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.
김주은 says
Is there a big difference between injecting 20cc and 10cc when injecting saline after epi injection?
ACLS says
During cardiac arrest, reduced venous return and impaired circulation create a low-flow state that compromises the delivery of intravenously administered medications. Epinephrine requires rapid transit from the injection site to the central circulation to exert its α- and β-adrenergic effects. However, smaller flush volumes (≤10 mL) often fail to overcome the hydrostatic resistance of peripheral venous networks, leaving medication in the catheter or adjacent vasculature.
Animal models of neonatal asphyxial cardiac arrest demonstrate that a 1 mL flush following umbilical venous epinephrine administration achieves return of spontaneous circulation (ROSC) in only 42.8% of cases, compared to 80% with 2.5 mL flushes. This discrepancy arises because smaller volumes cannot propel the drug past the ductus venosus into the right atrium—a critical step for systemic distribution during chest compressions.
Reference
Kind regards,
Jeff
Anh Nguyen says
Hi, would you give me any evidences why we not use adrenaline 1:1000 in cardiac arrest? What are complications? Thank you so much.
ACLS says
Reply curated using Perplexity and edited by this author:
While epinephrine (adrenaline) is a crucial medication in cardiac arrest management, using the 1:1000 concentration directly is not recommended due to potential complications. Here’s why the 1:10,000 concentration is preferred and the potential complications of using 1:1000 concentration:
Reasons for Not Using 1:1000 Concentration
1. Risk of Excessive Vasoconstriction:
The 1:1000 concentration is ten times more potent than the 1:10,000 concentration. This high potency can cause extreme vasoconstriction, potentially compromising blood flow to vital organs[1][3].
2. Increased Myocardial Oxygen Demand:
Higher concentrations of epinephrine can significantly increase heart rate and blood pressure, which in turn increases myocardial oxygen demand. This can worsen ischemia, especially in patients with underlying coronary artery disease[3][6].
3. Arrhythmogenic Potential:
Concentrated epinephrine has a higher risk of inducing dangerous arrhythmias, including ventricular tachycardia and ventricular fibrillation[1][2].
4. Standardization and Error Prevention:
Using a standard 1:10,000 concentration helps maintain consistency in dosing and reduces the risk of medication errors during high-stress resuscitation situations[5].
Potential Complications of Using 1:1000 Concentration
1. Severe Hypertension:
Rapid absorption or inadvertent intravascular injection of concentrated epinephrine can cause a hypertensive crisis[1].
2. Ventricular Arrhythmias:
Cases have been reported where high-dose epinephrine led to ventricular tachycardia and even cardiac arrest[1][2].
3. Myocardial Ischemia:
The increased cardiac workload can lead to myocardial ischemia or worsen existing ischemia[3][4].
4. Pulmonary Edema:
In some cases, epinephrine toxicity has been associated with the development of pulmonary edema[1][2].
5. Platelet Aggregation:
It has been theorized that high concentrations of epinephrine might promote platelet aggregation, potentially worsening microcirculatory occlusion[5].
6. Electrolyte Imbalances:
Epinephrine can cause acute hypokalemia, which may increase the risk of arrhythmias[1][2].
In conclusion, while epinephrine remains a cornerstone of cardiac arrest management, using the appropriate 1:10,000 concentration is crucial for maximizing its benefits while minimizing potentially life-threatening complications. The 1:10,000 concentration provides the necessary vasopressor effect without the excessive risks associated with more concentrated forms.
Sources
[1] Cardiovascular crisis after use of epinephrine: a case report and … https://pmc.ncbi.nlm.nih.gov/articles/PMC8572674/
[2] Intravenous epinephrine overdose in prehospital management of … https://pmc.ncbi.nlm.nih.gov/articles/PMC6954811/
[3] ACLS and Epinephrine | ACLS-Algorithms.com https://acls-algorithms.com/acls-drugs/acls-and-epinephrine/comment-page-7/
[4] Myocardial stunning secondary to erroneous administration of … https://journals.sagepub.com/doi/10.1177/2050313X231159732
[5] Deep Dive into the Evidence: Epinephrine in Cardiac Arrest – EMRA https://www.emra.org/emresident/article/deep-dive-epi
[6] ACLS and Epinephrine | ACLS-Algorithms.com https://acls-algorithms.com/acls-drugs/acls-and-epinephrine/
[7] Adrenaline and fluid bolus administration in resuscitation https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Adrenaline_and_fluid_bolus_administration_in_resuscitation/
[8] Part 6: Advanced Cardiovascular Life Support | Circulation https://www.ahajournals.org/doi/10.1161/circ.102.suppl_1.i-129
[9] [PDF] Effect of adrenaline on survival in out-of-hospital cardiac arrest https://com-emergency-a2.sites.medinfo.ufl.edu/files/2013/02/Effect-of-Adrenaline-on-survival.pdf
[10] A potentially lifesaving error: unintentional high-dose adrenaline … https://pmc.ncbi.nlm.nih.gov/articles/PMC11212146/
Kind regards,
Jeff
PUNITHAVATHY says
FOR paediatric cases with no iv access , epi administration via ET WILL BE 1;1000 ?
