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.
Umut Gulacti says
Dear Jing Han,
I live in Turkey. There is confusion about adrenaline dose in cardiac arrest. According to European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support,
Adrenaline is available most commonly in two dilutions:
1 in 10,000 (10 ml of this solution contains 1 mg of adrenaline)
1 in 1000 (1 ml of this solution contains 1 mg of adrenaline).
Both these dilutions are used routinely in Europe. The epinephrine protocol that you are performing is not wrong scientifically.
Alfy says
If I have adrenaline amp 1:1000 how do I give (how to dilute ) in patient with cardiac arrest ? And what about the intracardiac injection of adrenaline and how to be given ?
Jeff with admin. says
If epinephrine is administered IV, it should always be diluted to 1:10,000 which equals 0.1mg/ml or 1mg/10ml. 1:1000 and Epinephrine = 1mg/ml so 1ml of 1:1000 epi would need to be diluted with 9 mL of water.
Intracardiac injection is no longer a recommendation from the American Heart Association. Kind regards, Jeff
Aman says
Jeff, I met you in San Jose with the WSS course. Thanks for your input during the program… One question about 1mg epinephrine IV push in a Cardiac Arrest situation…
Could you not give 1:1000 epi in 1ml dose using a TB syringe (1cc) to get the correct dosage amount of epi as alternative to diluting the 1:1000 to 1:10000.
Thanks
Aman
ACLS says
Yes, I remember you! It was great to meet you at the course.
Regarding your question about epinephrine. You would want to take the 1:1000 epinephrine and dilute that with 9 mL of normal saline. This would give you a 1:10,000 dosage of epinephrine.
You never should give undiluted 1:1000 epinephrine IV. This could make the patient’s condition worse and result in further cardiac ischemia.
Hope that makes sense. Please let me know if you have any other questions.
Kind regards,
Jeff
Jeff with admin. says
If epinephrine is administered IV, it should always be diluted to 1:10,000 which equals 0.1mg/ml or 1mg/10ml. 1:1000 and Epinephrine = 1mg/ml so 1ml of 1:1000 epi would need to be diluted with 9 mL of water.
Intracardiac injection is no longer a recommendation from the American Heart Association.
Kind regards,
Jeff
Zach says
Hello, my question is as follows:
I have been unable to find information online thus far, but what is the reasoning behind our dosing regimen of epinephrine 1:10,000 in cardiac arrest? For example, why not administer 1.5 mg at 3-5 minute intervals, or at a shorter interval such as 1-3 or 2-4 f
Jeff with admin. says
Since the half-life of epinephrine is 5-10 minutes you give the epinephrine every 3-5 minutes. This keeps the epinephrine at peak levels. Giving it outside of the 3-5 minute parameter allows the epinephrine levels in the blood to be either higher than needed or lower that needed.
Kind regards,
Jeff
Luke says
Where have you got this information from? Wondering why they have changed the timing from 3 minutes (CPG, 2016) to 4 minutes.
Jeff with admin. says
The AHA ACLS Guidelines call for the administration of epinephrine every 3-5 minutes during cardiac arrest. This is the AHA recommendation.
Kind regards,
Jeff
SARAH says
IF YOU GIVE THIS CONCENTRATION FOR AN ANAPHALACTIC REACTION, WHAT DOSE WOULD YOU GIVE?
Jeff with admin. says
The standard intramuscular dose is a 1:1,000 concentration. This should be given in the lateral aspect of the thigh by intramuscular injection. The dose can be repeated every 5 to 15 minutes, depending upon the response, for three to four doses. The same is true for children except the dose is 0.01 mg/kg
Kind regards,
Jeff
laura padron says
very much enjoy your website. I am often asked why Epinephrine as a first line with infants and children who have a symptomatic non-vagolytic bracycardia. My response is cardiac output augmentation. What is your response. Thank you
Jeff with admin. says
Bradycardia in adults is typically a result of cardiac ischemia. Bradycardia in children is typically a result of hypoxia. There are other causes but these are the primary causes.
Neither, atropine in adults or epinephrine in children treats the cause. In the case of the adult, atropine buys you time while the problem of cardiac circulation is addressed. In the case of the child, epinephrine buys you time while the airway problem is addressed.
My response would be, “yes it is for cardiac augmentation and also vasoconstriction which will help shunt the blood to the vital organs. The epinephrine will buy you time while you correct the underlying problem that causing the bradycardia.”
Kind regards, Jeff
Sadeq says
Hello
I have a query please.
In which cycle of CPR , i have to give epinephrine in patient with PEA or pulsless rhythem?
As soon as possible or from the 2nd cycle?
Jeff with admin. says
As soon as possible. Kind regards, Jeff
stephanie freeo says
Hi Jeff so if one had to prepare an epi drip are you utilizing the 1:1000 mg and diluting in 500 ml NS. My institution has 4 mg in 500 , we don’t typically stick epibdrips in our pyxis and in a code situation which is the proper one to use to prepare a drop. I’ve even seen it as high as 16mg in 500 ml ND. Obviously using the pump and picking the right concentration ensure accuracy but which one is being diluted for IV use?
Jeff with admin. says
There is not a “best” concentration to use for preparing an epinephrine drip. The most important point would be to ensure that you have properly mixed and identified how much epinephrine is diluted into your 250 ml or 500 ml diluent. The most common factor that would dictate what epinephrine concentration is used is the concentration that is on hand. 4mg epinephrine in 500 ml is pretty standard and this is what I have seen used regularly.
In a code you will probably be using what is available on the crash cart. If this is 1:10,000 then you would want to make sure that you remove 10 ml of NS from the diluent for every dose of 1:10,000 epinephrine that you put in.
Kind regards, Jeff
Amy says
What is the max. Dose of epinephrine in cardiac arrest?
