What are the recommended dilutions and administration methods for epinephrine, amiodarone, lidocaine, and vasopressin during cardiac arrest, including pediatric weight‑based dosing?

Drug Dilutions and Administration in Cardiac Arrest

For pediatric cardiac arrest, administer epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 concentration) with a maximum dose of 1 mg every 3-5 minutes; amiodarone 5 mg/kg IV/IO bolus for refractory VF/pulseless VT (up to 3 doses); and lidocaine 1 mg/kg IV/IO as initial loading dose. 1

Epinephrine Dosing and Dilutions

Pediatric Dosing

• IV/IO route: 0.01 mg/kg (0.1 mL/kg of the 1:10,000 concentration = 0.1 mg/mL)
• Maximum single dose: 1 mg (10 mL of 1:10,000)
• Frequency: Repeat every 3-5 minutes 1
• Endotracheal route (if IV/IO unavailable): 0.1 mg/kg (0.1 mL/kg of the 1:1,000 concentration = 1 mg/mL) 1

Adult Dosing

• Standard dose: 1 mg IV/IO every 3-5 minutes 2
• High-dose epinephrine is NOT recommended for routine use 3

Timing Considerations

For nonshockable rhythms (asystole/PEA), administer epinephrine as soon as feasible - this is associated with improved outcomes in pediatric arrest 4. For shockable rhythms (VF/pulseless VT), give epinephrine after initial defibrillation attempts have failed 3.

Critical Pitfall

The endotracheal route requires a 10-fold higher concentration (1:1,000 vs 1:10,000) because absorption is significantly reduced. However, IV/IO is strongly preferred as the ET route is no longer recommended in current guidelines 1.

Amiodarone Dosing and Dilutions

Pediatric Dosing

• Cardiac arrest dose: 5 mg/kg IV/IO rapid bolus
• Maximum single dose: 300 mg
• Frequency: May repeat up to 3 total doses for refractory VF/pulseless VT 1
• Total daily maximum: 15 mg/kg 5

Preparation for Cardiac Arrest

• For rapid bolus during arrest: Mix in 100 mL D5W and infuse over 10 minutes to minimize hypotension 5
• Concentration should not exceed 2 mg/mL unless using a central venous catheter 6
• Must be diluted in D5W only (not normal saline) 6

Adult Dosing

• First dose: 300 mg IV/IO bolus
• Second dose: 150 mg IV/IO 2

Critical Pitfalls

• Amiodarone is only appropriate after defibrillation and epinephrine have been initiated in pulseless ventricular arrhythmias 5
• Use a volumetric infusion pump - drop counter sets can underdose by up to 30% 6
• Administer through central venous catheter when possible for concentrations >2 mg/mL 6
• Use glass or polyolefin bottles for infusions >2 hours; do not use evacuated glass containers 6

Lidocaine Dosing and Dilutions

Pediatric Dosing

• Initial loading dose: 1 mg/kg IV/IO 1

Adult Dosing

• First dose: 1-1.5 mg/kg IV/IO
• Second dose: 0.5-0.75 mg/kg IV/IO 2

Preparation

• Maximum concentration for cardiac arrest: Use undiluted 4% solution (40 mg/mL) or dilute as needed 7
• Maximum total dose: Should not exceed 300 mg in adults or 4.5 mg/kg in children 7

Vasopressin

Vasopressin is NOT routinely recommended in pediatric cardiac arrest - it is not included in current pediatric guidelines 1, 4.

In adults, vasopressin alone or in combination with methylprednisolone and epinephrine may be considered but offers no advantage as a substitute for epinephrine 3. The combination of vasopressin-steroids-epinephrine showed improved ROSC in some studies but did not improve survival to discharge with favorable neurologic outcomes 8.

Weight-Based Dosing Considerations

Transition to Adult Dosing

Current practice varies significantly across institutions 9:

• Most institutions (94%) use patient weight as the primary determinant
• Transition points vary: 44% switch at 50-60 kg, 27% at 60-80 kg, 12% at ≥100 kg
• PALS guidelines specify maximum of 1 mg epinephrine, corresponding to 100 kg 1

Obese Patients

43% of institutions report using ideal body weight when dosing epinephrine in obese pediatric patients 9.

Administration Routes and Techniques

Route Priority

1. Intravenous (IV) - preferred first-line
2. Intraosseous (IO) - if IV access unsuccessful or delayed
3. Endotracheal (ET) - no longer recommended; only if IV/IO impossible 1

IO Site Selection

Under normovolemic conditions, humeral IO (HIO) access achieves higher peak concentrations and faster ROSC compared to peripheral IV for epinephrine 10. However, under hypovolemic conditions, IV access proves superior 10. Sternal IO shows faster ROSC than tibial IO 10.

Flush Technique

After drug administration, follow with saline flush (1-5 mL based on patient size) to ensure drug delivery to central circulation 5.

Hemodynamic Monitoring During CPR

Target diastolic blood pressure ≥25 mm Hg in infants and ≥30 mm Hg in children ≥1 year during CPR when continuous invasive arterial monitoring is available 4, 11. This represents a new hemodynamic goal for high-quality CPR.

Post-ROSC, maintain systolic and mean arterial pressures above the 10th percentile for age and sex 4, 11.