What is the recommended dose of adrenaline (epinephrine) for adults and children?

Adrenaline Dosing for Anaphylaxis and Cardiac Arrest

For anaphylaxis, administer 0.01 mg/kg of 1:1000 (1 mg/mL) adrenaline intramuscularly into the anterolateral thigh, with a maximum of 0.5 mg for adults and 0.3 mg for children, repeated every 5-10 minutes as needed until symptoms resolve. 1, 2

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Anaphylaxis Treatment - First-Line Dosing

Adults and Children ≥30 kg

• Dose: 0.3-0.5 mg (0.3-0.5 mL) of 1:1000 concentration intramuscularly 2
• Maximum single dose: 0.5 mg per injection 1, 2
• Route: Intramuscular injection into the anterolateral aspect of the mid-thigh (vastus lateralis muscle) 1, 2
• Repeat interval: Every 5-10 minutes as clinically needed 1, 2

Children <30 kg

• Dose: 0.01 mg/kg (0.01 mL/kg) of 1:1000 concentration intramuscularly 2
• Maximum single dose: 0.3 mg per injection 2
• Route: Intramuscular injection into the anterolateral thigh 2
• Repeat interval: Every 5-10 minutes as needed 2

Autoinjector Dosing for Children

• 10-25 kg: Use 0.15 mg dose autoinjector 1
• ≥25 kg: Use 0.3 mg dose autoinjector 1

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Critical Administration Technique

Injection Site and Angle

• Insert needle at 90-degree angle perpendicular to the skin surface to ensure intramuscular delivery 1, 3
• Site: Anterolateral thigh (vastus lateralis muscle) - this achieves peak plasma concentration in 8±2 minutes versus 34±14 minutes with subcutaneous deltoid injection 1, 4
• Can inject through clothing if necessary during emergency situations 1
• Needle length: At least 1/2 to 5/8 inch to ensure intramuscular administration 2

Common Pitfalls to Avoid

• Never use subcutaneous route - results in significantly delayed absorption and suboptimal treatment 1, 3
• Never use deltoid muscle for initial anaphylaxis treatment - anterolateral thigh provides superior absorption 1
• Do not delay administration to achieve "perfect" technique - prompt intramuscular injection is more important than technical perfection, as delayed epinephrine is associated with anaphylaxis fatalities 1
• Avoid repeated injections at the same site - resulting vasoconstriction may cause tissue necrosis 2

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Repeat Dosing Protocol

No Maximum Number of Doses

• There is no maximum number of IM epinephrine doses for anaphylaxis 4
• Repeat every 5 minutes as needed until symptoms resolve 4
• Most patients require 1-2 doses, but approximately 10-20% require more than one dose 4
• Continue dosing if symptoms persist or progress - fatalities are associated with delayed epinephrine, not with giving multiple doses 4

When to Escalate Beyond IM Epinephrine

• If patient fails to respond to multiple IM doses, consider transitioning to IV epinephrine infusion 4
• IV infusion starting rate: 1-4 mcg/min, titrated up to maximum 10 mcg/min 1, 4
• Preparation: Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL D5W to yield 4.0 mcg/mL concentration 4, 3
• Alternative preparation: 1 mg in 100 mL saline (1:100,000 solution) at 30-100 mL/h (5-15 mcg/min) 1

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Cardiac Arrest Dosing - Distinct from Anaphylaxis

Adult Cardiac Arrest

• Dose: 1 mg IV/IO of 1:10,000 concentration (0.1 mg/mL) 5
• Timing: Administer as soon as vascular access is established for nonshockable rhythms 3
• Repeat interval: Every 3-5 minutes during resuscitation 6

Pediatric Cardiac Arrest

• Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO 3
• Maximum single dose: 1 mg 3
• Endotracheal route (if no IV/IO access):
  • Neonates: 0.01-0.03 mg/kg 5
  • Children/adolescents: 0.03-0.06 mg/kg 5
  • Follow with saline flush (1-5 mL) based on patient size 5

Pediatric Continuous Infusion

• "Rule of 6" preparation: 0.6 × body weight (kg) = mg diluted to 100 mL saline; then 1 mL/h delivers 0.1 mcg/kg/min 1, 3

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Safety Considerations

No Absolute Contraindications

• No absolute contraindication exists for using epinephrine to treat anaphylaxis, even in patients with cardiac disease, advanced age, or frailty 1, 3
• Risk of death from untreated anaphylaxis far exceeds any risk from epinephrine 4, 3

Concentration Verification Critical

• Always verify concentration before administration 3
• 1:1000 (1 mg/mL) for intramuscular use in anaphylaxis 1, 2
• 1:10,000 (0.1 mg/mL) for IV use in cardiac arrest 3
• Confusing concentrations can be fatal - dosing errors are common 7

Monitoring Requirements

• Monitor clinically for severity of allergic reaction and potential cardiac effects 2
• Assess: Respiratory status, blood pressure, and level of consciousness 3
• Watch for biphasic reactions - may occur up to 72 hours later (mean 11 hours) 1

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Special Populations

Neonatal Resuscitation

• Endotracheal dose: 0.05-0.1 mg/kg or prepare 0.1 mg/kg (1 mL/kg of 1:10,000) in a 5 mL syringe 7
• IV dose: 0.01-0.03 mg/kg, with suggested initial dose of 0.02 mg/kg (0.2 mL/kg of 1:10,000) in a 1 mL syringe 7
• Dose of 0.02 mg/kg enables use of 1 mL syringe for birth weights from 500 g to 5 kg 7

Tetraplegic Patients

• May require reduced doses due to denervation hypersensitivity 8
• Consider starting with 0.1 mg IV rather than standard 1 mg for cardiac arrest 8