Epinephrine Dosing in Cardiac Arrest
The recommended dose of epinephrine in cardiac arrest is 1 mg intravenously (IV) or intraosseously (IO) every 3-5 minutes for adults, and 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) with a maximum single dose of 1 mg for pediatric patients. 1
Adult Dosing
- Standard dose: 1 mg IV/IO every 3-5 minutes
- Concentration: 1:10,000 solution (0.1 mg/mL)
- Route of administration: IV or IO preferred
- If no IV/IO access is available, endotracheal administration may be considered at higher doses
Pediatric Dosing
- Standard dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO
- Maximum single dose: 1 mg (10 mL)
- Frequency: Every 3-5 minutes during resuscitation 2
- If no IV/IO access is available, endotracheal dose: 0.1 mg/kg (0.1 mL/kg of 1:1,000 concentration) 2
Evidence and Rationale
The standard dosing recommendation is supported by the American Heart Association guidelines, which classify this as a Class IIb recommendation with Level of Evidence B-R 1. This indicates that the intervention "may be reasonable" based on moderate-quality evidence from randomized controlled trials.
Research has shown that standard-dose epinephrine improves return of spontaneous circulation (ROSC) compared to placebo, with a relative risk of 1.40 for 30-day survival 1.
Special Considerations
High-Dose Epinephrine
High-dose epinephrine is not recommended for routine use in cardiac arrest as it has not demonstrated benefits for survival to hospital discharge or neurologically intact survival 1. Multiple studies have failed to show improved outcomes with high-dose epinephrine compared to standard dosing 3, 4.
However, high-dose epinephrine may be considered in specific circumstances:
- β-blocker overdose 2, 1
- Calcium channel blocker overdose 1
- When titrated to real-time physiologically monitored parameters 1
Timing of Administration
Early administration of epinephrine is particularly important in non-shockable rhythms, with studies showing increased ROSC, survival to hospital discharge, and neurologically intact survival when administered as soon as possible 1.
Cardiac Arrest in Anaphylaxis
In cardiac arrest occurring during anaphylaxis, higher doses may be considered:
- Initial resuscitation dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution)
- For unresponsive asystole or pulseless electrical activity: 0.1-0.2 mg/kg (0.1 mL/kg of 1:1,000 solution) 2
Common Pitfalls
- Delayed administration: Epinephrine should be given as early as possible, especially in non-shockable rhythms.
- Inappropriate high dosing: Using high-dose epinephrine routinely is not supported by evidence and may be harmful.
- Incorrect concentration: Ensure the correct concentration is used (1:10,000 for IV/IO administration).
- Inadequate frequency: Maintain the 3-5 minute dosing interval during ongoing resuscitation.
- Route confusion: Different concentrations are used for different routes (IV/IO vs. endotracheal).
Despite some research exploring alternative dosing strategies 5, 6, 4, the standard dosing regimen remains the recommended approach based on the most current and high-quality evidence.