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.
Anjali says
Helloo
Recently I took BLS and ACLS course, had a small query. May i know why epinephrine only can be given after 2 shocks(Defibrillator) during cardiac arrest
Jeff with admin. says
The AHA has sent the first dose of epinephrine to be given after the second shock because there is a need to deemphasize the use of medications and emphasize the use of early defibrillation and high-quality CPR.
In an effort to deemphasize medications epinephrine was moved to giving the first dose after the second shock.
Do understand that the American Heart Association guidelines are simply recommendations. There are many providers that choose to give epinephrine as early as possible if they have a efficient team of providers that are working together during a code.
Chris Gage says
Here is a study that was done to emphasize giving Epinephrine early in a code situation.
https://www.ncbi.nlm.nih.gov/pubmed/25909945
Jeff with admin. says
Thanks for sharing this. Kind regards, Jeff
Jody says
I also just renewed my ACLS and they taught to give the epi right away after the first defib. I asked “are we supposed to wait til after the second shock to give epi” and they explained the reasoning there was most likely it’d take you that long to get the IV in anyway. But on Page 94 of the ACLS manual in the agorithm, you can see that’s not the case because for PEA/asystole they list epi in that first step along with the IV access, but they don’t do that for shockable rhythms. Anyway, a couple weeks after the class I sent them the study showing 12% reduced ROSC with early epi and she simply said, “Interesting, but we follow the AHA guidelines.” BUT … that’s not their guidelines. Right?
Jeff with admin. says
You are correct and your instructor is incorrect.
American heart Association ACLS guidelines call for the administration of epinephrine after the second shock when using the left branch (VF/pVT) of the cardiac arrest algorithm.
When using the right branch (asystole/PEA) of the cardiac arrest algorithm, epinephrine can be given as soon as possible.
Kind regards,
Jeff
Jani Sava says
In case on an cardiorespiratory arrest with clear signs of cerebral death what is the success percentage after using Epinephrine?And about the venous route of administration is possible to be efficient as the ceasing of the circulation ???
Jeff with admin. says
This may help with your understanding of epinephrine: Epinephrine Curse or Cure?
Kelvan says
I have recently been told that epinephrine are contraindicated among patients taking antipsychotic medications. They even recommend that it should not be given even in an arrested patient undergoing CPR.
This is my first time to hear such concern.
Could I ask for a comment regarding this? Thank you.
Jeff with admin. says
AHA has not developed a recommendation with regard to this issue. I also have never heard about this concern. I could not find any articles regarding this issue when related to cardiac arrest.
Kind regards,
Jeff
Jonathan B Jung says
I found this on https://www.medicines.org.uk/emc/medicine/22030 :
Antidepressant agents:
Tricyclic antidepressants such as imipramine inhibit reuptake of directly acting sympathomimetic agents, and may potentiate the effect of adrenaline, increasing the risk of development of hypertension and cardiac arrhythmias.
Although monoamine oxidase (MAO) is one of the enzymes responsible for Adrenaline metabolism, MAO inhibitors do not markedly potentiate the effects of Adrenaline.
N says
Hello, I’m a new nurse in ER.
I am confused in some dosages of Adrenaline. If we start CPR and give Adrenaline in adult. The doctor will order Adrenaline 1 mg IV stat. So will we dilute before administer or not? (Adrenaline 1 mg/1 ml)
Jeff with admin. says
You will need to dilute 1 mg into 10 ml of NS before giving IV. The adrenaline dose concentration for IV administration should always be 0.1 mg/ml.
Kind regards,
Jeff
simna says
Thanks Jeff, i am also an ER staff here also doctors not advice for dilution. my question is there is any side effects for direct administration.
Jeff with admin. says
Any epinephrine that is given IV push should be at a concentration of 1 mg/10ml which is 1:10,000. For safety of the patient, it should not be any more concentrated. Most premad (boxed) ER syringes come 1 mg in 10 ml. If you are pulling a prepackaged epi syringe that is for IV use, it is most likely 1 mg/10 ml (1:10,000).
I would refuse to give anything that is more concentrated than that. Here is an article about deaths from concentrated epi given IV.
Kind regards,
Jeff
Ryan Wyatt says
Hi Jeff,
We had a code that became ROSC. This pt. Responded to epi very well. We started an epi drip at 4 mcg/min but MAP was 20 so doubled the dose, repeatedly doubling it until we were at 64 mcg/min which kept the HR at 100 and MAP OF 68. ACLS has a dose of 0.1-0.5 mcg/kg/min. Is that the max? The physician capped it at 100 mcg/min.
Jeff with admin. says
American Heart Assn. attempts to set their guidelines/parameters based upon safety and effectiveness. The low end dosing would be for effectiveness and the high end dosing would be directed at safety and reducing the negative effects of an epinephrine infusion. I would say that in a code situation there are times when you diverge away from the guidelines and if you see something working then you would go with it.
