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.
Marlynnz says
Hi jeff
Thanks for your excellent web. It helps me a lot.
In your opinion, which inotropic support best for cardiogenic shock. Im in dilemma between adrenaline and dobutamine.
Thank you in advance.
Jeff with admin. says
Since cardiogenic shock is a result of myocardial dysfunction, the main objective of treatment is directed at improving cardiac function and cardiac output to restore adequate oxygen delivery to peripheral tissues. Another important objective is to minimize myocardial oxygen demand.
Any drug that causes an increase in systemic vascular resistance (SVR) (afterload) should be avoided. This Includes phenylephrine and norepinephrine which both cause potent vasoconstriction.
Improve cardiac function:
The most effective way to improve cardiac function in the presence of cardiogenic shock is to reduce SVR. Medications which improve myocardial contractility and reduce SVR include dobutamine, milrinone, dopamine and epinephrine.
Nitroprusside, which is a pure vasodilator, may be of benefit for reducing the high systemic vascular resistance associated with cardiogenic shock. However, it may be necessary to use dopamine or epinephrine to improve perfusion pressure when nitroprusside is administered.
Diuretics may also be used if there is evidence of pulmonary edema or systemic venous congestion. Diuretics help reduce fluid overload in the vascular space.
Myocardial Oxygen Demand:
Another important aspect to the treatment of cardiogenic shock is the reduction of myocardial oxygen demand. This can be achieved by support with intubation and mechanical ventilation, maintenance of a normal temperature, and patient sedation.
Kind regards, Jeff
Herman says
Hello. I am confused to read that: “Medications which improve myocardial contractility and reduce SVR include dobutamine, milrinone, dopamine and epinephrine.”
Can you explain it in more details, please! How for example epinephrine reduces SVR?
Jeff with admin. says
These medications are dose-dependent. I will focus particularly on epinephrine and dopamine since those are primarily used in a dose dependent manner for ACLS.
Epinephrine and dopamine can be given as a low-dose infusion and when they are used in this way, they can increase myocardial contractility without significantly increasing systemic vascular resistance.
The effects of a low-dose infusion of epinephrine or dopamine can even help reduce SVR to help decrease the oxygen demand an ischemic heart.
Kind regards,
Jeff
Mustafa says
Hi Jeff
I confuse in cardic arrest regarding epi 1:1000
Only we have 1:1000 is it need to dilute with 9 ml NS ???
.. If 1:10000 epi available it is recommended also to dilute it with 9 ml NS. or no ??
Jeff with admin. says
1:1000 epinephrine is 1 mg of epinephrine in 1 mL solution.
1: 10,000 epinephrine is 1 mg of epinephrine in 10 mL solution.
When giving epinephrine intravenously, you need to dilute 1:1000 epinephrine in 9 mL of additional solution to have an equivalent of 1 mg epinephrine in 10 mL of solution.
If you already have 1:10,000 epinephrine then you do not need to dilute any further. 1:10,000 epinephrine is 1 mg of epinephrine in 10 mL solution
Kind regards,
Jeff
Mustafa says
Hi
1:10000 epi only we have in ampule 1mg/ml
My question ; do we need to dilute this ampule with NS or not will give direct…!!!
Jeff with admin. says
Dilute it with 9 ml of NS. Kind regards, Jeff
Mustafa says
Thx Jeff,,
That mean we have to dilute 9 ml NS for both ampules 1:1000 epi ( 1mg/ml) and 1:10000 epi ( 1mg/ml) ..
Am I right…!!???
Jeff with admin. says
Only dilute 1:1000 Epi. When you dilute the 1:1000 Epi. That makes it 1:10,000
1:1,000 Epi = 1mg/1 ml
1:10,000 Epi = 1mg/10 ml
Does that make sense?
Kind regards, Jeff
Mustafa says
Hi Jeff
Still not clear for me.
My question; 1:10000 epi ( we have ampule 1 ml ) actually it is 0.1 mg/ml. However, This ampule contains 1ml volume so need to dilute or not ..
Or will give direct IV ..
Jeff with admin. says
You can give that direct IV.
You will need 10 of those ampules to equal 1 mg of epinephrine which is the recommended dose for administration with the adult cardiac arrest algorithm.
I’m not sure if that would be the most effective and efficient way to utilize epinephrine by having to draw up 10 ampules in a single syringe.
Kind regards,
Jeff
Martin Etcheverry says
Hi There!
I do have a silly question: I’m from Argentina, and over here we usually utilize only 1ml – 1mg – 1:1000 epinephrine concentrations during a cardiac arrest. It would be better to use 10ml – 1 mg – 1:10000? Are there any studies about that? Thanks a lot!
