Epinephrine Dosing for Anaphylaxis and Cardiac Arrest
For anaphylaxis, administer 0.3-0.5 mg (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 as a rapid bolus. 1, 2
Anaphylaxis Dosing
The intramuscular route into the vastus lateralis is the first-line treatment for anaphylaxis, not intravenous administration. 1, 3
Adult Dosing
- Administer 0.3-0.5 mg (0.3-0.5 mL of 1:1000 concentration) intramuscularly into the anterolateral aspect of the thigh 1, 2
- Maximum dose per injection is 0.5 mg 2
- Repeat every 5-15 minutes as needed for persistent symptoms 1, 3, 2
- Can inject through clothing if necessary 2
Pediatric Dosing
- Children ≥30 kg: 0.3-0.5 mg (same as adults) 1, 3
- Children <30 kg: 0.01 mg/kg (0.01 mL/kg of 1:1000 concentration), maximum 0.3 mg per injection 1, 3, 2
- Repeat every 5-15 minutes as needed 1, 3
- Hold the child's leg firmly in place during injection to minimize injury risk 2
Intravenous Dosing for Refractory Anaphylactic Shock
IV epinephrine requires dramatically lower doses than cardiac arrest dosing and should only be used for refractory shock or when IV access is already established. 1, 3
- Bolus dose: 0.05-0.1 mg (50-100 mcg) using 1:10,000 concentration 1, 3
- Infusion rate: 5-15 mcg/min (0.05-0.1 mcg/kg/min) 1
- Close hemodynamic monitoring is mandatory due to rapid cardiovascular changes 1, 3
Cardiac Arrest Dosing
Administer 1 mg IV/IO as a rapid bolus every 3-5 minutes during ongoing resuscitation. 1, 4
Adult Dosing
- 1 mg IV/IO (1:10,000 concentration) as a rapid bolus 1, 4
- Repeat every 3-5 minutes until return of spontaneous circulation (ROSC) 1, 4
- Administer the first dose within 5 minutes of starting chest compressions 4
- Follow each bolus with at least 5 mL normal saline flush 4
Pediatric Dosing
- 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO as a rapid bolus 3, 4
- Maximum single dose of 1 mg 4
- Repeat every 3-5 minutes 3, 4
Post-ROSC Management
After achieving ROSC, transition to a continuous epinephrine infusion rather than continuing bolus dosing. 4
- Start at 0.05-0.1 mcg/kg/min and titrate to achieve MAP ≥65 mmHg 4
- Do not continue bolus dosing after ROSC to avoid dangerous blood pressure spikes 4
Critical Pitfalls to Avoid
Dosing Confusion Between Anaphylaxis and Cardiac Arrest
The most dangerous error is administering cardiac arrest doses (1 mg IV) to anaphylaxis patients, which can cause severe systolic dysfunction and potentially lethal cardiac complications. 5, 6
- Anaphylaxis requires 0.3-0.5 mg IM (1:1000), while cardiac arrest requires 1 mg IV (1:10,000) 1, 5
- Studies show widespread confusion among physicians, with only 16.8% administering epinephrine correctly for anaphylaxis 6
- Hospitals should stock clearly labeled, pre-filled intramuscular epinephrine syringes that are easily distinguished from IV formulations 3, 5
Route-Specific Errors
- Never give epinephrine as a slow infusion during active cardiac arrest—only rapid boluses are effective 4
- Avoid endotracheal administration if IV/IO access is available, as it produces lower drug concentrations and reduced survival 4
- Do not administer repeated injections at the same IM site, as vasoconstriction may cause tissue necrosis 2
Timing Errors
- Each minute of delay beyond 5 minutes from compression start significantly decreases survival and neurologic outcomes in cardiac arrest 4
- Early administration (within 1-3 minutes) for nonshockable rhythms improves ROSC and neurologically intact survival 1
Special Populations
Patients on Beta-Blockers
- May have refractory hypotension despite epinephrine 1
- Consider glucagon 1-5 mg IV over 5 minutes followed by infusion (5-15 mcg/min) 1
Anaphylaxis Progressing to Cardiac Arrest
Immediately switch to cardiac arrest dosing protocols (1 mg IV/IO every 3-5 minutes) if anaphylaxis causes cardiac arrest. 3
- For refractory pediatric arrest from anaphylaxis, higher doses (0.1-0.2 mg/kg of 1:1000) may be considered 3