How Epinephrine is Administered During CPR
Administer epinephrine 0.01 mg/kg (maximum 1 mg) intravenously or intraosseously every 3-5 minutes during CPR, with the first dose ideally given within 5 minutes of starting chest compressions. 1
Route of Administration
Intravenous (IV) or intraosseous (IO) administration is strongly preferred over endotracheal administration because it provides more reliable drug delivery and better hemodynamic response 1. While endotracheal administration is possible when vascular access is unavailable, it requires a higher dose (0.1 mg/kg of 1:1000 concentration) and produces less predictable effects 2.
Key Administration Details:
For IV/IO route:
- Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration)
- Maximum single dose: 1 mg
- Frequency: Every 3-5 minutes until return of spontaneous circulation (ROSC) 2, 1
For endotracheal route (only if IV/IO unavailable):
- Dose: 0.1 mg/kg (0.1 mL/kg of 1:1000 concentration)
- Requires 5 mL normal saline flush followed by 5 positive-pressure ventilations 2
Timing Considerations
The first dose should be administered within 5 minutes of starting chest compressions 1. Observational data demonstrate that every minute of delay in epinephrine administration significantly decreases ROSC, 24-hour survival, survival to discharge, and favorable neurological outcomes 1.
Rhythm-Specific Timing:
- For nonshockable rhythms (asystole/PEA): Give epinephrine as soon as vascular access is obtained
- For shockable rhythms (VF/pVT): Prioritize defibrillation first; administer epinephrine after initial CPR and defibrillation attempts are unsuccessful 3, 4
Administration Technique During CPR
Epinephrine should be administered during ongoing chest compressions without interrupting CPR 2. The timing of drug administration is less critical than maintaining continuous, high-quality chest compressions. A third rescuer should ideally prepare medications in advance so they can be given immediately when needed 2.
Practical Workflow:
- Continue CPR with minimal interruptions
- Establish IV or IO access during compressions
- Administer epinephrine during compressions (not during rhythm checks)
- Flush with normal saline
- Continue CPR for approximately 2 minutes before next rhythm check 2
Important Caveats
Do not use high-dose epinephrine (>0.01 mg/kg IV/IO). Multiple studies show no survival benefit and potential harm, particularly in asphyxial arrest 2, 3, 4. The only exception might be specific toxidromes like beta-blocker overdose 2.
Avoid routine sodium bicarbonate or calcium administration unless specific indications exist (hyperkalemia, calcium channel blocker overdose, documented hypocalcemia) 1.
Weight-Based Dosing:
Use actual body weight when known. If unknown, use length-based resuscitation tapes with precalculated doses, which are more accurate than age-based estimates 2. Do not exceed the maximum adult dose of 1 mg per dose 2, 1.
Hemodynamic Considerations
Recent evidence suggests the hemodynamic effect of epinephrine may diminish with repeated doses during prolonged resuscitation 5, 6. While current guidelines recommend 3-5 minute intervals, emerging data indicate more frequent dosing (every 1 minute) may provide superior blood pressure augmentation 6. However, continue following the established 3-5 minute interval until further evidence supports protocol changes 1, 3.