What are the dosing recommendations for intravenous (IV) push adrenaline (epinephrine) and atropine in pulseless patients?

IV Push Epinephrine and Atropine Dosing in Pulseless Patients

For adult pulseless patients, administer epinephrine 1 mg IV/IO every 3-5 minutes and consider atropine 1 mg IV/IO only for specific bradycardic conditions, not routinely for asystole or PEA. 1

Adult Dosing Recommendations

Epinephrine Administration

• Dose: 1 mg IV/IO (1:10,000 concentration) 1
• Frequency: Every 3-5 minutes during resuscitation 1
• Route priority: IV or IO access (IO if IV access cannot be established quickly) 2
• Maximum dose: No maximum cumulative dose is specified, but higher cumulative doses are associated with worse outcomes 3

Atropine Administration

• Current recommendation: Atropine is NOT routinely recommended for asystole or PEA in current advanced cardiac life support guidelines 1
• Historical use: If used (based on older protocols or specific indications):
  • Dose: 1 mg IV/IO 1
  • Maximum total dose: 3 mg 4
  • Note: Limited evidence suggests that 1 mg of atropine (but not higher doses) may improve survival to hospital admission in non-shockable rhythms, particularly asystole 4

Pediatric Dosing Recommendations

Epinephrine Administration

• Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) 1
• Frequency: Every 3-5 minutes 1
• Maximum single dose: 1 mg 1

Atropine Administration (if indicated)

• Dose: 0.02 mg/kg IV/IO 1
• Minimum dose: 0.1 mg 1
• Maximum single dose: 0.5 mg 1
• May repeat once if needed 1

Administration Considerations

IV/IO Access

• Establish IV or IO access as quickly as possible during resuscitation 1
• IO access is an effective alternative when IV access is difficult and provides comparable outcomes, though IV access shows slightly better outcomes when available 2
• Central venous access is ideal but should not delay drug administration 1
• Peripheral administration requires a 20-50 mL saline flush to ensure drug delivery to central circulation 1

Endotracheal Administration (only if IV/IO unavailable)

• Not recommended as first-line due to unpredictable absorption and effects 5
• If no alternative exists:
  • Epinephrine: 2-3 times the IV dose (2-3 mg for adults, 0.1 mg/kg of 1:1000 for children) 1
  • Dilute in 5-10 mL of normal saline 1
  • Follow with 5 ventilations to distribute medication 1
  • Note: Studies show this route may be ineffective for epinephrine 5

Algorithm for Pulseless Arrest Management

1. Begin high-quality CPR immediately

   • Push hard (at least 2 inches/5 cm in adults) and fast (100-120/min)
   • Allow complete chest recoil
   • Minimize interruptions in compressions
   • Avoid excessive ventilation

2. Establish IV/IO access while continuing CPR

3. Check rhythm and determine if shockable (VF/pVT) or non-shockable (asystole/PEA)

4. For all pulseless rhythms:

   • Administer epinephrine 1 mg IV/IO (adult) or 0.01 mg/kg (pediatric)
   • Repeat every 3-5 minutes during continued resuscitation

5. For shockable rhythms (VF/pVT):

   • Defibrillate immediately
   • Resume CPR for 2 minutes before rhythm check
   • Consider antiarrhythmic medications after second shock

6. For non-shockable rhythms (asystole/PEA):

   • Continue CPR
   • Identify and treat reversible causes (Hs and Ts)
   • Atropine is not routinely recommended but may be considered in specific bradycardic conditions

Important Considerations and Pitfalls

• Higher cumulative epinephrine doses are associated with worse functional outcomes and increased in-hospital mortality 3
• Avoid delays in CPR or defibrillation to administer medications
• Do not routinely use atropine for asystole or PEA per current guidelines 1
• Correct hypovolemia before or during vasopressor administration when suspected 6
• Monitor for ROSC continuously during resuscitation
• Change compressor every 2 minutes to maintain high-quality CPR 1
• Consider reversible causes of arrest (Hs and Ts) throughout resuscitation 1

By following these evidence-based recommendations for epinephrine and atropine administration in pulseless patients, you can optimize the chances of achieving return of spontaneous circulation while minimizing potential adverse effects of these medications.