What is the proper administration and dosage of adrenaline (epinephrine) in medical emergencies?

Proper Administration and Dosage of Epinephrine in Medical Emergencies

Epinephrine should be administered intramuscularly at a dose of 0.2 to 0.5 mg (1:1000) into the anterolateral aspect of the thigh every 5 to 15 minutes as needed for anaphylaxis, while cardiac arrest requires 1 mg intravenously every 3-5 minutes. 1

Anaphylaxis Management

Initial Administration

• Administer epinephrine early by intramuscular injection to all patients with signs of systemic allergic reaction, especially hypotension, airway swelling, or difficulty breathing 1
• The recommended dose for adults and children ≥30 kg is 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 solution) intramuscularly into the anterolateral aspect of the thigh 1, 2
• For children <30 kg, administer 0.01 mg/kg (0.01 mL/kg), up to 0.3 mg (0.3 mL) intramuscularly 2
• Injection into the lateral aspect of the thigh produces rapid peak plasma epinephrine concentrations 1
• Many patients will require additional doses, with recurrence of symptoms after 5 to 15 minutes reported 1

Alternative Routes in Anaphylactic Shock

• When an IV line is in place, it is reasonable to consider IV administration at a dose of 0.05 to 0.1 mg (5-10% of the cardiac arrest dose) 1
• IV infusion (5-15 μg/min) is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest 1
• Although not specifically studied, intraosseous (IO) epinephrine is likely effective at comparable doses to IV administration 1

Monitoring and Additional Considerations

• Close hemodynamic monitoring is essential as cardiovascular and respiratory status can change rapidly 1
• When anaphylaxis produces obstructive airway edema, rapid advanced airway management is critical, sometimes requiring emergency cricothyroidotomy or tracheostomy 1
• Avoid injection into buttocks, digits, hands, or feet to prevent tissue damage 2

Cardiac Arrest Management

Standard Dosing

• For cardiac arrest, administer 1 mg IV every 3-5 minutes 3, 4
• This is approximately 10-20 times higher than the dose used for anaphylaxis when given intravenously 1
• In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority 1

Common Pitfalls and Safety Considerations

Dosing Errors

• Confusion between anaphylaxis dosing and cardiac arrest dosing is common and potentially fatal 5
• Iatrogenic overdose can occur when cardiac arrest doses are inappropriately administered for anaphylaxis 5
• Clear labeling and packaging of different epinephrine concentrations is essential to avoid inappropriate usage 5

Special Populations

• Use with caution in patients with underlying heart disease as epinephrine may aggravate angina pectoris or produce ventricular arrhythmias 2
• Patients with hyperthyroidism, Parkinson's disease, diabetes, and pheochromocytoma are at greater risk of adverse reactions 2
• Elderly patients and pregnant women may be at greater risk of developing adverse reactions when epinephrine is administered parenterally 2

Adverse Effects

• Common adverse reactions include anxiety, restlessness, tremor, weakness, dizziness, sweating, palpitations, pallor, nausea, vomiting, headache, and respiratory difficulties 2
• Serious complications include arrhythmias, rapid rises in blood pressure producing cerebral hemorrhage, and angina 2
• A significant number of hospital doctors, regardless of seniority and specialty, have knowledge deficits regarding correct administration of epinephrine in anaphylaxis 6