Jeff with admin. says
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.
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
rajlaxmi madhukumar achari says
hey jeff…. i have a question how much epinephrine maximum doses can be used in adult cardiac arrest case.where a cpr last for4 hours…
Jeff with admin. says
Epinephrine may be administered every 3-5 minutes as long a a code persists. The half life of epinephrine is 3 minutes so it does not build up in the system. There is no total maximum dose. The max individual dosing for cardiac arrest is 1mg administered every 3-5 minutes.
Kind regards,
Jeff
Crystal says
Patient came in with normal vitals. rash and chest complaint. Nurse gave 1/1,000 .7mg IV push. patient is now in ICU 20% heart function, was vomiting and coughing up blood instantly, before going unconscious.
Jeff with admin. says
1:1,000 epi is only supposed to be given Sq or IM.
1:10,000 is for IV administration.
I don’t think the coughing blood was related but 1:1,000 can definitely put a person into cardiac arrest, tachyarrhythmias, or at the least cause cardiovascular compromise due to the major vasoconstrictive and inotropic effects.
Kind regards,
Jeff
Eileen says
For adult ACLS they say give 1mg of Epinephrine every 3-5 minutes. If I have 1:10,000 epi syringe, do I give the whole 10mls and then flush with NS? Also, I’m confused in the amount of Epi for PALS.
For example the PALS tape says for a child with a KG of 30 give 0.33mg of Epinephrine 1:10,000, it says 3.3mls. Am I giving a whole 3.3mls of a 10ml syringe of 1:10,000?
Jeff with admin. says
Question 1: Yes, you would give the whole 10 mL of 1 mg epinephrine and then flush with 20 mL of normal saline.
Question 2: Yes, you would give 3.3 mL of the 10 mL syringe and then follow that with 20 mL of normal saline.
Kind regards,
Jeff
Kelly Christoff says
Hi Jeff,
would you agree that while the Code is in progress (ie chest compressions ongoing) that starting ANY vasopressor as an infusion is pointless whether epinephrine, phenylephrine, levophed etc?
Instead should be continuing with epi 1 mg IV/IO direct q 3-5 minutes. Have had a couple of team leads ask us to start infusions before ROSC.
thanks,
kelly
Jeff with admin. says
I agree. There is no research that supports this as an effective treatment before ROSC.
It is not recommended within the American Heart Association guidelines to start any type of vasopressor infusion until after ROSC occurs.
The focus should be on high-quality chest compressions, early defibrillation when needed, the administration of epinephrine 1 mg every 3 to 5 minutes, and a thorough search for any underlying factors that could have precipitated the cardiac arrest.
Kind regards,
Jeff
Amir says
If epinephrine is administered by an intramuscular injection using a device similar to an insulin pen, would it make administering more convenient for users? And what would be the recommended dosage? Based on my thinking, the dosage would be greater, as the diffusion of the epinephrine would reduce the amount entering blood vessels. Or is there something I am missing? And what other considerations I must take into account?
Jeff with admin. says
In cardiac arrest emergency situations epinephrine should not be given IM. Epinephrine should only be given by rapid IV/IO push.
The IM onset of action and absorption would be too slow for the treatment within the cardiac arrest algorithm.
Kind regards,
Jeff
Hartarto says
Hi Jeff, i have a question
In my case after post resuscitation ( female/ 65 yo with asistole, and after three times got ephinephrine with intubation ) does we need ephinephrine drip or with syringe pump ? For tappering off the effect of ephinephrine during the code
And what dose should we start to maintenance the bloodpressure, in my experience the BO often drop after resuscitation with ephinephrine, SHOULD We start from 0.5 mcg/kg/min and go down slowly ? Every SBP > 120 mmhg or when we decrease the dose ?
Jeff with admin. says
You will use an epinephrine drip. In practice, I have seen both starting with 0.5 mcg/kg/min and taper down, and I have seen starting with 0.1 mcg/kg/hr and tapering up for effect. The objective is typically keep the MAP < 65 mmHg. Kind regards, Jeff
Robin Rothrock MD says
Jeff,
Could you clarify the strength to give via ETT route if an IV could not be established; please clarify for adult, pedi, and neonate. I have read literature elsewhere today which says to use twice the dose of 1:10,000 and to then dilute it in 9ml of NS. Do they mean use twice the dose of 1:000 and then dilute with 9ml? Other literature says to use the same strength as IV route (1:10,000) and put it in the ETT. Please clarify how to use both strengths via ETT for Adult, ped, and neonate and the wait time between another dose.
