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.
Sarmad says
Recently, faced a situation, we received epinephrine injections -labelled as “for intramuscular”. I don’t know is this injection safe to use intravenously.
Jeff with admin. says
You would need to make sure that the concentration of the epinephrine was suitable for intravenous injection. Only 1:10,000 should be given intravenously. Typically epinephrine for intramuscular injection is 1:1000 and is used for the treatment of anaphylaxis.
The concentration would be the reason for the contraindication. At the concentration of 1:1000 you would not want to give the epinephrine intravenously.
Kind regards,
Jeff
rajesh bhavsar says
In newborn resucitation , its advised to give CPAP before starting cardiac massage as it is hypoxia which is the cause of heartstop. In a situation where there are two doctors like anaesthetist and neonatologist present at the time of resucitation and neonatologist is struggling to ventilate the newborn because of meconium aspiration, should the anesthetist wait to secure iv access and start cardiac massage ( when there is heart activity below 50 beats / minutes) until the 5 breaths are been succesfully delivered ?
Jeff with admin. says
Focus on treating the hypoxia, clearing the airway, and chest compressions if necessary. The IV mill come later if the interventions do not correct the problem.
Kind regards,
Jeff
Dr Ihsanulhaq Misgar says
How many times we can repeat giving epinephrine boluses during ACLS?
Jeff with admin. says
There is no maximum limit on the number of doses of epinephrine that can be given during ACLS treatment of cardiac arrest.
Kind regards,
Jeff
nadka says
whould giving 1:1000 of epi during cardiac arrest undiluted cause harm vs benefit in ROS? please explain
Jeff with admin. says
It could cause harm. Here’s why. 1:1000 epinephrine is very concentrated. The higher the concentration in a rapid bolus dose, the stronger the effect of vasoconstriction.
When dealing with cardiac arrest, you want some vasoconstriction for the purpose of improving blood pressure (preserving end organ function), but this must be weighed against the risk of coronary arterial constriction. Excessive coronary arterial constriction caused by epinephrine may worsen ischemia and ultimately lead to more cardiac tissue damage.
So if you give a concentrated bolus dose of epinephrine 1:1000 this will increase the likelihood of excessive coronary arterial constriction and increase the risk of worsening ischemia.
Kind regards,
Jeff
Sid says
I think cardiac tissue damage can be taken care of later on in post cardiac arrest care. the point is you have to get that ROSC first, or shall i say survive the patient first and then rectify cardiac tissue damage later on with medication to improve circulation to the affected area. surgery is the last resort if deemed necessary.
Jeff with admin. says
The main reason why I would disagree with this is because there has been no evidence showing that epinephrine improve survival to hospital discharge.
By giving high concentration epinephrine or extreme doses of epinephrine, it is likely that you are going to exacerbate the problem and not achieve ROSC.
There is some evidence that ROSC improves with epinephrine, but there is no change in survival to hospital discharge.
Kind regards,
Jeff
nadka says
Thank you for clarifying Jeff.
J-Paul says
Hi Admin …just clarification
Doesn’t Epinephrine at higher dose have affinity for beta-2 receptors on coronary arteries (contrary to peripheral where they bond to Alpha-1) and thus cause coronary vasodilation ?
Khatoon says
Hi,, iam from Saudi Arabia
I would like to aske what is the maximum dose of adrenaline if patient hypotensive and his weight is 88Kg ??
Jeff with admin. says
The dosing of epinephrine for post-cardiac arrest hypotension is 0.1-0.5 mcg/kg/min. So you would calculate the dose by taking 0.5 µg/kg/minute X 88 kg.
So the maximum dose would be 44 mcg/min.
Kind regards,
Jeff
Milton says
Hello,
is there a certain time that you should give the first dose of epinephrine? For example, should you give compressions for at least 2 minutes and then administer the first dose?
Thanks
Jeff with admin. says
For PEA/Asystole, the first dose of epinephrine is given as soon as possible.
For pulseless VT and VF, the first dose of epinephrine is given after the 2nd shock during CPR.
(Never delay CPR for the administration of any medication)
Kind regards,
Jeff
Ernest says
Thank you for the answer. To seek clarification,does this mean that we should try to assess rhythm(e.g Via AED) before adrenaline administration?
Jeff with admin. says
Yes, the rhythm should be identified prior to the administration of medications. Rhythm identification is critical for treatment within ACLS protocol.
Kind regards,
Jeff
Hanif says
Im from southest asian country
Im just wanna ask you
It is any complications if im given thr patient iM adrenaline first if pt suddenly no pulse,no breathing,cardiac monitoring show asystolea because we cannot get iv cannulation and we cannot get ett tube on the first 10 minutes.It is wrong about the route.This pt was survive but in critical impression,he get symptoms like APO but cannot treat he as ACS because of ECG was normal,that show Sinus Rythm,It is any research about IM adrenaline,and im not asking about anaphylatic shock.But im asking about cpr person that contribute from BLS and ALS route…
Hope u can answer my question…thanks
Jeff with admin. says
Some literature has shown that IM route may have similar affects for the treatment of cardiac arrest. If no other route for the administration of epinephrine is avaliable, this could be a possible solution. There should not be any differrent complications whether the epinephrine is delivered IV or IM. Tissue injury around the site of injection may be the only possible long term side effect.