ACLS says
Yes. That is correct. The epinephrine concentration used for endotracheal administration in pediatrics is typically 1:1000, which corresponds to 1 mg/mL.
Kind regards,
Jeff
AHMED says
Hi
If we have vial of 1 mg in one ml adrenaline with no strength mentioned then WHAT does it mean.? Is it 1:1000.? And if yes then we have it dilute it in 9 ml normal saline to make it 1:10000 before giving in CPR.?
ACLS says
1 mg per ML is 1:1,000 concentration strength. Yes, you would dilute this with 9 ml of NS to make it 1:10,000 (0.1 mg/ml)
Kind regards,
Jeff
kamin says
Hi , i would like to ask can adrenaline be given via im route for cardiac arrest case? in a situation in which difficult
to gain iv access and the difficult intubation patient while preparing for other measure
ACLS says
No, epinephrine is typically administered intravenously (IV) during cardiac arrest to rapidly increase the heart’s pumping strength and stimulate blood flow. Intramuscular administration is not recommended for cardiac arrest situations, as it may not be as effective in delivering the medication quickly to the bloodstream.
Kind regards, Jeff
Camilo says
Whats the rationale behind the dilution of epinephrine to 9ml nss? Thanks
ACLS says
The dilution in 9 mL of normal saline is done improve the delivery and distribution of the medication, a larger volume of fluid is often used to help push the medication into the bloodstream and increase its overall effectiveness.
Kind regards,
Jeff
Ronald Quah says
Hi ACLS. Is there any study or clinical study to your answer. Because as I understand, during a resus, the faster we give adrenaline, the quicker the effect. It would be a waste of time to further dilute the adrenaline than to just immediately administer it immediately without dilute.
ACLS says
Concentrated epinephrine that is not diluted prior to injection can worsen ischemia. When a medication like epinephrine is concentrated, the pharmacological effects are much stronger. When epinephrine is diluted prior to injection it will result in the positive vasoactive effect without the increased risk of worsening ischemia.
Kind regards, Jeff
Tim says
If a patient is already on an epi drip and they code, are we still doing epi pushes per the algorithm?
ACLS says
This is not clarified within the AHA guidelines. I have seen it done either way. Some people stop the drip and only use the Epi pushes and some people leave the epi drip going and still use the Epi pushes.
Kind regards,
Jeff
JoJo says
Is there a max number of doses that should be given during a code. At some point does the epi become toxic?
ACLS says
There is not a max number of doses. Epinephrine is metabolized fairly quickly by the body.
Kind regards, Jeff
Jake says
Can you give more than 1mg epi push during a code? Say like 2mg epi push? Then wait the standard time.
ACLS says
The maximum single dose that can be given during a code is 1 mg. There are no standards that call for anything greater than 1 mg IV push every 3 to 5 minutes.
Kind regards,
Jeff
Lauren says
Hi Jeff,
Should epi being given during a code be given rapid IV push? I have seen ACLS guidelines specifically mention giving Amiodarone rapidly, but I have not seen any specifics mentioned for epi. Thanks so much in advance.
ACLS says
Yes. Epinephrine is given rapid IV push. This is true for any medication given during the cardiac arrest algorithm.
Kind regards,
Jeff
ACLS says
For an epinephrine infusion, 1 mg is diluted in 500 ml of normal Saline or D5W.
Kind regards,
Jeff
Cecilia says
Thank you for taking questions.
Is the dosing of 2-10 mcg/min for the epi infusion in the brady algorithm and in post cardiac care algorithm using the epinephrine concentration of 1:10,000 or 1:1000? Thank you again.
ACLS says
For an epinephrine infusion, 1 mg is diluted in 500 mg of normal Saline or D5W.
Kind regards,
Jeff