Administration Rate for Cardiac Arrest Medications
During cardiac arrest, epinephrine should be administered as a rapid IV/IO bolus followed by a flush, not as a slow infusion. 1
Epinephrine Administration During Active Cardiac Arrest
Route and Technique
- Administer epinephrine 1 mg as a rapid IV/IO bolus during cardiac arrest, which is the standard approach for all arrest medications requiring immediate systemic delivery 1, 2
- IV/IO access is strongly preferred over endotracheal administration, as endotracheal epinephrine has been associated with reduced ROSC and survival to hospital discharge in adult studies 1
- Follow each medication bolus with a flush of at least 5 mL of normal saline to ensure complete drug delivery 1
Timing and Frequency
- Administer the first dose of epinephrine within 5 minutes of starting chest compressions for optimal outcomes 1
- Repeat epinephrine 1 mg every 3-5 minutes until return of spontaneous circulation (ROSC) is achieved 1, 3
- For shockable rhythms (VF/pVT), give epinephrine after initial CPR and defibrillation attempts are unsuccessful 4
- For non-shockable rhythms, administer epinephrine as soon as feasible after confirming the rhythm 4
Pediatric Dosing Specifics
- Pediatric dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO as a rapid bolus, with maximum single dose of 1 mg 1
- Administer every 3-5 minutes during ongoing resuscitation 1
- If using endotracheal route (only when IV/IO unavailable), increase dose to 0.1 mg/kg (0.1 mL/kg of 1:1000 solution), maximum 2.5 mg 1
Other Cardiac Arrest Medications - Administration Rates
Amiodarone
- Administer as rapid IV/IO bolus with flush during cardiac arrest for shock-refractory VF/pVT 1
- Adult dose: 300 mg first dose, 150 mg second dose
- Pediatric dose: 5 mg/kg IV/IO, may repeat twice up to 15 mg/kg total 1
- Note: When patient has perfusing rhythm (not in arrest), amiodarone should be given slowly over 20-60 minutes 1
Lidocaine
- Administer 1 mg/kg as IV/IO bolus during cardiac arrest as alternative to amiodarone 1
- May be used for shock-refractory VF/pVT 1
Medications Requiring Slow Administration (Even During Arrest)
- Sodium bicarbonate: Administer slowly IV/IO even during cardiac arrest 1
- Calcium chloride: Administer slowly 1
- Magnesium sulfate: Give over 10-20 minutes (faster administration acceptable for torsades de pointes) 1
Post-ROSC Epinephrine Infusion (After Arrest)
Transition to Continuous Infusion
Once ROSC is achieved and patient requires ongoing vasopressor support:
- Dilute 1 mg epinephrine in 250 mL of D5W to create 4 mcg/mL concentration 2
- Start infusion at 0.05-0.1 mcg/kg/min and titrate to achieve target MAP ≥65 mmHg 2, 5
- Titrate every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve desired blood pressure 2
- Maximum rate: 2 mcg/kg/min 2
- Wean gradually over 12-24 hours once hemodynamically stable, decreasing doses every 30 minutes 2
Pediatric Post-ROSC Infusion
- Use "rule of 6" for preparation: 0.6 × body weight (kg) = mg diluted to 100 mL; then 1 mL/h delivers 0.1 mcg/kg/min 5
- Start at 0.05-0.1 mcg/kg/min and titrate to effect 5
Critical Pitfalls to Avoid
During Active Arrest
- Never give epinephrine as a slow infusion during active cardiac arrest - this delays achieving therapeutic plasma concentrations and reduces effectiveness 1, 2
- Do not delay epinephrine beyond 5 minutes from start of compressions, as each minute of delay significantly decreases survival and neurologic outcomes 1, 6
- Avoid excessive cumulative doses - doses above 3 mg total during arrest may be associated with worse neurologic outcomes in ECPR patients 7
Route Selection Errors
- Do not use endotracheal route if IV/IO access is available or achievable, as it produces lower drug concentrations and potentially harmful beta-2 vasodilatory effects 1
- Never administer sodium bicarbonate or calcium via endotracheal tube - these non-lipid-soluble drugs can cause airway injury 1