Pediatric Adrenaline Dosing per PALS Protocol
The recommended dose of adrenaline (epinephrine) for pediatric cardiac arrest according to PALS is 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) administered intravenously or intraosseously, with a maximum single dose of 1 mg, repeated every 3-5 minutes. 1, 2, 3
Route-Specific Dosing
IV/IO Route (Preferred)
- Dose: 0.01 mg/kg
- Concentration: 1:10,000 (0.1 mg/mL)
- Volume: 0.1 mL/kg
- Maximum: 1 mg per dose
- Frequency: Every 3-5 minutes during ongoing cardiac arrest 1, 4, 2, 3
Endotracheal Route (Only if IV/IO access unavailable)
- Dose: 0.1 mg/kg (10 times the IV dose)
- Concentration: 1:1000 (1 mg/mL)
- Volume: 0.1 mL/kg
- Maximum: 2.5 mg per dose
- Technique: Flush with 5 mL normal saline and follow with 5 positive-pressure ventilations 4, 2
Critical Implementation Points
The IV/IO route is strongly preferred over endotracheal administration. Evidence shows that endotracheal epinephrine achieves lower drug concentrations and may produce transient β-adrenergic vasodilating effects that can cause hypotension and reduced coronary perfusion 4. While some studies suggest endotracheal administration can be effective, particularly in infants 5, the IV/IO route remains the gold standard.
Timing Algorithm
- First dose: Administer immediately after obtaining vascular access during CPR
- Subsequent doses: Every 3-5 minutes throughout resuscitation
- Do not delay: If IV/IO access is not established, use endotracheal route rather than withholding epinephrine 4, 2
Weight Estimation When Actual Weight Unknown
Use a length-based resuscitation tape (e.g., Broselow tape) with precalculated doses—this is more accurate than age-based or visual estimates 4, 3. These tapes approximate weight within 10-20% of actual body weight and are validated for clinical use 3.
Common Pitfalls to Avoid
High-Dose Epinephrine
Do not use high-dose epinephrine routinely. The 2010 and subsequent PALS guidelines explicitly state that high-dose epinephrine (>0.01 mg/kg IV) is not recommended and may be harmful, particularly in asphyxial arrest 4. High-dose epinephrine showed no survival benefit and potential harm in pediatric studies 4.
Dosing in Obese Children
Use actual body weight for epinephrine dosing, not ideal body weight 4. While there are theoretical concerns about dosing in obesity, there is insufficient evidence to support dose adjustments, and using ideal body weight could result in underdosing 3.
Maximum Dose Confusion
The 1 mg maximum corresponds to a patient weight of 100 kg 6. However, practice patterns vary widely—surveys show only about half of institutions follow PALS guidelines precisely, with many transitioning to flat dosing at weights between 50-80 kg 6. Stick to the guideline: use weight-based dosing up to 100 kg, then cap at 1 mg.
Route-Specific Concentration Errors
This is a critical safety issue:
- IV/IO uses 1:10,000 (more dilute)
- Endotracheal uses 1:1000 (more concentrated)
Administering the wrong concentration via the wrong route can result in either severe underdosing or life-threatening overdose 1, 4, 2.
Special Considerations
Anaphylaxis Dosing (Different from Cardiac Arrest)
For anaphylaxis, the dose is 0.01 mg/kg IM (maximum 0.3 mg for children <30 kg, maximum 0.5 mg for children ≥30 kg) using 1:1000 concentration, repeated every 5-10 minutes as needed 7, 8. This is distinct from cardiac arrest dosing.
Dosing Interval Evidence
Recent evidence suggests that epinephrine dosing intervals <3 minutes are associated with improved return of spontaneous circulation and shorter CPR duration, though not necessarily improved neurologic outcomes 9. The standard 3-5 minute interval remains appropriate, but avoiding delays beyond 5 minutes is important 9, 10.
Sustained ROSC Considerations
Studies show that the mean first epinephrine dose in patients achieving sustained ROSC is approximately 0.011 mg/kg, supporting the current standard dose recommendation 5. Higher initial doses (>0.01 mg/kg) were associated with failure to achieve sustained ROSC 5.