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.
Rozita Dol says
I would like to know the effect on the patient if receive 1mg epinephrine iv within 2 minutes interval instead of 3-5minutes.
Jeff with admin. says
If epinephrine was given at a 2 minute interval, it probably would not make that much of a difference. The effect would be that you would have a higher degree of vasoconstriction.
The main reason for the epinephrine given every 3-5 minutes is because the half-life of epinephrine is 2-3 minutes and therefore you would still have circulating epinephrine if you gave it every 2 minutes.
Kind regards,
Jeff
jackson says
Does it make any difference if you push this medication through a extension set, followed by a 20 ml pre-filled syring, or .. does it have to be pushed through an iv line with followed by a pre-filled syringe, and followed with say a bag of NS, to keep vein open? Could you do the push with out the tkvo solution? Rookie questiong. Thanks.
Jeff with admin. says
The medication should be pushed into the circulatory system through the port that is closest to the body. You can do the push without the tkvo solution just make sure to follow the medication with 20ml of NS rapid IV bolus.
Kind regards,
Jeff
pres says
can epinephrine be given during a patient’s arrest through infusion? example, 10 ampules of epinephrine in 100ml NS for 3 doses 20 minutes interval. is that a correct intervention? because i have encountered this and am really doubtful with the order. and how many maximum doses of epi should be given?
Jeff with admin. says
This would not be considered within standard ACLS protocol for cardiac arrest. Epinephrine should be given rapid IV push in 1 mg doses every 3-5 minutes. It should also be followed by 20ml NS rapid IV push to flush into the central circulation as quickly as possible.
Kind regards,
Jeff
Jay says
Is there a max dose of Epi that can be given IV?
Jeff with admin. says
If you mean single one time dose, I would say that the standard of care is 1mg.
If you mean total accumulative dose, there is not a max total accumulative dose.
Kind regards,
Jeff
steveahm says
Jeff – I am confused as to the dosing parameters on the main frame of Epinephrine: specifically, the dosing for post-arrest hypotension where the drug is said to be dosed at mcg/kg/min. I have always used Epi @ mcg/min, not per kgm, for continuous infusion for hypotension. Please clarify, as I missed a test question on your sample tests, as I am not famililar with inclusion of kgm as part of the equation. THANKS!
Jeff with admin. says
Your facility may have it’s own protocol for dosing of epinephrine that comes up with numbers that are close to the same dosing. AHA uses weight based dosing for the control of post-arrest hypotension because epinephrine used for post arrest hypotenstion is a much higher dose than that used for pacing in symptomatic bradycardia.
For instance, if you are treating a 70 kg adult for hypotension post arrest the dose of 0.1-0.5 mcg/kg/min will be 7-35 mcg per minute.
If you are treating any adult for symptomatic bradycardia with epinephrine your dose will be 2-10 mcg/min.
This is a big difference in dosing especially at the higher end.
Kind regards,
Jeff
gaargento@att.net says
When giving drugs through a PICC/central line, is 10cc flush enough? What about if a patient has a dialysis cath, can this be used to push drugs if necessary?
Jeff with admin. says
During cardiac arrest, all medications are supposed to be followed by a 20ml push of NS. 10ml is not enough to get the medications deep into the central circulatory system.
I have not heard of a dialysis cath being used for anything except dialysis. I would opt for a peripheral cath. Also, many dialysis caths are loaded with heparin that can have a high concentration. This requires certain procedures for removing the heparin before use of the catheter.
I don’t think that anyone not experienced with use of a dialysis cath should attempt to use the cath.
Kind regards,
Jeff
Sujie says
Right me if I’m wrong. As far as I have been working, if there is no IV or central line access, we can always use the dialysis cath but we have to withdraw each lumen at least 15 to 20cc of blood then only we can use it to push any drugs in just to ensure there is no more heparin inside it. Same like other IV access, all medications supposed to be followed by a 20mL push of NS.
Jeff with admin. says
You would need to follow your hospital policy regarding the emergency use of a hemodialysis cath. Generally speaking, they can be used in emergencies if accessed properly. Removal of concentrated heparin prior to use is critical. Remove 10 ml of blood and then flush with 10 ml of NS prior to any medication administration.