Jeff with admin. says
The max dose to be given in a single dose it is 1mg.
If you mean total accumulative max dose, there is no total max dose.
Kind regards,
Jeff
Patricia P says
Why do you only do 2 minutes of CPR instead of 3 minutes, if epinephrine can only be given every 3-5 minutes? Why don’t you do compressions for 3 minutes for the epinephrine to circulate?
Jeff with admin. says
As far as I know, the administration of epinephrine has nothing to do with the length of time that CPR is performed.
2 minutes cycles of CPR was chosen to create continuity and standardization for professionals or non-professionals who are delivering CPR.
Also, if epinephrine is given at the beginning of a round of HIGH-QUALITY CPR then 2 minutes would be sufficient for it to achieve full effect.
Kind regards,
Jeff
Nor Faizah says
In our facility. We give epinephrine every 4 minutes or every 2nd pulse check which will be easier for the team to remember.
Vinay says
Epinephrine IV bolus is given as 1:1000 or 1:10000 dilution?
Jeff with admin. says
IV bolus is given as Epinephrine 1:10,000 which is 0.1 mg/ml
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
Jing Han says
Hi Dr Jeff, I am a junior Emergency Resident with only 2 years of experience. My friends and I cannot find any publications that insist on IV bolus of epinephrine in dilution of 1:10000. The current ACLS guideline only states that 1mg be given but it did not insist on dilution to 1:10000. However, the PALS did state that the pediatric dose be diluted to 1:10000.
Some other medical personnel stated this website: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3)/Pages/16.aspx
But the case stated here are not resus cases.
Because my hospital protocol always use 1:1000 1mg epinephrine IV push during resuscitation, I am greatly shocked when I learned of a different practice elsewhere. But I cannot find any substantial evidence. In the textbook 8thTintinalli page 164, it is stated that the epinephrine be diluted to 1:10000 but it did not site any reference. Using pubmed and google yielded no publications that compared the 2 different dosing or the perils of epinephrine 1:1000 IV push.
Dear Dr Jeff, I need help! With some back-up evidence, I can organize a meeting and highlight this issue and save lives!
Kind regards
JH
Jeff with admin. says
Hi Jing,
I have also searched for clear research that states what is recommended by the AHA regarding the concentration of epinephrine, and your reference is about the only “official” thing I could come up with. I have had other tell me that they use 1:1000 without harmful effect.
I do think that part of the reason why AHA makes the recommendation has to do with continuity. They want to ensure that there is standard continuity with the administration of the medication so they just say “everybody prepare epinephrine 1:10,000 (1mg/10ml) for administration within cardiac arrest. This keeps everyone doing the same thing and provides continuity.
I would encourage you to reach out to the AHA and discuss this issue since it is their recommendation that only 1:10,000 (1mg/10ml) be used for cardiac arrest. They possibly may be able to help point out the research that you are looking for.
Kind regards,
Jeff
Shaun says
My protocols here in east Texas use 1:1000 IV for cardiac arrest. Way different than I have done over the last decade.
Rodrigo Rabelo says
In 2016 what about epi endotracheral administration ? Is it in or out ?
Sounds confusing …
Jeff with admin. says
Yes epinephrine can still be administered via ET tube if IV access is not available.
Kind regards,
Jeff
Chris says
Good Afternoon
Is it permissible within these protocols, rather than using one dose of 1:10,000 epinephrine every 3-5 minutes, to hang an epinephrine drip? If you mix 10mg of 1:1000 epinephrine in 100mL and run at 3mL /min, it comes out to 1mg epinephrine every 3 minutes.
Thanks,
Chris
Jeff with admin. says
Within ACLS protocol this would not be permissible. The epinephrine should be pushed rapidly and followed with a 20 ml bolus of NS. The reason why the infusion is not acceptable is because the epinephrine needs to enter the central circulation as a bolus to achieve the desired effect. I have not heard of any studies that use an infusion of epi rather than the every 3-5 minute boluses. Kind regards, Jeff
Diego Carrington says
How is the epinephrine dose calculated for neonatal / pediatric patients?
Jeff with admin. says
It is calculated by weight.
For cardiac arrest and bradycardia it is 0.01 mg/kg (0.1 mL/kg of 1:10 000 solution) maximum of 1 mg (10 mL)
For hypotensive shock it is: 0.1 – 1 mcg/kg/min
Kind regards,
Jeff
Mueanthep Chomvilailuk says
if the patient have central line, do I have to dilute adrenaline to 1:10,000?
(In cardiac arrest)
Thank you
Jeff with admin. says
Yes, you must dilute epinephrine to 1:10,000 (0.1mg/ml). Kind regards, Jeff
Esmaeil says
But why exactly?? What are its physiological reasons? Does it cause peripheral or central damage? How? how dangerous are them? What about the time we spend diluting??! Especially when we have ACLS in pre-hospital setting, two or one nurse, is it worth it?! Please give me a suitable answer with a link or reference book. Thank you very much ma’am/sir.
ACLS says
Administering epinephrine more frequently than every 2 minutes during cardiac arrest is not recommended because it may lead to excessive vasoconstriction, potentially compromising blood flow to vital organs. The 2-minute interval allows for better balance in supporting circulation without causing harmful effects.
Kind regards,
Jeff
Naashi says
Why do we need to give epinephrine 1mg IV every 3 minutes or every 5 minutes? what if it is given other than the required minutes?
Jeff with admin. says
Since the half-life of epinephrine is 5-10 minutes you give the epinephrine every 3-5 minutes. This keeps the epinephrine at peak levels. Giving it outside of the 3-5 minute parameter allows the epinephrine levels in the blood to be either higher than needed or lower that needed. Kind regards, Jeff