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.
Kelly Fulford says
I was told the EMTs drilled into the collar bone to administer epinephrine. Say it works faster to get to the heart. Is this true?
Jeff with admin. says
I have never heard about or read any literature that indicated this form of administration is more effective. A peripheral IV is the easiest and perfered method of administration of emergenc medications. If IV access cannot be obtained, then an intraosseous catheter can be placed. This is usually placed into the sternum or into the flat aspect of the tibia of the patient.
Kind regards,
Jeff
Laura says
Hi! I was told you could use endotracheal epinephrine only once in adults, but I couldn’t confirm this information anywhere. Is this true? or could it be administered every 3min as in IV? Thank you
Jeff with admin. says
Epinephrine can be given every 3-5 minutes but endotracheal tube. Kind regards, Jeff
Rachel says
Can you push an amp of epi during symptomatic bradycardia after 2 doses of .5 of Atropine with unconfirmed MI?
Jeff with admin. says
According to the American Heart Association ACLS guidelines, epinephrine IV push is not used for the treatment of bradycardia.
In this situation that you describe you would be better off using transcutaneous pacing so that you can have good rate control without compromising the patients coronary oxygen supply.
If you have bradycardia with suspected myocardial infarction, you have to be careful that you do not increase oxygen consumption significantly. Giving any type of bolus medication that will increase the heart rate can make it more difficult to regulate coronary oxygen supply and demand.
Kind regards,
Jeff
elise brown says
If someone arrests in clinic, and you have IM epi available (i.e. an Epi pen) but you do not have access to IV epi (so even if you establish an IV, you have no drug to give), would you give Epi IM? (I understand this hasn’t been studied and is therefore not “recommended,” but in the real world — sometimes unstudied situations occur!)
Jeff with admin. says
I would not give the IM Epinephrine because the epinephrine to have any benefit needs to be rapidly injected into the central circulation. The small dose of epinephrine that is in the epi pen will be useless for the patient in cardiac arrest and may slow down the initiation or continuation of high quality CPR and early defibrillation.
That said, the focus should be on high quality CPR and early defibrillation. High quality CPR and early defibrillation are the only two interventions that have shown clear evidence that they improve outcomes for patients with cardiac arrest.
Kind regards,
Jeff
Chris says
Can I give 2 of the premixed syringes of 1:10,000 EPI Via ET tube (total volume of 20ml) or would I have to mix 2mg of epi 1:1000 with NS for a total of 10ml
Jeff with admin. says
You may use 1:10,000 straight or dilute 1:1000 to equal 10 mL via ET tube for adult. (i.e., 2 mg of 1:1,000 epinephrine diluted with 8 mL NS in a 10 mL syringe)
Kind regards,
Jeff
mikey says
hye,is there a maximum dose of epinephrine given thru ETT tube during resus in pead patient??or we can give every 3-5 minutes
Jeff with admin. says
This site is generally directed toward adult advanced cardiovascular life support training, however, I can answer this question for you.
For the pediatric patient, AHA gives no recommendation for a maxium total dose for administration over the course of a pediatric cardiac arrest. The recommendation for ET tube administration is 2.5mg epinephrine followed by a 5ml normal saline flush, following by 5 consecutive positive pressure ventilations. This can be repeated every 3-5 minutes for epinephrine.
It must be stated per AHA that:
“The effectiveness of endotracheal epinephrine during cardiac arrest is controversial. Some studies showed it to be as effective as vascular administration while other studies have not found it to be as effective. Animal studies suggested that a higher dose of epinephrine is required for endotracheal than for intravascular administration because the lower epinephrine concentrations achieved when the drug is delivered by the endotracheal route may produce predominant transient peripheral β2-adrenergic vasodilating effects. These effects can be detrimental, and cause hypotension, lower coronary artery perfusion pressure and flow, and a reduced potential for ROSC”
Kind regards,
Jeff
aly mamdoh says
if there is no iv line and i want to give adrenaline during arrest what is the second preferred route is it intra osseus or ett route better ??
Jeff with admin. says
Thanks for the question. You asked: “if there is no iv line and i want to give adrenaline during arrest what is the second preferred route is it intra osseus or ett route better ??”
Reply:
Intraosseous would be the second preferred route. And if intraosseous is not available then you would use endotracheal tube. Intraosseous is better than endnotracheal tube.
Kind regards,
Jeff
Adam says
So, eip 1:10 000 is 0.1-0.5 mcg/kg/min and that is given intravenously, correct?
and
epi auto-injector is 1:1000 is 0.3 mg adult , 0.15mg pediatric, correct?
why are the doses different for auto-injector (IM) vs. intravenously??
Thanks in advance for the help.
-Adam
Jeff with admin. says
1:10,000 is a ratio.
Epinephrine 1:10,000 = 0.1 mg/ml = 0.01%
Epinephrine 1:1,000 = 1.0 mg/ml = 0.1%
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). ONLY GIVE 1:,000 SQ OR IM. This is important so I will repeat it one more time…ONLY GIVE 1:1,000 SQ or IM.