Kind regards,
Jeff
Ryan says
If a patient is on a max dose of continuous epinephrine (as well as other vasoactive drugs) prior to arresting, is there any literature that supports NOT administrating additional epi 1 mg IVP every 3-5 minutes? I am dealing with providers that give the rationale that all the receptors are “filled up” and additional epi pushed rapidly would not have any added benefit. I can’t find literature supporting either sides of this topic. AHA’s GWTG-R patient management tool, when inquiring about the administration of Epinephrine bolus, asks if there is a documented medical reason why a bolus was not administered in the first 5 minutes of the arrest. One of these choices state “Patient already receiving vasopressor (e.g. Epinephrine) as a continuous IV infusion prior to and during arrest” Do you think this is their way of saying it is an acceptable reason, or do you think they are asking that as part of their research (or both)? I have tried to reach out to AHA for clarification, but nobody wants to take an official stance on the topic.
Jeff with admin. says
In the situation, you describe there is no literature to support or refute the administration of vasoactive medications by IV push when a continuous infusion of epinephrine is already being given. If the patient was on a max dose of continuous epinephrine at the time of cardiac arrest, the surgeon would not be wrong to withhold the epinephrine pushes. He also would not be wrong to give the epinephrine pushes. There is just no literature to support or refute either.
Remember, epinephrine has never been shown to improve survival to hospital discharge. It has been shown to improve ROSC, but no survival to hospital discharge. If a person is maxed out with an epinephrine infusion, it is very unlikely that the administration of more epinephrine is going to improve the situation.
Kind regards,
Jeff
j-paul says
For post-cardiac arrest use.how would one dilute epinephrine for infusion?
Jeff with admin. says
Dilute 4mg of Epinephrine in 250 ml of NS OR D5W
This gives you a concentration of 16 mcg/ml.
Kind regards,
Jeff
Kim says
Based on experience …i just want to clarify why on earth will an ER stop resuscitation upon receiving from paramedics when there is an agonal / bradycardic rhythm- no pulse. They state that there is no signs of life so they stop resuscitation and said that its only the medication and cpr of paramedics causing the rhythm. But isnt that the point of giving adrenaline?!?!
Jeff with admin. says
I would need to know a bit more of the situation. How long had CPR been going? What was the rhythm? Was the patient intubated? I agree with your statement that “no signs of life” is not a very good criterion since you started with a dead person.
If these paramedics would intubate and then monitor ETCO2 this would remove any doubt as to whether they should stop CPR. Persistently low ETCO2 readings > 10 mmHg during CPR in intubated patients after 20 mins have essentially zero survival.
Kind regards,
Jeff
Day says
Hi
I want to know if it IS posible yo use epinephrine And norepinephrine infusion pure without dilution
Like in a 30kg patient order norepinephrine (4mg/cc) pure 1cc/hr
( 0,55mcg/kg/min) or it always need dilution?
Also The manufacturer recommmends norepi only in dextrose or dextrosaline
Whats your experience with saline?
Jeff with admin. says
Both epinephrine and norepinephrine must be diluted before they are given.
Epinephrine and norepinephrine both cause significant vasoconstriction and this is exponentially compounded when the medication is given in its concentrated form.
Both must be diluted.
The manufactures instructions for dilution should be followed. Sometimes things like the formation of precipitate can happen when manufacturer instructions are not followed.
Kind regards,
Jeff
Carlos says
Can epinephrine And norepinephrine infusion be given “pure” without dilution
Example in a parient 22kg
Put norepi pure at 0,5 Cc/hr (0,38 mg/kg/min). ???
Jeff with admin. says
Both epinephrine and norepinephrine must be diluted before they are given.
Epinephrine and norepinephrine both cause significant vasoconstriction and this is exponentially compounded when the medication is given in it’s concentrated form.
Both must be diluted.
Kind regards,
Jeff
Risa says
Hi Jeff, could we give atropine for bradychardia patient with cardiogenic shock due to acute MI ? It takes a while for me to take dopamine, in the hospital i worked in . Thank you
Jeff with admin. says
You would NOT want to give atropine for bradycardia caused by cardiogenic shock due to acute MI. This would significantly increase the oxygen consumption of the heart and could potential he worsen the MI.
The best alternative in this type of situation would be to use transcutaneous pacing until PCI can be implemented.
Kind regards,
Jeff
Jody Nitz says
I have been teaching ACLS and PALS for years.
In an inpatient setting, why should the ACLS/PALS team wait until after the second shock to deliver EPI?
In the hospital this is generally given ASAP after the first shock. AHA says this is wrong. Most hospital staff wonder why as the patient already has an IV in place which is what the card says to work on after the first shock.
Any science behind this?
Jeff with admin. says
I’ve never seen any actual studies looking at this specific criteria only (epinephrine immediately or after the second shock).
The primary reason that I have heard several times is AHA wants to emphasize the importance of initiation high-quality CPR and early defibrillation. In order to do this, they deemphasize the use of medications.
They also stress that in the hospital setting, the actions can be tailored according to the teams capabilities which means that you actually can give epinephrine whenever the team teams yet reasonable, but I have not seen specific science on this either.
It has also been my experience that epinephrine is given as soon as possible at the teams discretion for both branches of the cardiac arrest algorithm.
In 2015, American Heart Association did make a change in the right branch of the cardiac arrest algorithm (PEA and asystole) which allows for epinephrine to be given as soon as IV access is available. However, for the left branch of the cardiac arrest algorithm (VF and pVT) it remains to be given after the second shock during CPR.
Kind regards,
Jeff
Rosalinda Gumapac says
Hi Jeff! How often do we need to give epi during cardiac arrest?
Thank you!
Jeff with admin. says
After the first dose, Epinephrine is given every 3–5 minutes.
Kind regards,
Jeff