From the Guidelines
Epinephrine should be administered to patients in cardiac arrest as soon as feasible, with a recommended dose of 1 mg IV/IO every 3 to 5 minutes, as it has been shown to improve return of spontaneous circulation, despite its impact on long-term neurological outcomes remaining controversial. The administration of epinephrine is a standard part of advanced cardiac life support (ACLS) protocols, and its use is supported by the most recent guidelines, including the 2023 American Heart Association focused update on adult advanced cardiovascular life support 1.
The medication works through its alpha-adrenergic effects, which cause peripheral vasoconstriction, increasing coronary and cerebral perfusion pressures during chest compressions, thereby improving blood flow to vital organs during cardiac arrest. While epinephrine also has beta-adrenergic effects that increase heart rate and contractility, these may actually increase myocardial oxygen demand and potentially worsen outcomes.
Key considerations for the administration of epinephrine in cardiac arrest include:
- The initial cardiac rhythm, with epinephrine administered as soon as possible for non-shockable rhythms (asystole and pulseless electrical activity) 1
- The potential benefits and risks of epinephrine, including its ability to improve return of spontaneous circulation, but with uncertain effects on long-term neurological outcomes 1
- The importance of administering epinephrine in a timely manner, with the goal of improving outcomes in cardiac arrest patients 1
Overall, the use of epinephrine in cardiac arrest is supported by the most recent and highest-quality evidence, and it remains a cornerstone of cardiac arrest management, with the goal of improving patient outcomes, including return of spontaneous circulation and survival to hospital discharge 1.
From the Research
Circumstances for Epinephrine Administration in Cardiac Arrest
Epinephrine is administered in cardiac arrest under the following circumstances:
- When a patient's heart stops beating (cardiac arrest) and they are unresponsive, not breathing, or not breathing normally 2, 3, 4
- As part of Advanced Cardiac Life Support (ACLS) for adult out-of-hospital cardiac arrest, according to the American Heart Association (AHA) guidelines 3, 5
- When the initial rhythm is pulseless electrical activity or asystole, and there is a risk of secondary ventricular fibrillation or pulseless ventricular tachycardia 6
- In an attempt to improve return of spontaneous circulation (ROSC), although it may not improve survival to discharge or neurologic outcome 2, 3, 4
Timing and Dosing of Epinephrine
- The standard dose of epinephrine is 1 mg per administration in adults, with higher doses potentially being harmful 2, 4
- Earlier administration of epinephrine in cardiac arrest may be associated with improved outcomes, although the optimal timing is still unclear 2, 3
- The dosing interval for epinephrine may vary depending on the patient's condition, with more frequent administration potentially being associated with the development of secondary ventricular fibrillation or pulseless ventricular tachycardia 6
Route of Administration
- Intravenous administration is the preferred route for epinephrine, although intramuscular administration may be beneficial in certain situations 2