If epinephrine is administered IV, it should always be diluted to 1:10,000 which equals 0.1mg/ml or 1mg/10ml.
Kind regards,
Jeff
ihsan says
Hi Jeff,
in the guideline of cardiac arrest, epi dosage is 1 mg IV push. Should it be any different on what ratio to give? with 1:1000 you give 1ml, 1:10.000 give 10ml (according to pict), is it not?
Excuse my confusion, i hope you can help me with this.
regards,
Ihsan
Jeff with admin. says
1:10,000 is a ratio.
Epinephrine 1:10,000 = 0.1 mg/ml = 0.01%
Epinephrine 1:1,000 = 1.0 mg/ml = 0.1%
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). ONLY GIVE 1:,000 SQ OR IM. This is important so I will repeat it one more time…ONLY GIVE 1:1,000 SQ or IM.
If epinephrine is administered IV, it should always be diluted to 1:10,000 which equals 0.1mg/ml or 1mg/10ml.
Kind regards,
Jeff
jeremin says
hi sir. i am just confused, is AHA mentioning about the proper time to initiate giving EPI in cardiac arrest. i mean can we nurses give EPI while physicians or the code blue team are not yet around.? thanks.
Jeff with admin. says
This is dependent on whether your hospital has a standing protocol that allows for the administration of these medications with the standing order/protocol. AHA does not regulate how individual hospitals implement their own protocols, they just set the guidelines as recommendations for best practice. You will need to find out whether nurses can do this and it should be in your Operating Procedure Manual.
Kind regards,
Jeff
Jules011 says
Should epi be given before Vasopressin or after?
Jeff with admin. says
Vasopressin can be given in replace of the first or second dose of epinephrine. It is only given once since it’s half-life is around 20 minutes. Kind regards, Jeff
Patricia says
Should Epi be given immediately after the 1st shock and resuming CPR or should you wait 1 2 min cycle and give another shock and resume CPR before the 1st dose of Epi is given
Jeff with admin. says
According to the AHA ACLS guidelines, epinephrine should be give after the second shock during CPR. It is my experience that we give epinephrine as soon as we can, but this deviates from the AHA ACLS guidelines. I have had many discussions about this issue with a variety of health care professionals and their consensus is to give the epinephrine as soon as you can. The AHA chooses to place it after the second shock mainly because they want to deemphasize the importance as compared with high quality CPR and rapid defibrillation. Just make sure if you give it as soon as you can to not place its importance over high quality CPR and early defibrillation.
Kind regards,
Jeff
JDP says
Sir.
I have some question about using epinephrine during CPR .
first.
I want to know the right concentration of epinephrine during CPR.
The AHA guideline : Intravenous Push/IO: 1mg epinephrine IV is given every 3-5 minutes.
You suggest that epinephrine concentration should be 1:10000( 0.1mg/ml).
To keep your suggestion, we have to infuse diluted epinephrine 10ml every 3~5min during CPR
Is this way right?
Second.
What is the reason that epinephrine is used every 3~5min by bolus infusion not continuous infusion during CPR? I think that there are some benefit of continous epinephrine infusion during CPR .
If there is not difference between bolus and continuous infusion, we don’t need to check every infusion time and prepare next epinephrine. Is there a evidence that continuous infusion of epinephrine is worse than bolus infusion?
Jeff with admin. says
Question #1 answer: Yes that is correct.
Question #2 answer: There is not evidence to suggest that an infusion is any better than bolus administration every 3-5 minutes. Since the half-life of epinephrine is 5-10 minutes, giving 1mg bolus doses would be just as effective as continuous infusion. I’m not sure of any other details for why bolus dosing is preferred over infusion.
Kind regards,
Jeff
sam delarosa says
Dear Jeff
Its me again.
The ACLS protocol is to give 1:10000 dilution (1mg) of epi.
During cardiac arrest (the patient is dead) why can not we just push the 1:1000 dilution
and just followed up with 20mls normal saline?
is there any difference?
Thanks Jeff
Sam
Jeff with admin. says
The patient is dead, but you want them alive.
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.
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3%283%29/Pages/16.aspx
http://www.medicscribe.com/2010/05/24/medication-errors-epinephrine/
Kind regards,
Jeff
jette123 says
Jeff,
How do you dilute 1:1000 epi to 1:10,000 epi? How much normal saline would I use?
Thanks,
Chris
Jeff with admin. says
When diluting 1:1000 epinephrine to get 1:10,000, 1mg (1ml) can be diluted with 9 ml of NS to obtain the concentration of 0.1mg/ml or 1:10,000. Care must be taken that the epinephrine vial is not racemic epinephrine (inhailed epi) or epinipherine/lido 1% (used for injection for numbing agent)
1:1000 amp of epinephrine can be diluted to be given in a code but is usually avoided due to a high potential for error.
Kind regards,
Jeff
Jeff with admin. says
When diluting 1:1000 epinephrine, 1 mg (1ml) can be diluted with 9 mL of normal saline to obtain the concentration of 0.1 mg/mL or 1:10,000. Care must be taken that the epinephrine is I’ll is not racemic epinephrine (inhaled epi) or epinephrine/lidocaine 1% (used for injection of you numbing agent).