Kind regards,
Jeff
Sally says
Thanks Jeff, Helpful site as I am preparing for a cardiac arrest with nursing students tomorrow in the simulation lab.
mercysuganya sm says
What is the maximum dose of epinephrine in cardiac arrest?
Jeff with admin. says
According to AHA, the amount to be given in a single dose during cardiac arrest is 1mg. This dose can be repeated every 3-5 minutes and there is no maximum on the number of times that the 1 mg dose can be repeated.
Kind regards,
Jeff
Shue says
Can I adminster epi 1mg, (undiluted) 1:1000 every 3-5min during resuscitation or must I dilute epi to 1:10,000 (as I only have 1:1000 available)? What is the potential problem/ harm if I give the undiluted epi instead?
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 premade 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
Jenny says
Hello,
I recently started using this site to prepare for ACLS. Thank you for taking the time to create this site and sharing your expertise. It has been so helpful in going over this info for the first time.
I was just wondering why some of the drugs in the med list are not further elaborated upon (e.g. magnesium)…are there specific dosing information that we must know for these drugs?
Thank you in advance.
Jeff with admin. says
I have only included the drugs that you will be tested on for ACLS certification. All of the other drugs including magnesium, sotolol, metoprolol, cardizem….are not primary ACLS medications but may be used as secondary medications. I have not seen These included recently because of a desire by AHA to deemphasize the focus on medications when there is no research that verifies their effectiveness at improving survival to hospital discharge.
Kind regards,
Jeff
sundas says
What is the mechanism when epinephrine is given via ETT? How does it act to treat cardiac arrest?
Jeff with admin. says
If systemic (venous) access is not available the epinephrine given via an ETT can get epinephrine into the systemic system. The desire would be a systemic affect just as with venous administration.
Kind regards,
Jeff
aenoya says
hey jeff I admire your patience!
Jeff with admin. says
I am humbled. If I have any patience at all, it comes from Jesus my savior. When he saved me, he changed me, and I thank Him for that. Kind regards, Jeff
Alem says
Thank you for sharing your knowledge and for your kindness. You are my brother in Christ. God bless you.
Jeff with admin. says
It is my privilege to be able to share.
God bless you too Alem.
Kind regards, Jeff
Tawanda Tarakini says
Hi Jeff
Thank you for this great site . Could you please clarify during treatment of VF can I give epinephrine 1:1000 undiluted follwed by 20ml normal saline flush and elavation for about 10 sec or I have to dilute is it first with normal saline to make 1:10000
Jeff with admin. says
When administering epinephrine IV, you should always dilute epinephrine to 1:10,000. A dilution of 1:10,000 gives you 0.1mg/ml so you will administer 10ml of the mixed solution with each dose delivered.
Many code carts are now stocked with premixed ready to inject medications. These type of premixed syringes are ideal since they reduce errors that occur when mixing medications.
Kind regards, Jeff
Dolly says
In the Adult Immediate Post-Cardiac Arrest care Algorithm Epi. infusion is 0.1-0.5 mcg/kg per minute. In the Adult Bradycardia (with a pulse) or hyotension the Epi. infusion in 2-10 mcg per minute.
Why is the ROSC Epi. mcg/kg/min and the brady mcg/ min. It is confusing. Please help me make sense out of it.
Jeff with admin. says
On page 76 of the AHA ACLS provider manual, epinephrine for the treatment of hypotension is listed as a weight based infusion. The dosing is listed as 0.1-0.5 mcg/kg/min (for example a 70kg adult: 7-35 mcg/min would be given).
So you see this dose for post-arrest hypotension would be much higher than the dose given for transcutaneous pacing.
Kind regards,
Jeff
stacie says
Vasopressin can be given as a substitute for the first or second dose of epi. Is it preferred to use Vasopressin instead of epi for one of these doses? If ample amounts of epi are available, is it preferred to only use epi? Thanks for this site, its helping clear some of the fog.
Jeff with admin. says
Epinephrine and Vasopressin have been shown to be equally effective. Vasopressin has a much longer half-life that is why it is only given once. It is really just preference whether to use vasopressin over epinephrine. Most codes I have been in, the vasopressin is included usually as a replacement for the 2nd dose of epinephrine. However, the literature shows no difference in outcomes whether with use of epi or vasopressin.
Kind regards,
Jeff