What is the recommended dose of adrenaline (epinephrine) in cardiac arrest?

Recommended Dose of Adrenaline in Cardiac Arrest

Administer 1 mg of epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest, with no maximum cumulative dose limit. 1, 2

Standard Dosing Protocol

• The dose is 1 mg (1 mL of 1:10,000 solution) administered intravenously or intraosseously every 3 to 5 minutes throughout the resuscitation effort. 1
• This dosing applies to both shockable rhythms (VF/pVT) and non-shockable rhythms (PEA/asystole). 1
• Continue administering this dose repeatedly until return of spontaneous circulation (ROSC) is achieved or resuscitation efforts are terminated. 1, 2
• There is no officially defined maximum cumulative dose or maximum number of doses in current guidelines. 2

High-Dose Epinephrine: Not Recommended

High-dose epinephrine (0.1 to 0.2 mg/kg) is NOT recommended for routine use in cardiac arrest. 2

• While high-dose epinephrine may increase rates of ROSC, it does not improve survival to hospital discharge. 2
• The adverse effects in the post-arrest period may negate any potential advantages during the arrest itself. 2
• Multiple large randomized controlled trials have confirmed no survival benefit with high-dose regimens compared to standard dosing. 3

Exceptional Circumstances for High-Dose Consideration

High-dose epinephrine may be considered only in these specific scenarios:

• β-blocker overdose 2
• Calcium channel blocker overdose 2
• When titrated to real-time physiologically monitored parameters (such as arterial line monitoring showing inadequate coronary perfusion pressure) 2

Pediatric Dosing

• The recommended pediatric dose is 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration), with a maximum single dose of 1 mg. 2
• Repeat every 3 to 5 minutes. 2
• High-dose epinephrine is not recommended for routine pediatric use. 2

Evidence on Dosing Intervals

Interestingly, recent evidence suggests that longer dosing intervals may be associated with better outcomes, though current guidelines remain unchanged:

• A large retrospective study of over 20,000 in-hospital cardiac arrests found that epinephrine dosing intervals of 6-10 minutes were associated with significantly improved survival compared to the guideline-recommended 4-5 minute intervals. 4
• Patients receiving epinephrine every 8-9 minutes had an adjusted odds ratio of 1.79 for survival to hospital discharge compared to those receiving it every 4-5 minutes. 4
• A meta-analysis found no significant difference in neurological outcomes when comparing different epinephrine administration intervals. 5
• One study examining reduced epinephrine dosing (0.5 mg instead of 1 mg) found no significant difference in survival or neurological outcomes. 6

Despite this emerging evidence, the current standard remains 1 mg every 3-5 minutes per AHA guidelines. 1

Common Pitfalls to Avoid

• Do not use high-dose epinephrine routinely without specific indications such as β-blocker or calcium channel blocker toxicity. 2
• Avoid epinephrine in cardiac arrest associated with sympathomimetic drug overdose where it may be harmful. 2
• Do not delay epinephrine administration while attempting to establish advanced airway access—vascular access and drug therapy take priority. 1
• Ensure proper dilution: Use 1 mg of 1:10,000 solution (not 1:1,000 which is for intramuscular anaphylaxis dosing). 1