What is the rescue dose for epinephrine (epi)?

Rescue Dose of Epinephrine

For anaphylaxis, repeat the same intramuscular dose (0.3 mg for adults, 0.15 mg for children) every 5 minutes as needed until symptoms resolve—there is no maximum number of doses. 1, 2

Anaphylaxis Rescue Dosing

Intramuscular Route (Preferred)

• Repeat the initial dose every 5 minutes if symptoms fail to resolve or worsen 1, 2
• Standard adult dose: 0.3 mg IM (from autoinjector or 0.3 mL of 1:1,000 solution) 1, 2
• Pediatric dose: 0.15 mg IM for children 15-30 kg; 0.3 mg IM for children >30 kg 1, 2
• 6-28% of patients require a second dose, and some need three or more doses 1, 2
• The interval between doses can be as frequent as every 5 minutes if clinically indicated 2

When to Escalate Beyond IM Dosing

If multiple IM doses fail to control symptoms, transition to IV epinephrine infusion 1, 2:

• Starting rate: 1-4 mcg/min, titrated up to maximum 10 mcg/min based on response 2
• Requires continuous hemodynamic monitoring 1, 2
• Preparation: Add 1 mg (1 mL of 1:1,000) to 250 mL D5W to yield 4 mcg/mL concentration 2

IV Bolus Dosing (When IV Already Established)

• 0.05-0.1 mg IV (0.5-1 mL of 1:10,000 solution) can be given when IV access is already in place 1
• This represents 5-10% of the cardiac arrest dose 1
• IV route carries significant risk of dilution/dosing errors—IM remains safer for first-line treatment 2

Cardiac Arrest Rescue Dosing

Standard Dosing

• 1 mg IV/IO every 3-5 minutes during ongoing cardiac arrest 1, 3
• Use 1:10,000 concentration (0.1 mg/mL) for IV/IO administration 3
• Pediatric dose: 0.01 mg/kg IV/IO (maximum 1 mg), repeated every 3-5 minutes 3, 4

High-Dose Epinephrine Is NOT Recommended

• High-dose epinephrine (0.1 mg/kg) as rescue therapy is associated with worse outcomes in pediatric cardiac arrest 3, 5
• A randomized trial found only 1/34 children survived 24 hours with high-dose rescue versus 7/34 with standard-dose rescue 5
• Among asphyxial arrests, 0/12 survived with high-dose versus 7/18 with standard-dose 5
• Continue standard 1 mg doses (or 0.01 mg/kg in children) rather than escalating 3, 5

Critical Pitfalls to Avoid

Concentration Confusion

• Always use 1:1,000 (1 mg/mL) for IM injection in anaphylaxis 2
• Use 1:10,000 (0.1 mg/mL) for IV bolus in cardiac arrest 3
• Mixing these concentrations can result in 10-fold dosing errors 2

Premature Cessation

• Fatalities are associated with delayed or inadequate epinephrine dosing, not with giving multiple doses 2
• Continue dosing every 5 minutes as long as symptoms persist or progress 2
• The short half-life of epinephrine (rapidly metabolized within minutes) necessitates repeat dosing 2

Route Selection Errors

• Never delay epinephrine to establish IV access in anaphylaxis—IM is faster and safer 1, 2
• IM injection in the vastus lateralis achieves peak levels in 8±2 minutes versus 34±14 minutes with subcutaneous deltoid injection 2
• Endotracheal administration requires 5-10 times the IV dose due to poor bioavailability and should only be used if IV/IO access cannot be established 3

Absolute Contraindication Myth

• There is no absolute contraindication to epinephrine in anaphylaxis, even in elderly patients or those with cardiac disease 2
• The risk of death from untreated anaphylaxis far exceeds the risk of epinephrine-related adverse effects 2