Adrenaline Dosage Recommendations
For anaphylaxis in adults, administer 0.3-0.5 mg (1:1000) intramuscularly into the anterolateral thigh, repeated every 5-15 minutes as needed; for children, give 0.01 mg/kg (maximum 0.3 mg) by the same route and interval. 1, 2
Anaphylaxis
Adults and Children ≥30 kg
- Intramuscular (preferred route): 0.3-0.5 mg of 1:1000 solution (0.3-0.5 mL) into anterolateral thigh 1, 2
- Repeat every 5-15 minutes as needed based on clinical response
- Autoinjector delivers 0.3 mg per dose 1
Children <30 kg
- Intramuscular: 0.01 mg/kg of 1:1000 solution (maximum 0.3 mg per dose) 1, 2
- Repeat every 5-15 minutes as needed
- Pediatric autoinjector delivers 0.15 mg per dose 1
Intravenous Route (When IV Access Available)
- IV bolus: 0.05-0.1 mg of 1:10,000 solution (0.5-1 mL) 1
- This is 5-10% of the cardiac arrest dose
- IV infusion: 5-15 μg/min for refractory shock 1
- Requires continuous hemodynamic monitoring 1
Critical caveat: The 2020 AHA guidelines 1 supersede older recommendations and establish intramuscular as the preferred initial route due to superior safety, ease of administration, and rapid plasma concentrations. IV epinephrine should be reserved for patients with established IV access and refractory shock, as it carries higher risk of adverse cardiovascular events.
Cardiac Arrest
Standard ACLS Dosing
- Adults: 1 mg IV/IO (1:10,000 solution) every 3-5 minutes 3
- Children: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution, maximum 1 mg) every 3-5 minutes 3
Anaphylaxis-Induced Cardiac Arrest
- Initial adult dose: 1-3 mg IV (1:10,000) over 3 minutes 3
- Subsequent doses: 3-5 mg IV over 3 minutes 3
- Infusion: 4-10 mg/min if arrest persists 3
- Children: Start with 0.01 mg/kg (0.1 mL/kg of 1:10,000), then escalate to 0.1-0.2 mg/kg (0.1 mL/kg of 1:1000) for refractory asystole 3
The evidence supports higher epinephrine doses in anaphylactic arrest compared to standard cardiac arrest, though this remains based on limited data and expert consensus 3. Prolonged resuscitation is encouraged in anaphylaxis as outcomes may be better than other arrest etiologies 3.
Severe Bronchospasm
For bronchospasm refractory to adequate epinephrine doses, use inhaled beta-agonists (nebulized albuterol 2.5-5 mg in 3 mL saline) rather than additional epinephrine. 3
Epinephrine is not the primary treatment for isolated bronchospasm unless it occurs as part of anaphylaxis. The guidelines 3 clearly position nebulized albuterol as the treatment for epinephrine-resistant bronchospasm, with repeat dosing as necessary.
Local Infiltration Anesthesia
The evidence provided does not contain specific FDA-approved dosing for local anesthetic infiltration with epinephrine. However, general principles from the research 4 indicate:
- Epinephrine concentrations of 2.5-5 μg/mL (1:400,000 to 1:200,000) should be added when large local anesthetic doses are used
- Maximum doses are block-specific and patient-specific rather than fixed milligram amounts
- Epinephrine reduces systemic absorption and toxicity risk
Key Clinical Pitfalls
Route confusion: Never confuse 1:1000 (IM) with 1:10,000 (IV) concentrations—this is a 10-fold dosing error 2
Delayed administration: Epinephrine remains underutilized despite being the cornerstone of anaphylaxis treatment 5. Antihistamines and corticosteroids are second-line only and should never delay epinephrine 3, 1
Inadequate needle length: Standard 0.3 mg autoinjector needles may be too short for obese patients, while 0.15 mg needles may be too long for infants <15 kg 6
Site selection: Never inject into buttocks, digits, hands, or feet due to vasoconstriction and tissue necrosis risk 2. The anterolateral thigh is mandatory 1, 2
Monitoring gaps: Close hemodynamic monitoring is essential when using IV epinephrine, as severe hypertension (31%), tachycardia (47%), and rare Takotsubo syndrome (3%) can occur 7
Biphasic reactions: Symptoms may recur 1-72 hours after initial resolution in up to 20% of cases, though the ability of antihistamines or steroids to prevent this is unclear 5