Epinephrine Dosing for Pediatric Cardiac Arrest
For a child in cardiac arrest, administer epinephrine 0.01 mg/kg (maximum 1 mg) IV/IO as a bolus every 3-5 minutes during resuscitation; continuous infusion is NOT the standard of care during active cardiac arrest. 1
Bolus Dosing Protocol
The 2020 American Heart Association Pediatric Advanced Life Support Guidelines provide clear, algorithmic guidance:
Standard Dosing Regimen
- Dose: 0.01 mg/kg IV or IO
- Concentration: Use 0.1 mg/mL (1:10,000) solution
- Volume: 0.1 mL/kg of the 0.1 mg/mL concentration
- Maximum single dose: 1 mg
- Frequency: Repeat every 3-5 minutes throughout the arrest 1
Alternative Route (If IV/IO Unavailable)
- Endotracheal dose: 0.1 mg/kg
- Concentration: Use 1 mg/mL (1:1,000) solution
- Volume: 0.1 mL/kg of the 1 mg/mL concentration
- Note: IV/IO routes are strongly preferred due to more reliable absorption 1, 2
Critical Timing Considerations
The 2025 AHA/AAP guidelines emphasize that intervals of ≤5 minutes between doses are associated with better outcomes 2. Observational data show that intervals <3 minutes between epinephrine doses correlate with improved survival, though this must be balanced against maintaining high-quality CPR with minimal interruptions.
Administer epinephrine during chest compressions—the timing of drug administration is less important than minimizing interruptions in compressions 3.
Why NOT Continuous Infusion During Arrest?
The guidelines specify bolus dosing only during active cardiac arrest. While one animal study suggested continuous infusion (10 mcg/kg/min) maintained higher cortical cerebral blood flow during CPR 4, this has not translated to human pediatric guidelines or improved clinical outcomes. The evidence base and all major guidelines consistently recommend intermittent boluses.
Continuous epinephrine infusions are reserved for post-resuscitation hemodynamic support, not during the arrest itself.
High-Dose Epinephrine: Avoid It
Do not use high-dose epinephrine (0.1 mg/kg) in pediatric cardiac arrest. Multiple studies demonstrate:
- No improvement in return of spontaneous circulation 5, 6
- Decreased survival with high-dose regimens 6
- Potential for harm 6
The 2010 guidelines explicitly moved away from high-dose strategies after randomized controlled trial evidence showed worse outcomes 3, 6.
Common Pitfalls to Avoid
Dosing errors: Over 50% of pediatric arrests involve incorrect epinephrine dosing 5. Always calculate weight-based doses carefully and have them pre-drawn for high-risk patients 7.
Route confusion: The concentration differs by route:
- IV/IO: 1:10,000 (0.1 mg/mL)
- Endotracheal: 1:1,000 (1 mg/mL)
Using the wrong concentration is a potentially fatal error.
Delayed administration: Each minute of delay in non-shockable rhythms reduces survival odds by approximately 4% 8. Establish vascular access early and prepare doses in advance.
Interrupting compressions: Never stop CPR to give epinephrine. Administer during ongoing compressions 3.
Forgetting the maximum dose: Even in larger children, cap the single dose at 1 mg (adult dose) 1.
Integration with CPR Algorithm
Epinephrine administration fits into the broader cardiac arrest management:
- Start CPR immediately (15:2 compression-ventilation ratio with two rescuers)
- Establish IV/IO access during the second 2-minute CPR cycle
- Give first epinephrine dose as soon as access is obtained
- Repeat every 3-5 minutes until return of spontaneous circulation or termination of efforts
- For shockable rhythms (VF/pVT): Give epinephrine after the second shock, then every 3-5 minutes 3
Post-Resuscitation Considerations
After return of spontaneous circulation, stop bolus epinephrine and transition to continuous infusion if ongoing hemodynamic support is needed. The typical post-arrest infusion range is 0.05-2 mcg/kg/min, titrated to blood pressure and perfusion 9.