Sincerely,
RR
Jeff with admin. says
In adult, pedi, and neonate use 1:1000 epi and dilute in 10 ml of NS.
Example: So if you give 2.5 mg of epi, this would be 2.5 ml of medication and add this to 7.5 ml of NS.
1:10,000 would not be ideal for the ETT since you would need to place such a large volume of fluid.
Kind regards,
Jeff
Preston says
Jeff I had a question.
If all you had was 1:10,000 epinephrine as 1mg in 1mL syringe and someone was having an anaphylactic reaction, there would be no harm in giving 0.3mg IM into the thigh with this concentration correct?
Jeff with admin. says
I don’t understand your question. 1:10,000 epinephrine is by nature 0.1 mg per ML.
1:1000 epinephrine is 1 mg per ML.
If you gave .3 mg of 1:10,000 epinephrine you would be giving three ML’s.
Kind regards,
Jeff
Susan Devlin-Varin says
Hi Jeff;
In a cardiac arrest situation, all you have is 1:000 (1mg) of epinephrine available. Other than the concentration, why would it be any different than 1:10,000 (1mg). It’s all 1mg. Please exclude safety, etc. It’s an arrest situation and all you have is 1:1000 (1mg). Yes you can push it 5 seconds faster than 1:10,000. But I would think 1mg would be 1 mg. Please keep in mind, I wholeheartedly agree that 1:10,000 is best, but what if you don’t have it (true situation).
Jeff with admin. says
In that situation, you would dilute the 1:1000 epinephrine with 9 mL of normal saline to make it 1:10,000. Then push the medication and follow it with 20 mL NS.
Here’s the reason. Highly concentrated epinephrine causes potent coronary vasoconstriction. This could actually worsen cardiac ischemia.
The desired effect that you want to achieve from the epinephrine is the vasoconstriction to improve end organ perfusion. The more diluted epinephrine will help provide this affect.
Kind regards,
Jeff
Suchan says
As u mention that via iv route, epinephrine is given 1:10000 then in cardiac arrest via Iv 1:1000 or 1:10000 concn is given i am a bit confused… then if 1:1000 concn can’t be used then why ? Pls will u explain
Thanks with regards
Jeff with admin. says
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.
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
Erik says
During a code,when the doctor decides to start epinephrine drip,what usually is the rate for a standard 4 mg/250 bag?
Jeff with admin. says
An Epinephrine drip would only be started in the post cardiac arrest phase. The dosing for BO maintenance is 0.1-0.5 mcg/kg/min (for example a 70kg adult: 7-35 mcg/min would be given).
During a code 1 mg of epinephrine is given IV push every 3-5 minutes.
Kind regards,
Jeff
Jacquie Palmer says
Hi Jeff,
At my hospital they will start an Epi drip during a code but still push 1mg during the code per the acls time interval. Is that beneficial one way or the other? Does it really make a difference to push 1 mg while the drip is going at a rate of 80-100 (mcg or mg sorry I can’t remember which setting). Thks in advance
Jeff with admin. says
It probably won’t make that much of a difference to have the epinephrine infusion running.
The only thing that could possibly happen is that you could end up with more vasoconstriction that you want. Also, if a patient is having cardiac arrest from ischemia this might make the ischemia worse.
It’s unlikely to make much of a difference and I do not know any literature that supports what the hospital is doing.
Kind regards,
Jeff
Dheeraj Bhardwaj says
Hi Jeff
My question is if a patient with acute MI and having So2 75% having sinus tachycardia be administered with epinephrine at a primary health center where incubation facility is not available only oxygen is available what can be done in such situations
Kind regards
Dheeraj Bhardwaj
Jeff with admin. says
I need to clarify on a couple of things.
I’m going to restate your question with the given scenario. You have a patient with an acute MI and his oxygen saturation is 75%. The patient cannot be intubation due to limited resources. What can be done in the situation?
Am I understanding your question correctly?
I also need a little more information. PCI would be the main intervention that should be performed at this time. Are there resources available to perform PCI?
Kind regards,
Jeff
Iyad says
Greetings
Thank you so much for the excellent information.
My question if the rhythm change from Shockable to non shockable and still 3 minutes not pass from the last dose. So can we give or we should wait until till 3 minutes passed.
Jeff with admin. says
Wait until three minutes have passed. The three minute time delay between doses is related to the half-life of epinephrine. It would not be necessary to give the epinephrine until the three-minute mark because the epinephrine has not been metabolized fully and is still available in the circulatory system.
Kind regards,
Jeff