What is the recommended dose of adrenaline (epinephrine) for adult cardiac arrest vs neonatal cardiac arrest?

Adrenaline Dosing in Cardiac Arrest: Adult vs Neonatal

For adult cardiac arrest, administer 1 mg IV/IO epinephrine every 3-5 minutes; for neonatal cardiac arrest, administer 0.01 mg/kg (maximum 1 mg) IV/IO every 3-5 minutes. 1, 2

Adult Cardiac Arrest Dosing

Standard-dose epinephrine (1 mg IV/IO every 3-5 minutes) is the recommended approach for adult cardiac arrest, though evidence shows improved return of spontaneous circulation (ROSC) without proven survival benefit. 1

Key Dosing Parameters

• Standard dose: 1 mg IV/IO administered every 3-5 minutes during resuscitation 1
• Route priority: IV/IO preferred; if access delayed, endotracheal administration at 2-2.5 mg can be considered 1
• No maximum cumulative dose: Guidelines do not define a maximum number of doses—continue as clinically appropriate 2

High-Dose Epinephrine (NOT Recommended)

• High-dose epinephrine (0.1-0.2 mg/kg) is NOT recommended for routine use in adult cardiac arrest 1, 2
• Multiple large randomized trials showed no survival benefit despite improved ROSC rates 3
• Exception: Consider high-dose only for specific toxicologic emergencies (β-blocker or calcium channel blocker overdose) or when titrated to real-time hemodynamic monitoring 1, 2

Evidence Quality

The 2015 AHA guidelines downgraded epinephrine from "reasonable" to "may be reasonable" (Class IIb) after a placebo-controlled trial showed improved ROSC but no survival to discharge benefit, though the study was underpowered 1. The α-adrenergic vasoconstrictor effects improve coronary and cerebral perfusion pressure, but β-adrenergic effects may increase myocardial oxygen demand and reduce subendocardial perfusion 1.

Neonatal/Pediatric Cardiac Arrest Dosing

For neonates and children, the weight-based dosing is 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes, with a maximum single dose of 1 mg. 2

Key Dosing Parameters

• Pediatric dose: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution) 2
• Maximum single dose: 1 mg (do not exceed adult dose) 2
• Frequency: Repeat every 3-5 minutes as needed 2
• High-dose NOT recommended: Do not use high-dose epinephrine routinely in pediatric patients 2

Practical Calculation

• For a 3 kg neonate: 0.01 mg/kg × 3 kg = 0.03 mg = 0.3 mL of 1:10,000 solution
• For a 10 kg infant: 0.01 mg/kg × 10 kg = 0.1 mg = 1 mL of 1:10,000 solution
• For a 35 kg child: 0.01 mg/kg × 35 kg = 0.35 mg, but cap at 1 mg maximum

Critical Pitfalls to Avoid

Concentration Errors

• Adult cardiac arrest uses 1:10,000 concentration (1 mg/10 mL) for IV/IO administration 1
• Pediatric dosing also uses 1:10,000 concentration to minimize calculation errors 2
• The 1:1,000 concentration (1 mg/mL) is reserved for IM/subcutaneous anaphylaxis, NOT cardiac arrest 4

Timing Errors

• Do not delay epinephrine administration beyond the first 3-5 minute interval in non-shockable rhythms 1
• In ventricular fibrillation/pulseless VT, prioritize defibrillation first, then epinephrine after initial shocks fail 1
• Recent data suggests administration intervals <3 minutes or >5 minutes show no outcome benefit over the recommended 3-5 minute window 5

Dosing Misconceptions

• Do not routinely use high-dose epinephrine based on older animal studies—human trials consistently show no survival benefit 1, 3
• Do not combine vasopressin with epinephrine as routine practice—this offers no advantage over epinephrine alone 1
• Do not exceed 1 mg maximum in pediatric patients even if weight-based calculation suggests higher dose 2

Post-ROSC Considerations

• Recognize that β-adrenergic effects may cause harm in the post-arrest period, including increased myocardial work and arrhythmias 1
• Avoid epinephrine in cardiac arrest from sympathomimetic drug overdose where catecholamine excess is the underlying problem 2