergencies.
Kind regards,
Jeff
Emmanuel Rama says
Good day!
I just wanna ask, when can we give the 1st dose of epinephrine? is there any specifications like after the 1st cycle of cpr? 2nd cycle, 3rd cycle, etc.
ACLS says
For the left branch of the cardiac arrest algorithm when treating ventricular fibrillation and pulseless ventricular tachycardia, epinephrine is to be given After the second shock during CPR.
For the right branch of the cardiac arrest algorithm when treating pulseless electrical activity or asystole, Epinephrine is given as soon as intervenous access is available
Kind regards,
Jeff
Bethel Tadesse says
Hi,
I was wondering how fast does epinephrine react/start to work once inside of the body.
ACLS says
Peak plasma concentrations for epinephrine administered IV is approximately two minutes.
Kind regards, Jeff
Aiman says
If the patient is on Epinephrine drip IV and has cardiac arrest that require boluse of epinephrine , what should we do with the drip. Continue the same? increase the rate? Or stop during the ode and epinephrine boluses?
ACLS says
The amount of epinephrine that is infusing in the epinephrine drip is extremely small. The drip may be stopped or the drip may be left infusing. It will not change The outcome and will not affect the epinephrine boluses that are being given.
Kind regards,
Jeff
Marielle says
Hi, I have a question. During a code, in giving IV epi, is it necessary to dilute it with NS or is it okay to just give the drug as is? (Assuming an IV line has been established already)
Thanks.
ACLS says
1 mg of Epinephrine should always be diluted in 10 mL of normal saline. Many crash carts will have this already prepared in pre-diluted vials. However, some crash carts have a concentrated solution of 1 mg in 1 mL. In this case, you would want to dilute with an additional 9 mL of NS.
Kind regards,
Jeff
Dannie says
So to clarify, if the patient is on vasopressin drips during code, we may hold?
Deborah Onyekachukwu Aniemeka says
Multiple vasopressor drips**
ACLS says
Yes.
Dr Mustafa says
V. Good discussion
John Joshua Gonzales says
Hello! What is the dose of epinephrine during cardiopulmonary arrest?
ACLS says
The dosing for epinephrine during cardiac arrest is 1 mg per dose administered every 3 to 5 minutes.
Kind regards,
Jeff
Johny says
I’m sorry for the question but I just need to clarify that for cardiac arrest, we need to administer 10ml of Epinephrine every 3-5 minutes? Since that equates to 1mg of Epi? Thank you so much!
ACLS says
Typically the epinephrine will come in a pre-filled syringe that is 1mg in 10 ml so that would be correct.
Kind regards,
Jeff
Cherry says
hi! what if the available stock for epinephrine is 1mg/ml ampule. Do we still need to dilute in nss to complete 10ml? why? thank you.
ACLS says
Yes, it does need to be diluted with normal Saline 10 mL to achieve a 1mg/10ml (1:10000) dilution.
1mg/ml (1:1000) is highly concentrated and if given IV push bolus, this can lead to potent vasoconstriction and possible cardiac ischemia.
Kind regards, Jeff
R J Ramamurthi says
Single most important drug for effective resuscitation – why can’t we agree on ‘Epinephrine’ as a universal name instead of ‘adrenaline’; understand lots of countries still use the name ‘adrenaline’, but wouldn’t it be safer to agree on ONE name to avoid confusion?
ACLS says
I completely agree with you. The world needs to get together and decide on one name. Kind regards, Jeff
Pornthep Wong says
As recommended by AHA, 20ml of fluid should be flushed after each dose of epinephrine iv via peripheral vein.
ACLS says
Yes. That is correct. Kind regards, Jeff
Alicia says
Can you give epinephrine IV push through a peripheral vein? Or does it have to be through a central line or IO?
ACLS says
Epinephrine can be given IV push through a peripheral IV. All of the medications that are used in basic ACLS can be given through a peripheral IV. Kind regards, Jeff
Dr karam says
What is the dose of epinephrine through the et tube for adult or pediatric?
How it should be given ? Diluted or not
ACLS says
Adult:
Endotracheal Tube: 2-2.5mg epinephrine is diluted in 10cc NS and given directly into the ET tube.
Pediatric:
The recommended tracheal dose of epinephrine during pediatric resuscitation is approximately 10 times the dose given via IV. This would be 0.1 mg/kg diluted in 1-5 ml of NS.
Kind regards, Jeff
Stephanie says
Adult-
IV 1 mg every 3-5 min
ET 2-2.5 mg how often?
Pediatric
IV 0.01mg/kg every 3-5 min
ET 0.1mg/kg how often?
ACLS says
The administration timing is the same regardless of the route of administration.
Kind regards,
Jeff
Paul says
Endotracheal administration of Epinephrine is not recommended under the ACLS 2015 guidelines.
ACLS says
On the page listed below in Table 2 you will find the recommendations for epinephrine administration via ET tube for kiddos.
American Heart Association 2015 Pediatric Guidelines
Kind regards, Jeff
Nidia Johnson says
How do you calculate the correct dose of epinefrine in a 50kg patient.
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). So this is not weight based.
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). So for a 50 kg patient this would be (0.1x 50/min – 0.5 x 50/min) which works out to 5-25 mcg/min.
Hope that makes sense.
Kind regards,
Jeff
Jaber says
In cpr when i give 4 mg adrinalin in 4 times
Can i contenu cpr and give more adrinalin or 4 mg is maximum
ACLS says
There is no limit on the amount of adrenaline (epinephrine) that can be given. You just give 1 mg every 3-5 minutes for the duration of the code.
Kind regards,
Jeff