What is the recommended dose of epinephrine (adrenaline) for cardiac arrest?

Epinephrine Dosing in Cardiac Arrest

The recommended dose of epinephrine for cardiac arrest is 1 mg intravenously (IV) or intraosseously (IO) every 3 to 5 minutes during resuscitation efforts. 1

Standard Dosing Recommendations

Adult Dosing

• Standard dose: 1 mg IV/IO every 3-5 minutes during CPR 1
• Administration route: Intravenous (IV) or intraosseous (IO) is preferred
• Concentration: 1:10,000 solution (0.1 mg/mL) for IV/IO use
• If no IV/IO access is available, endotracheal administration may be considered, though this is less effective

Pediatric Dosing

• Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO 1
• Maximum single dose: 1 mg
• Frequency: Every 3-5 minutes during CPR
• For endotracheal administration (if no IV/IO access): 0.1 mg/kg (0.1 mL/kg of 1:1,000 solution) 1

Evidence Supporting Standard Dosing

The recommendation for standard-dose epinephrine is based on evidence showing:

• Improved return of spontaneous circulation (ROSC) compared to placebo 1
• Improved survival to hospital admission 1
• In the PARAMEDIC 2 trial, epinephrine improved 30-day survival (RR 1.40,95% CI 1.07-1.84) 1

The American Heart Association (AHA) guidelines classify this recommendation as Class IIb, Level of Evidence B-R, indicating that it "may be reasonable" based on moderate-quality evidence from randomized controlled trials 1.

High-Dose vs. Standard-Dose Epinephrine

High-dose epinephrine (0.1-0.2 mg/kg) is not recommended for routine use in cardiac arrest. 1

While high-dose epinephrine may increase rates of ROSC, trials have not demonstrated any benefit for:

• Survival to hospital discharge
• Neurologically intact survival
• Long-term outcomes 1

High-dose epinephrine may be considered only in specific circumstances:

• β-blocker overdose
• Calcium channel blocker overdose
• When titrated to real-time physiologically monitored parameters 1

Timing of Administration

Early administration of epinephrine is particularly important in non-shockable rhythms:

• For non-shockable rhythms (PEA/asystole): Administer epinephrine as soon as possible
• For shockable rhythms (VF/pVT): Prioritize defibrillation, then administer epinephrine if defibrillation is unsuccessful

Studies show that early administration of epinephrine in non-shockable rhythms is associated with increased ROSC, survival to hospital discharge, and neurologically intact survival 1.

Alternative Dosing Strategies

Recent research has examined alternative dosing strategies:

• Lower doses (0.5 mg): Not shown to significantly change outcomes compared to standard dosing 2
• Different dosing intervals: Neither shorter (<3 min) nor longer (>5 min) intervals have been associated with improved neurological outcomes 3, 4
• Single-dose protocols: Associated with similar survival to hospital discharge but decreased ROSC rates compared to multi-dose protocols 5

Common Pitfalls and Considerations

1. Delayed administration: Particularly harmful in non-shockable rhythms where early epinephrine administration is critical
2. Excessive focus on epinephrine: Remember that high-quality CPR and early defibrillation (for shockable rhythms) remain the cornerstone of cardiac arrest management
3. Route of administration: IV/IO routes are preferred; endotracheal administration is less reliable
4. Vasopressin: Offers no advantage as a substitute for or in combination with epinephrine 1
5. Monitoring: When ROSC is achieved, be prepared to manage potential post-resuscitation catecholamine effects including tachyarrhythmias and hypertension

By following these evidence-based recommendations for epinephrine dosing in cardiac arrest, providers can optimize the potential for successful resuscitation while avoiding unnecessary or potentially harmful practices.