In the process of “going with it”, you are remaining aware of the potent vasoconstrictive effects of epinephrine and monitoring for side effects. After stabilization, I can imagine that reduction of the epi infusion occurred as soon as possible.
Kind regards,
Jeff
kev says
1ml adrenaline into 9ml NS is correct is it not?
Jeff with admin. says
Yes. Thanks for the correction. Dilute 1ml of 1mg/ml epi into 9 ml of NS to get 0.1mg/ml. Thanks for pointing this out. Kind regards, Jeff
Tiravut says
Is there any study that shown the different outcome between administration of epinephrine every 3 minutes and every 5 minutes?
May be in some patients, e.g. who arrest from myocardial infarction, given more frequent epinephrine can worsen the outcomes because epinephrine can increase myocardial oxygen demand and worsen ischemia.
Thank
Jeff with admin. says
Thanks for the question. You asked:
“Is there any study that shown the different outcome between administration of epinephrine every 3 minutes and every 5 minutes?
May be in some patients, e.g. who arrest from myocardial infarction, given more frequent epinephrine can worsen the outcomes because epinephrine can increase myocardial oxygen demand and worsen ischemia.”
Reply:
I am not aware of any research between changes in outcomes outcomes related to the administration times for epinephrine within cardiac arrest.
I think that this would be worthwhile research.
Here are a couple of recent studies that have been performed and show that administration of epinephrine may be detrimental in cardiac arrest.
http://www.bmj.com/content/353/bmj.i1577
http://content.onlinejacc.org/mobile/article.aspx?articleid=2020181
Kind regards,
Jeff
Hilgendh says
Hi! In my “Fast Facts for Critical Care” book, it lists the gtt range for Epinephrine as 0.04-0.1mcg/kg/min. I see you list it as 0.1-0.5mcg/kg/min. Can you explain? I’m a new hire to critical care and have so much to learn!!!
Thanks
Jeff with admin. says
For post cardiac arrest treatment of hypotension, the AHA guidelines recommended an infusion dose of 0.1-0.5 mcg/kg/min.
For the treatment of symptomatic bradycardia, the AHA guidelines recommended an infusion dose of 2-10 mcg/min.
Remember, you are titrating these medications to achieve the desired effect. I’m not sure why they have listed 0.04-0.1 mcg/kg/min. I’m not sure if that is referring to the treatment of bradycardia or post-cardiac arrest hypotension. It may just be a general dosing for a variety of diagnosis.
Kind regards,
Jeff
Brendon Yeap says
Hi, I would like to know, as according to ACLS guideline 2015. is there a role of NAVEL drugs be given through the ETT?
Jeff with admin. says
If IV access is not available, any medication that can be administered via ET tube should be administered by that route if an ET tube is in place. Get an IO in place asap if IV access cannot be placed rapidly.
Kind regards,
Jeff
Evie says
My husband was taken to the emergency room, “unresponsive, no vital signs, fixed, dilated pupils”. ER resident ordered epinephrine 1:1,000mg. This was given via IV every 3 minutes according to the records, with the total of 21 ampules in the span of 2 hours. Basically, he was deemed DOA. Was this action prudent or just a panic attempt @ “resuscitating” him?
Jeff with admin. says
I’m so sorry to hear about your loss.
Epinephrine 1 mg IV is routinely given every three minutes during cardiac arrest.
The 1 mg dose can typically come in two forms 1:10,000 (most common). 1:10,000 is the dilution. This means that there is 1 mg in 10 mL of fluid.
The other concentration is 1:1,000. This means that there is 1 mg in 1 mL of fluid. For intravenous purposes, this needs to be diluted with 9 mL of fluid to make the concentration 1:10,000.
If a physician had to order 1:1,000 epinephrine it would have been the team’s responsibility to ensure that the epinephrine was diluted to 1:10,000.
All of that said, it’s unlikely that any of the ER interventions would have changed the outcome if your husband had been in the condition you stated above for more than 15 or 20 minutes prior to arrival in the ER.
If your husband was in cardiac arrest before arriving at the ER, epinephrine would have also been administered by the EMT crew.
Lynn, I will pray for you and your family as you go through this difficult situation. May God give you comfort and peace through our loving savior Jesus.
Kind regards,
Jeff
Marie says
Epinephrine iv push every 3-5 min
How many times?
Jeff with admin. says
There is no limit on the number of times that epinephrine can be given.
Kind regards,
Jeff
Concerned says
What would happen to a male about 220lbs if they took 1mg of 1:1000 pushed straight in the vein?
Helencats says
If using epinephrine IV infusion for post cardiac arrest hypotension for a 70kg adult, how would you calculate and set I vac. Thank you
Jeff with admin. says
The dose would be 0.1-0.5mcg/kg/min.
