What is the proper dosage and administration of adrenalin (epinephrine) in emergency situations?

Adrenaline (Epinephrine) Dosing and Administration in Emergency Situations

For anaphylaxis, administer 0.3-0.5 mg (0.3-0.5 mL of 1:1000 concentration) intramuscularly into the anterolateral thigh, repeating every 5-15 minutes as needed; for cardiac arrest, give 1 mg IV/IO (1:10,000 concentration) every 3-5 minutes. 1, 2

Anaphylaxis Management

The intramuscular route into the lateral thigh is the preferred initial approach because it provides rapid peak plasma concentrations, is easy to administer, and has superior safety compared to IV administration. 2, 1

Adult Dosing for Anaphylaxis

• Initial dose: 0.3-0.5 mg IM (0.3-0.5 mL of 1:1000 solution) into the anterolateral aspect of the thigh 1, 3
• Repeat frequency: Every 5-15 minutes as necessary until symptoms resolve 2, 1
• Multiple doses: If several doses are required, consider starting an IV infusion (5-15 μg/min) rather than repeated boluses 4, 3

Pediatric Dosing for Anaphylaxis

• Children ≥30 kg: 0.3-0.5 mg IM (same as adults) 1
• Children <30 kg: 0.01 mg/kg IM (0.01 mL/kg of 1:1000), maximum 0.3 mg 1, 2
• Age-based dosing:

  • 12 years: 500 μg (0.5 mL of 1:1000) 3

  • 6-12 years: 300 μg (0.3 mL of 1:1000) 3
  • <6 years: 150 μg (0.15 mL of 1:1000) 3

IV Administration for Severe Anaphylaxis

Only use IV epinephrine when the patient has established IV access and is in anaphylactic shock with severe hypotension or bronchospasm. 4, 3

• Dose: 0.05-0.1 mg (5-10% of cardiac arrest dose) using 1:10,000 concentration 2
• Initial bolus in monitored setting: 50 μg (0.5 mL of 1:10,000) for adults, repeatable as needed 3
• Continuous infusion: 5-15 μg/min for refractory cases 4

Cardiac Arrest Management

Standard-dose epinephrine (1 mg IV/IO every 3-5 minutes) remains the evidence-based approach for cardiac arrest, as it improves return of spontaneous circulation compared to placebo. 2, 5

Adult Cardiac Arrest Dosing

• Standard dose: 1 mg IV/IO every 3-5 minutes using 1:10,000 (0.1 mg/mL) concentration 2
• Route: Intravenous or intraosseous 2
• Timing: Administer as early as possible; delays beyond 20 minutes are associated with worse neurological outcomes 6

Pediatric Cardiac Arrest Dosing

• Initial dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO every 3-5 minutes 2
• Refractory arrest: Consider higher doses of 0.1-0.2 mg/kg of 1:1000 concentration 2

Special Consideration: Anaphylaxis Progressing to Cardiac Arrest

If anaphylaxis causes cardiac arrest, immediately switch to cardiac arrest dosing protocols (1 mg IV/IO every 3-5 minutes for adults, 0.01 mg/kg for children), as standard resuscitative measures take priority over anaphylaxis-specific dosing. 2

Critical Safety Considerations

Preventing Fatal Dosing Errors

A major safety concern is the 10-fold overdose that occurs when cardiac arrest doses (1 mg IV) are mistakenly given to anaphylaxis patients. This error causes severe systolic dysfunction, ventricular arrhythmias, and potentially lethal cardiac complications. 7

• Stock prefilled IM syringes: Hospitals should maintain clearly labeled, prefilled intramuscular epinephrine syringes (1:1000) that are visually distinct from IV formulations (1:10,000) 2, 7
• Concentration awareness: 1:1000 (1 mg/mL) is for IM use in anaphylaxis; 1:10,000 (0.1 mg/mL) is for IV use in cardiac arrest 1, 7

Administration Technique

• Never inject into: Buttocks, digits, hands, or feet due to risk of tissue necrosis 1
• Preferred site: Anterolateral thigh for IM injections 1, 2
• If extravasation occurs: Infiltrate the site with phentolamine to prevent tissue necrosis 2

High-Risk Populations

Exercise caution in patients with underlying cardiovascular disease, hyperthyroidism, Parkinson's disease, diabetes, and pheochromocytoma, as they are at greater risk for adverse reactions including ventricular arrhythmias, angina, and hypertensive crisis. 1

Adjunctive Therapy for Anaphylaxis

After epinephrine administration, provide supportive care:

• Fluid resuscitation: Aggressive IV crystalloid (0.9% saline or lactated Ringer's) at high rates, as up to 37% of circulating volume may be lost 3, 4
• Antihistamines: Chlorphenamine 10 mg IV (adult dose) 3
• Corticosteroids: Hydrocortisone 200 mg IV (adult dose) 3
• Persistent bronchospasm: IV salbutamol infusion, consider aminophylline or magnesium sulfate 3

Note: Antihistamines, beta-agonists, and corticosteroids have no proven benefit during cardiac arrest from anaphylaxis and should not delay epinephrine or resuscitation. 4

Monitoring and Follow-up

• Close hemodynamic monitoring is essential, especially in anaphylactic shock, as cardiovascular and respiratory status can change rapidly 2, 4
• Mast cell tryptase levels: Obtain blood samples at presentation, 1-2 hours after symptom onset, and at 24 hours or during convalescence to confirm anaphylaxis 3
• Airway management: When anaphylaxis causes obstructive airway edema, rapid advanced airway management is critical 4