Should I administer adrenaline (epinephrine) at every cycle of cardiopulmonary resuscitation (CPR)?

Epinephrine Administration During CPR

Epinephrine should be administered every 3 to 5 minutes during cardiopulmonary resuscitation (CPR), not with every CPR cycle. 1

Recommended Dosing Schedule for Epinephrine

• Administer epinephrine 1 mg IV/IO every 3 to 5 minutes during cardiac arrest 1
• Operationally, this typically means giving epinephrine every second cycle of CPR after the initial dose 1
• The timing of drug administration is less important than minimizing interruptions in chest compressions 1
• A third rescuer should prepare drug doses before rhythm checks to minimize delays 1

Rationale for Current Recommendations

• Epinephrine increases rates of return of spontaneous circulation (ROSC) and short-term survival through its alpha-adrenergic effects 1
• The 3-5 minute interval is based on established protocols from clinical trials 1, 2
• Observational data suggest better outcomes when epinephrine is given sooner in cardiac arrest 1
• No significant difference in neurological outcomes has been found between shorter (<3 min) or longer (>5 min) dosing intervals compared to the standard 3-5 minute interval 3

Important Considerations During Resuscitation

• For shockable rhythms (VF/pVT), prioritize defibrillation and CPR initially before administering epinephrine 1
• For non-shockable rhythms, administer epinephrine as soon as possible 1
• Higher doses of epinephrine have not shown improvement in survival to discharge or long-term outcomes 1
• Focus on high-quality CPR with minimal interruptions in chest compressions 1

Common Pitfalls to Avoid

• Do not administer epinephrine with every CPR cycle (typically every 2 minutes) as this would exceed the recommended frequency 1
• Do not delay epinephrine administration in non-shockable rhythms 1
• Do not interrupt chest compressions for drug administration 1
• Do not use higher doses of epinephrine as they have not shown improved outcomes 1

Special Situations

• In pediatric cardiac arrest, epinephrine dosing is weight-based at 0.01 mg/kg (maximum 1 mg) every 3-5 minutes 1
• For patients with anaphylaxis who progress to cardiac arrest, the standard cardiac arrest dosing of epinephrine should be used rather than the lower anaphylaxis dosing 4

Following these evidence-based recommendations for epinephrine administration during CPR will help optimize resuscitation efforts while maintaining focus on high-quality chest compressions, which remain the cornerstone of effective CPR.