What is the recommended dose of adrenaline (epinephrine) for anaphylactic shock?

Adrenaline Dosing for Anaphylactic Shock

For anaphylactic shock, administer 0.2 to 0.5 mg of adrenaline (1:1000 concentration) intramuscularly into the anterolateral thigh, repeating every 5 to 15 minutes as needed. 1

Initial Route and Dose

Intramuscular administration is the preferred first-line route because it provides rapid peak plasma concentrations, is easy to administer, and has an excellent safety profile. 1

• Adult IM dose: 0.2 to 0.5 mg (using 1:1000 concentration = 1 mg/mL) 1
• Injection site: Anterolateral aspect of the mid-thigh 2, 3
• Frequency: Repeat every 5 to 15 minutes as needed 1
• Many patients require multiple doses, with symptom recurrence commonly reported within 5 to 15 minutes 1

Intravenous Route (When IV Access Already Established)

If an IV line is already in place and the patient remains in shock despite IM adrenaline, consider IV administration at a significantly lower dose of 0.05 to 0.1 mg (using 1:10,000 concentration = 0.1 mg/mL). 1, 4

Critical Dosing Distinction

• IM dose: 0.2-0.5 mg of 1:1000 (1 mg/mL) 1
• IV bolus dose: 0.05-0.1 mg of 1:10,000 (0.1 mg/mL) - this is only 5-10% of the cardiac arrest dose 4
• Never confuse these concentrations - administering 1:1000 IV instead of 1:10,000 can cause fatal arrhythmias 4

IV Infusion Alternative

Continuous IV infusion is a reasonable alternative to repeated boluses, allowing careful titration and avoiding overdose. 1, 4

• Prepare by adding 1 mg (1 mL) of 1:1000 adrenaline to 250 mL D5W (concentration: 4 μg/mL) 4
• Alternative: Add 1 mg to 100 mL saline (concentration: 10 μg/mL) 4
• Typical infusion rate: 5-15 μg/min 5

Monitoring Requirements

Close hemodynamic monitoring is mandatory because cardiovascular and respiratory status can deteriorate rapidly in anaphylactic shock. 1

• Continuous blood pressure monitoring 4
• Continuous pulse oximetry and ECG monitoring 4
• Frequent reassessment for airway compromise 1

Cardiac Arrest from Anaphylaxis

If anaphylaxis progresses to cardiac arrest, immediately switch to standard cardiac arrest protocols with 1 mg IV/IO every 3-5 minutes using 1:10,000 concentration. 1, 6

Standard resuscitative measures and immediate epinephrine administration take priority over all other interventions. 1

Common Pitfalls to Avoid

• Delaying adrenaline administration while focusing on antihistamines or corticosteroids - these have no proven benefit in anaphylactic shock and should never delay epinephrine 1
• Using subcutaneous route - this has delayed onset compared to IM and is not recommended 7
• Injecting into buttocks, digits, hands, or feet - risk of tissue necrosis and inadequate absorption 2
• Administering IV adrenaline too rapidly - increases risk of fatal arrhythmias 4
• Using wrong concentration for IV route - confusion between 1:1000 and 1:10,000 is a common and potentially fatal error 4, 8

Airway Management Considerations

Given the potential for rapid development of oropharyngeal or laryngeal edema, immediate referral to a provider with advanced airway expertise is essential. 1

Emergency cricothyroidotomy may be necessary if airway obstruction develops. 1

Adjunctive Therapy

While adrenaline is the cornerstone of treatment, aggressive fluid resuscitation is fundamental as anaphylactic shock can cause up to 37% reduction in circulating blood volume due to vasodilation and increased capillary permeability. 5

For patients on beta-blockers who are refractory to adrenaline, consider glucagon 1-5 mg IV over 5 minutes followed by infusion. 4