Do we mix Adrenaline (Epinephrine) with Normal Saline for Anaphylaxis treatment?

Anaphylaxis Treatment: Epinephrine Administration Protocol

For anaphylaxis treatment, epinephrine should be administered intramuscularly at a dose of 0.01 mg/kg (maximum 0.5 mg in adults, 0.3 mg in children) without dilution in normal saline for first-line treatment. 1

First-Line Treatment: Intramuscular Epinephrine

• Administer epinephrine 0.01 mg/kg (maximum 0.5 mg in adults, 0.3 mg in children) intramuscularly into the anterolateral thigh (vastus lateralis) 1
• Use 1:1000 concentration (1 mg/mL) for intramuscular injection 1
• Can repeat every 5-15 minutes if symptoms persist 1
• Do NOT routinely dilute epinephrine with normal saline for intramuscular administration

Intravenous Epinephrine (Only for Specific Scenarios)

Intravenous epinephrine is reserved for specific situations:

1. Cardiac arrest due to anaphylaxis 2
2. Profound hypotension not responding to:
   • Intramuscular epinephrine injections
   • Intravenous fluid resuscitation 2

When IV epinephrine is deemed necessary:

• Aqueous epinephrine 1:1000,0.1 to 0.3 mL (0.1-0.3 mg) can be diluted in 10 mL of normal saline 2
• Administer intravenously over several minutes 2
• Requires continuous hemodynamic monitoring 2

Alternative: Epinephrine Infusion

For cases not responding to IM epinephrine and requiring continuous support:

• Option 1: Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL D5W (concentration 4.0 μg/mL)

  • Infuse at 1-4 μg/min (15-60 drops/min with microdrop)
  • Maximum rate: 10.0 μg/min 2

• Option 2: Add 1 mg (1 mL) of 1:1000 epinephrine to 100 mL saline (concentration 10 μg/mL)

  • Initial rate: 30-100 mL/h (5-15 μg/min)
  • Titrate based on clinical response and side effects 2

Additional Critical Management Steps

1. Position patient recumbent with elevated lower extremities 2
2. Establish and maintain airway - consider endotracheal intubation if necessary 2
3. Administer oxygen to patients with prolonged reactions, pre-existing hypoxemia, or requiring multiple epinephrine doses 2
4. Fluid resuscitation with normal saline:
   • Adults: 1-2 L at 5-10 mL/kg in first 5 minutes
   • Children: up to 30 mL/kg in first hour 2

Common Pitfalls to Avoid

1. Delay in epinephrine administration - this is the most common and potentially fatal error 3
2. Subcutaneous injection - has delayed onset compared to intramuscular route 3
3. Routine IV administration - higher risk of potentially lethal arrhythmias 2
4. Relying on antihistamines as first-line treatment - they do not relieve airway obstruction, hypotension, or shock 4
5. Unnecessary dilution of IM epinephrine - diluting the standard dose is not recommended for routine anaphylaxis management

Key Points

• Epinephrine is universally recommended as the first-line treatment for anaphylaxis 1, 3
• The intramuscular route in the anterolateral thigh provides the optimal therapeutic window 3
• Intravenous administration should be reserved for cardiac arrest or profound hypotension not responding to IM epinephrine and fluid resuscitation 2
• When IV epinephrine is necessary, dilution in normal saline and careful administration over several minutes with continuous monitoring is recommended 2

Remember that prompt administration of epinephrine is the most critical intervention in anaphylaxis management, with no absolute contraindications in this life-threatening condition.