Therefore, you would take 70kg x 0.1 mcg and 70kg x 0.5 mcg. This would give you a range of 7-35 mcg/min. You would titrate this based upon what blood pressure you want to maintain. Usually, the order will read something like “titrate epinephrine drip to keep SBP > 90.”
Kind regards,
Jeff
Leticia says
Good day, how to administer epinephrine during cardiac arrest if our stock is 1mg/ml, do we need to dilute it into 9ml or can we give it without dilution? Thank u
Jeff with admin. says
The 1 mg/ml (1:1,000) should be diluted to 1 mg/10 ml (1:10,000). Therefore, you would need to dilute what you have with 9 mL of diluent.
Kind regards,
Jeff
Paulo Kraemer says
Hi, Jeff
The AHA CPR Guidelines only state that the epinephrine dose in CPR is 1 mg, they don’t mention anything about the dilution of the 1 mg presentation.
Could you please clarify the supposed need to dilute?
Thanks.
Jeff with admin. says
On crash carts, epinephrine will usually come pre-diluted. The proper dilution is 1 mg in 10 mL of normal saline for IV administration. This 10 mL mix should be pushed rapidly and then followed with a 10 mL normal saline push.
Kind regards,
Jeff
Astri says
I want to ask, bout the route of ephinephrin when the access of peripheral iv can’t be performed immidietly when someone get cardiac arrest,can intramuscular injection is given because the acls said that the route are IV,IO and endotracheal? And how about the dosage?
Jeff with admin. says
Intramuscular epinephrine cannot be given as a replacement for intravenous epinephrine. Intramuscular injections are absorbed very slowly. When epinephrine is used in a code situation, this must be a rapid intravenous bolus.
Epinephrine is given for its vasoconstrictive and chronotropic effects. If it is not given rapid IV bolus it will not be effective.
Also, epinephrine will cause tissue extravasation and necrosis if used intramuscularly.
Kind regards,
Jeff
Macarena Staudenmaier says
Hey Jeff, my question is Doesn´t IV Epi cause vasoconstriction of the arm blood vessels resulting distal necrosis? Or is this not true because of the low doses of Epi used during CPR? If so, wouldn´t another access be preferred?
Thank you
Jeff with admin. says
Epinephrine can cause significant vasoconstriction. This is a risk when giving epinephrine in a peripheral IV. This is also another good reason why you always follow the epinephrine with 20 mL of normal saline.
The objective is to get this into the central circulation as quickly as possible. Peripheral IV remains the preferred route for emergency administration of medications because of the ease of access.
Kind regards,
Jeff
Gleb Esin says
Adrenaline can be administered by peripheral veins for a limited time.
http://www.wessexics.com/The_Bottom_Line/Review/?id=6892495633638977747
mjs.bell@gmail.com says
Under ACLS drugs, you have epinephrine for v tach and v fib…this should only be for bradycardia, correct?
Jeff with admin. says
Your statement is incorrect. Epinephrine is used also within the cardiac arrest algorithm for its vasopressor effects. In the cardiac arrest algorithm, epinephrine is first give after the 2nd shock during CPR and then it is given every 3-5 minutes after that.
It is also used for the post cardiac arrest treatment of hypotension. The dosing in the post-cardiac arrest algorithm for the treatment of hypotension is 0.1-0.5 mcg/kg/min.
Kind regards,
Jeff
Doug Peterson says
Jeff –
I am curious about the reasoning/research behind waiting to give Epinephrine after the second shock. Is this to focus responders on compressions and shock or is there evidence of detrimental effects if given prior to the second shock?
Jeff with admin. says
Yes, you are correct. In an effort to focus efforts on compressions and defibrillation, medications have been deemphasized and are placed later in the algorithm to ensure that early and effective CPR + early defibrillation is carried out.
Remember these are just guidelines. In the unit where I work when there is a cardiac emergency, we have an efficient team that works in coordination. Just about everything that is done takes place simultaneously. Someone is performing CPR, someone is preparing for defibrillation, someone is pushing medications and others are providing assistance where it is needed. This allows for rapid movement through the algorithm.
Also, epinephrine has not been shown to improve survival to hospital discharge and therefore much less emphasis has been placed on it.
Kind regards,
Jeff
Doug Peterson says
Jeff –
I am also curious about why the AHA recommends waiting to give Amiodarone until after the 3rd cycle.
Jeff with admin. says
In an effort to focus efforts on compressions and defibrillation, medications have been deemphasized and are placed later in the algorithm to ensure that early and effective CPR + early defibrillation is carried out.
Remember these are just guidelines. In the unit where I work when there is a cardiac emergency, we have an efficient team that works in coordination. Just about everything that is done takes place simultaneously. Someone is performing CPR, someone is preparing for defibrillation, someone is pushing medications and others are providing assistance where it is needed. This allows for rapid movement through the algorithm.
Also, amiodarone has not been shown to improve survival to hospital discharge and therefore much less emphasis has been placed on it.
Kind regards,
Jeff