Adrenaline (Epinephrine) Vasopressor Dosing per AHA Guidelines
For adult cardiac arrest, administer epinephrine 1 mg IV/IO every 3-5 minutes during CPR, starting after the first dose of defibrillation for shockable rhythms or as soon as possible for non-shockable rhythms. 1
Adult Cardiac Arrest Dosing
Standard Dose Protocol
- Dose: 1 mg IV/IO (1:10,000 concentration = 10 mL of 0.1 mg/mL solution)
- Frequency: Every 3-5 minutes during ongoing CPR
- Route: Intravenous (IV) or intraosseous (IO) 1
Timing Based on Rhythm
Shockable Rhythms (VF/pVT):
- Administer epinephrine after the third defibrillation attempt if initial CPR and defibrillation are unsuccessful 1
- Priority sequence: CPR → defibrillation → epinephrine if first attempts fail
Non-Shockable Rhythms (Asystole/PEA):
- Administer epinephrine as soon as feasible - earlier administration is associated with improved ROSC 1
- All 16 observational studies in recent systematic reviews found earlier epinephrine improved ROSC for non-shockable rhythms 1
Important Caveats
The 2024 AHA focused update reaffirms that while epinephrine increases ROSC and short-term survival, it does not improve long-term neurological outcomes 1. The strategy focuses on administering the drug that increases survival while working to shorten time-to-drug delivery for all patients.
Pediatric Cardiac Arrest Dosing
For pediatric cardiac arrest with non-shockable rhythms, administer epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO as soon as possible, as this is associated with favorable outcomes. 2
Pediatric Dosing Protocol
- Dose: 0.01 mg/kg IV/IO (maximum single dose: 1 mg)
- Concentration: 1:10,000 (0.1 mg/mL)
- Volume: 0.1 mL/kg
- Frequency: Every 3-5 minutes during CPR 2
Pediatric Timing Considerations
- For non-shockable rhythms: Give epinephrine immediately - this is a 2025 guideline emphasis 2
- For shockable rhythms: Administer if defibrillation is not immediately possible 2
Anaphylaxis Dosing (Non-Cardiac Arrest)
For anaphylaxis without cardiac arrest, give epinephrine 0.3-0.5 mg IM (1:1000) into the lateral thigh, repeated every 5-15 minutes as needed - intramuscular is the preferred initial route. 3
Anaphylaxis Protocol
Adults and Children ≥30 kg:
- Dose: 0.3-0.5 mg IM (Class I recommendation)
- Concentration: 1:1000 (1 mg/mL)
- Volume: 0.3-0.5 mL
- Site: Lateral thigh (anterolateral aspect)
- Frequency: Every 5-15 minutes as needed 3, 4
Children <30 kg:
- Dose: 0.01 mg/kg IM (maximum 0.3 mg per dose)
- Concentration: 1:1000
- Pediatric autoinjector: Delivers 0.15 mg 3, 4
Alternative Routes for Anaphylaxis
IV Epinephrine (when IV already in place):
- Dose: 0.05-0.1 mg IV push (Class IIa recommendation)
- Concentration: 1:10,000 (0.1 mg/mL)
- Volume: 0.5-1 mL
- Note: This is 5-10% of the cardiac arrest dose 3
IV Infusion for Refractory Shock:
- Dose: 5-15 mcg/min continuous infusion (Class IIa recommendation)
- Preparation: Add 1 mg epinephrine to 250 mL D5W = 4 mcg/mL 3, 5
- Use: For recurrent shock or post-arrest shock from anaphylaxis 3
Critical Safety Point for Anaphylaxis
Common dosing error: Administering cardiac arrest dose (1 mg IV) instead of anaphylaxis dose (0.05-0.1 mg IV) can cause severe systolic dysfunction and potentially lethal cardiac complications 6. The 10-fold concentration difference (1:1000 IM vs 1:10,000 IV) is a frequent source of iatrogenic overdose.
Anaphylaxis-Induced Cardiac Arrest
For cardiac arrest secondary to anaphylaxis, follow standard ACLS protocols with 1 mg IV/IO epinephrine every 3-5 minutes, but intramuscular remains the preferred initial route if IV/IO not yet established. 3
- Standard BLS/ACLS takes priority (Class I recommendation)
- IM epinephrine (0.3-0.5 mg) preferred initially for ease, effectiveness, and safety
- Transition to standard cardiac arrest dosing (1 mg IV/IO) once vascular access obtained
- IO epinephrine likely effective at comparable doses 3
Key Distinctions Summary
| Indication | Dose | Concentration | Route | Frequency |
|---|---|---|---|---|
| Adult cardiac arrest | 1 mg | 1:10,000 | IV/IO | Every 3-5 min |
| Pediatric cardiac arrest | 0.01 mg/kg (max 1 mg) | 1:10,000 | IV/IO | Every 3-5 min |
| Anaphylaxis (adult) | 0.3-0.5 mg | 1:1000 | IM (thigh) | Every 5-15 min |
| Anaphylaxis (child <30 kg) | 0.01 mg/kg (max 0.3 mg) | 1:1000 | IM (thigh) | Every 5-15 min |
| Anaphylactic shock (IV available) | 0.05-0.1 mg | 1:10,000 | IV push | PRN |
| Refractory anaphylactic shock | 5-15 mcg/min | 4 mcg/mL | IV infusion | Continuous |
Evidence Quality Note
These recommendations come from the 2020 and 2024 AHA Guidelines for CPR and Emergency Cardiovascular Care (Class I, LOE C-LD for most recommendations) 3, 1 and 2025 Pediatric Advanced Life Support Guidelines 2. The evidence base relies heavily on observational data and consensus opinion, as randomized trials are limited by ethical constraints in cardiac arrest research.