What is the protocol for administering epinephrine (Epi) for anaphylaxis during cardiac arrest outside of a hospital setting?

From the Guidelines

Epinephrine should not be used for anaphylaxis during cardiac arrest outside the hospital, instead, focus on high-quality CPR and standard cardiac arrest protocols. For cardiac arrest, use epinephrine 1 mg IV/IO every 3-5 minutes as part of standard advanced cardiac life support (ACLS) protocols, as recommended by the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. This is a higher dose than used for anaphylaxis. If anaphylaxis is suspected to have caused the arrest, continue CPR and ACLS protocols, including standard-dose epinephrine. Once return of spontaneous circulation (ROSC) is achieved, then consider additional anaphylaxis treatments like antihistamines or steroids.

The rationale is that during cardiac arrest, maintaining circulation through CPR and following established ACLS algorithms takes priority. The higher dose of epinephrine used in cardiac arrest is already addressing the cardiovascular effects of anaphylaxis. Focusing on anaphylaxis-specific treatments during active cardiac arrest could distract from critical resuscitation efforts. According to the American Heart Association guidelines, there is no proven benefit from the use of antihistamines, inhaled beta agonists, and IV corticosteroids during anaphylaxis-induced cardiac arrest 1.

Some key points to consider when administering epinephrine in this context include:

• The recommended dose of epinephrine in anaphylaxis is 0.2 to 0.5 mg (1:1000) intramuscularly, to be repeated every 5 to 15 min as needed 1.
• In patients with anaphylactic shock, close hemodynamic monitoring is recommended 1.
• IV infusion of epinephrine may be considered for postarrest shock in patients with anaphylaxis, but this should not take priority over standard ACLS protocols 1.

Overall, the priority in cardiac arrest due to anaphylaxis should be to follow standard ACLS protocols, including the administration of epinephrine at the recommended dose for cardiac arrest, rather than anaphylaxis-specific treatments.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION Inject Adrenalin® intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary.

The injection may be repeated every 5 to 10 minutes as necessary Adults and Children 30 kg (66 lbs) or more: 0.3 to 0.5 mg (0.3 mL to 0. 5 mL) of undiluted Adrenalin® administered intramuscularly or subcutaneously in the anterolateral aspect of the thigh, up to a maximum of 0.5 mg (0.5 mL) per injection, repeated every 5 to 10 minutes as necessary. Children less than 30 kg (66 lbs): 0.01 mg/kg (0. 01 mL/kg) of undiluted Adrenalin® administered intramuscularly or subcutaneously in the anterolateral aspect of the thigh, up to a maximum of 0.3 mg (0.3 mL) per injection, repeated every 5 to 10 minutes as necessary.

The protocol for administering epinephrine (Epi) for anaphylaxis during cardiac arrest outside of a hospital setting is to inject 0.3 to 0.5 mg of undiluted epinephrine intramuscularly or subcutaneously into the anterolateral aspect of the thigh, repeated every 5 to 10 minutes as necessary for adults and children 30 kg (66 lbs) or more. For children less than 30 kg (66 lbs), the dose is 0.01 mg/kg, up to a maximum of 0.3 mg per injection, repeated every 5 to 10 minutes as necessary 2.

From the Research

Protocol for Administering Epinephrine (Epi) for Anaphylaxis during Cardiac Arrest

• The administration of epinephrine for anaphylaxis during cardiac arrest outside of a hospital setting requires careful consideration of the dose and route of administration 3.
• For anaphylaxis, epinephrine is typically given intramuscularly at a low dose, whereas for cardiac arrest, a higher dose is required intravenously 3.
• However, in cases of anaphylaxis-induced cardiac arrest, the use of intravenous adrenaline infusion may be considered as a more aggressive approach 4.
• A case report suggests that unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest may have a favorable outcome, potentially due to the development of a shockable rhythm and counteraction of severe vasoplegic state 5.
• International guidelines recommend administration of 1 mg of intravenous epinephrine every 3-5 minutes during cardiac arrest, but the optimal dose of epinephrine is not known 6.
• Reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes after OHCA 6.
• Prompt and early use of epinephrine should be considered in cases of anaphylaxis, and patients should be supplied with autoinjectable epinephrine and instructed on its use 7.

Key Considerations

• The dose and route of administration of epinephrine are critical in cases of anaphylaxis during cardiac arrest.
• Clear packaging and labeling of epinephrine syringes are essential to avoid inappropriate usage and unnecessary complications 3.
• Precise instructions, closed-loop communication, and unambiguous labeling of syringes can help avoid errors in epinephrine administration 5.
• Patients with anaphylaxis should be instructed on the signs and symptoms of anaphylaxis and the use of autoinjectable epinephrine 7.