1:1000 ampule of epinephrine can be given in a code but is usually avoided due to a high potential for error.
Kind regards, Jeff
Paulo Kraemer says
Hi, Jeff
I understand that a push dose of epinephiene 1 mg in the 1:1000 presentation could be fatal in a living person, BUT, in a patient under cardiac arrest it is different, because the blood flow is much slower (around 80% slower) than the normal blood flow with a normal beating heart with a normal cardiac output, even with high quality chest compressions…
So, administering epinephrine 1 mg / 1:1000 (undiluted) instead of 1 mg / 10:0000 would pose no hazard at all, since the medication is followed by 20 ml NS bolus just after the administration. When this epinephrine reaches the central circulation, it will be already diluted, it takes from 1 to 2 min to reach the central circulation (even with high quality chest compressions), agaist the 8 to 10 seconds in a living person.
That’s what I think.
Regards
Jeff with admin. says
Epinephrine in a concentrated dose can cause significant vasoconstriction and therefore can increase the risk of worsening coronary ischemia. 1 Mg Epinephrine should be diluted in 10 mL of normal saline if it is not already premixed as most doses come on a crash cart.
This is one point where epinephrine can be a double edge sword. You have to weigh the risks of worsening coronary ischemia with the beneficial vasoconstrictive and chronotropic effects.
Dilute the epinephrine.
Kind regards,
Jeff
Scott Quick MICP, PM CCPM says
Giving Epinephrine by continuous infusion is like liquid pacemaker, While not recommended anymore by American Heart in the algorythms, It is still used by many old school E.R. Docs with great results. But I am just a doppie Paramedic, So the AHA wont listen to me. When the AHA did at least give it mention, we ignored the recommended dose. We put 30 Ml of 1:000 EPI. in 500 Ml saline and ran it at 125 an hour, (AHA Recommended) which gives you your 1mg. every 5 minutes. However, When we put the same 30 ml.Epi in a 250 bag and ran it nearly wide open, we were turning Asystole into V-Fib shockable rythyms. The one catch is once you get a rythym, shut the drip off or it will put them back into V-Fib. My partner and I had the highest save rate in our county. We finally admitted to our Medical Control Physician after him pestering us what we were doing. We told him the first aspect is that we better pick whom we were going to work, then explained our EPI theory. Out of 200 arrests we saved 192. He also began using it in the E.R. with similar results.A few of the other E.R. Docs began using with great results as well. However, the AHA conventions are sponsored for each aspect of ACLS a hard to get into with information, and are financially funded. Ask your Medical Control Authority to at least perform a field study of this dosing regiment for condideration in your protocols. Remember ACLS are gudelines not a bible for cardiac care……
Jeff with admin. says
Per AHA guidelines, epinephrine infusion is now considered an equally effective alternative to mechanical pacing. See the section on the bradycardia algorithm here.
Scott Quick says
I was referring to.continuous infusion during a cardia arrest. Either asystole or v-fib responds well to the infusion. The use of Bicarb earlier than suggested by the AHA is also excellent prior to the infusion. Even the AHA won’t deny that giving a catecholomine in an acidotic body witll most likely show futile results. The AHA needs to open up for suggestions by the people that handle arrests every day in the field.
Alexander Dejaco says
I am wondering about a few things that you mentioned:
192/200 saves, what does that mean?
that you brought them somehow “alive” to the ER (with rosc or still under compressions?)
and do you know the hospital discharge rate?
there is some evidence that the 1mg/4min is already generally much too high because it causes a lot of problems in the rosc phase and patient care afterwards/long-term and also worsens longer term outcome.
If your saverate is true, then I wonder if the endpoint of hospital discharge with good neurologic outcome is also above average.
192/200 is like 10000% above americas and europes positive outcome rate of cardiac arrest.
Also, did you count ALL cardiac arrest, or just those where immediate good quality bystander compressions were made?
I am sceptic that of your 200 cases all of them were witnessed arrests with immediate compressions.
Or if not, that even those patients that had no chest compressions for 5-10 minutes for example, still had a good outcome in like 90% of the time, by your courageous secretly change of dosing, not backed up by any literature.
Please let us know those details, I am very curious.
cheers
Alexander Dejaco says
I wanted to add that there is enough evidence that EPI increases ROSC, but actually worsens long term outcome. I can give you the references if you want. Have you looked into all the literature before trying your strategy (which is actually giving more epi than the guideline, right?)
best wishes,
cheers
Alexander
Ann says
Can Respiratory give Epi down the ET / Trach tube during a code. I was advised it wasnt in my scope of practice but have for years.
Jeff with admin. says
This can be give by an RT with a written or verbal order the same way as when you follow an order to give other medications like Albuterol, Atrovent, or NAC. Kind regards, Jeff
Jeff with admin. says
This can be given by an RT with a written or verbal order the same way as when you follow an order to give other medications like Albuterol, Atrovent, or NAC.
Kind regards,
Jeff