How often is epinephrine (epi) administered during a cardiac arrest (code)?

Epinephrine Administration Frequency During Cardiac Arrest

Administer 1 mg of IV/IO epinephrine every 3 to 5 minutes during cardiac arrest, continuing until return of spontaneous circulation (ROSC) is achieved, with no maximum cumulative dose limit. 1, 2

Standard Adult Dosing Protocol

• Give 1 mg IV/IO epinephrine every 3-5 minutes throughout the resuscitation effort until ROSC occurs 1, 2
• The first dose should ideally be administered within 5 minutes of starting chest compressions to optimize outcomes 1
• There is no officially defined maximum number of doses in current American Heart Association guidelines 2
• Continue administering epinephrine at this interval regardless of how many doses have been given, as long as cardiac arrest persists 1

Pediatric Dosing Considerations

• For children, administer 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) with a maximum single dose of 1 mg 1
• Maintain the same 3-5 minute interval between doses as in adults 1
• If IV/IO access is unavailable but an endotracheal tube is in place, the ET dose is 0.1 mg/kg (0.1 mL/kg of 1:1000 concentration) 1

Timing and Administration Technique

• Minimize interruptions in chest compressions when administering epinephrine - give the drug during compressions, not during rhythm checks 1
• The timing of drug administration is less critical than maintaining continuous, high-quality chest compressions 1
• If sufficient rescuers are present, have a third rescuer prepare drug doses before rhythm checks so epinephrine can be administered immediately 1

Evidence Base and Rationale

The 3-5 minute interval is based on pharmacokinetic data showing epinephrine has a half-life of approximately 2.6 minutes during cardiac arrest 3. This relatively short half-life supports repeated dosing to maintain therapeutic plasma levels 3. While some research has explored alternative dosing strategies (single-dose protocols, lower doses, or different intervals), none have demonstrated superior outcomes compared to the standard 3-5 minute protocol 4, 5, 6.

High-Dose Epinephrine: Not Recommended

• Do not use high-dose epinephrine (0.1-0.2 mg/kg) routinely during cardiac arrest 2
• While high-dose epinephrine may increase ROSC rates, it does not improve survival to hospital discharge and may cause harm in the post-arrest period 2
• High-dose epinephrine may be considered only in exceptional circumstances such as beta-blocker or calcium channel blocker overdose 2

Special Circumstance: Anaphylaxis-Related Cardiac Arrest

If cardiac arrest occurs during anaphylaxis, the dosing strategy differs significantly:

• Use high-dose IV epinephrine with rapid progression: start with 1-3 mg (1:10,000 dilution) IV over 3 minutes, then 3-5 mg over 3 minutes, followed by a 4-10 mg/min infusion 1
• For children with anaphylaxis-related arrest, initial dose is 0.01 mg/kg repeated every 3-5 minutes, with higher subsequent doses (0.1-0.2 mg/kg) considered for unresponsive asystole or pulseless electrical activity 1
• Prolonged resuscitation efforts are encouraged in anaphylaxis-related arrest, as outcomes are more favorable in young patients with healthy cardiovascular systems 1

Common Pitfalls to Avoid

• Delaying the first epinephrine dose beyond 5 minutes from CPR initiation decreases survival rates 1
• Stopping epinephrine administration prematurely - continue every 3-5 minutes until ROSC or termination of resuscitation 1
• Using intervals longer than 5 minutes between doses, which may allow plasma levels to drop below therapeutic range 3
• Interrupting chest compressions to administer epinephrine - give the drug during compressions 1