What is the recommended epinephrine (adrenaline) dose for an anaphylactic reaction?

Epinephrine Dosing for Anaphylaxis

For adults and children weighing ≥30 kg, administer 0.3 to 0.5 mg of epinephrine (1:1000 concentration) intramuscularly into the anterolateral thigh, repeated every 5 to 15 minutes as needed. 1, 2, 3

Adult Dosing

• Administer 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 solution) intramuscularly into the anterolateral aspect of the mid-thigh for all adults 1, 3
• The FDA-approved dose range is 0.3 to 0.5 mg, with the American Heart Association recommending this same range 4, 3
• Repeat doses every 5 to 15 minutes based on clinical response, as approximately 6-19% of patients require a second dose 1, 2

Pediatric Dosing

• For children weighing ≥30 kg (66 lbs): use the adult dose of 0.3 to 0.5 mg intramuscularly 3
• For children weighing <30 kg: administer 0.01 mg/kg (0.01 mL/kg of 1:1000 solution), up to a maximum of 0.3 mg 1, 2, 3
• Specific autoinjector recommendations: 0.15 mg for children 15-30 kg (or 7.5-25 kg per some guidelines), and 0.3 mg for children ≥25-30 kg 4, 2
• Repeat every 5 to 10 minutes as necessary 3

Route and Site of Administration

• Intramuscular injection into the anterolateral thigh (vastus lateralis muscle) is the mandatory first-line route, producing rapid peak plasma concentrations superior to subcutaneous administration 1, 2
• Never inject into buttocks, digits, hands, or feet due to risk of tissue injury 3
• The lateral thigh site ensures adequate muscle depth and rapid absorption 5

Intravenous Epinephrine (Reserved for Refractory Cases)

• IV epinephrine should only be used for cardiac arrest, profound hypotension unresponsive to IM epinephrine and IV fluids, or anaphylactic shock when IV access is already established 1, 2, 6
• IV bolus dose: 0.05 to 0.1 mg (0.5 to 1 mL of 1:10,000 solution) 2
• Continuous IV infusion: add 1 mg (1 mL of 1:1000) to 1000 mL of 0.9% normal saline, starting at 2 μg/min (120 mL/h) and titrating up to 10 μg/min (600 mL/h) based on blood pressure, heart rate, and oxygenation 1, 2, 6
• Continuous hemodynamic monitoring is essential during IV administration 6

Critical Safety Points

• There are no absolute contraindications to epinephrine in anaphylaxis, even in elderly patients with cardiovascular disease—the benefits far outweigh the risks 1, 2
• Withholding epinephrine due to fear of adverse effects is dangerous and not recommended 1
• Common transient adverse effects include pallor, tremor, anxiety, palpitations, and tachycardia, which are acceptable given the life-threatening nature of anaphylaxis 1
• The presence of sulfites in epinephrine formulations should not deter use 3

Common Pitfalls to Avoid

• Delayed administration is the most critical error—epinephrine is most effective when given immediately at symptom onset 7, 5
• Failure to inject epinephrine promptly contributes to anaphylaxis fatalities 7
• Do not use subcutaneous route as it has delayed onset compared to intramuscular 7
• Call emergency services (9-1-1) immediately when anaphylaxis is suspected 4
• Be prepared to administer repeat doses, as up to 28% of patients may require additional epinephrine 8