Epinephrine Dosing for Adult Cardiac Arrest and Anaphylaxis
For adult cardiac arrest, administer 1 mg IV/IO every 3-5 minutes using 1:10,000 concentration (0.1 mg/mL); for anaphylaxis, give 0.3-0.5 mg IM into the lateral thigh using 1:1000 concentration (1 mg/mL), repeatable every 5-15 minutes. 1, 2, 3
Cardiac Arrest Dosing
Standard dose epinephrine is 1 mg IV/IO (1:10,000 concentration) administered every 3-5 minutes during ongoing resuscitation. 1, 3
This dosing improves return of spontaneous circulation (ROSC) compared to placebo, though evidence for improved survival to discharge or neurologically intact survival remains unclear. 3
Early administration within 1-3 minutes is associated with better outcomes for non-shockable rhythms (asystole/PEA). 3
High-dose epinephrine (0.1-0.2 mg/kg) does not improve survival or neurological outcomes compared to standard dosing and may worsen post-arrest outcomes despite potentially increasing ROSC rates. 3, 4
The 3-5 minute interval is based on expert consensus; research shows no significant outcome difference with intervals <3 minutes or >5 minutes. 5
Anaphylaxis Dosing
Intramuscular injection into the anterolateral thigh is the preferred first-line route, delivering 0.3-0.5 mg (using 1:1000 concentration) for adults. 1, 2, 3
The lateral thigh produces the most rapid peak plasma epinephrine concentrations compared to subcutaneous or deltoid injection. 1, 3
Repeat doses every 5-15 minutes as needed—many patients require multiple doses due to symptom recurrence. 1, 2, 3
Autoinjectors deliver 0.3 mg per dose for adults. 1
IV Epinephrine for Anaphylactic Shock
When IV access is already established or for refractory anaphylactic shock, use dramatically lower doses than cardiac arrest: 0.05-0.1 mg (50-100 mcg) as a slow IV bolus using 1:10,000 concentration. 1, 2, 3
For persistent shock, initiate continuous IV infusion at 5-15 mcg/min, which allows careful titration and avoids epinephrine overdosing. 1, 2, 3
Close hemodynamic monitoring is mandatory due to rapid cardiovascular changes in anaphylactic shock. 1, 3
Critical Distinction to Prevent Fatal Errors
The concentration and route differ critically between indications: 1:1000 (1 mg/mL) IM for anaphylaxis versus 1:10,000 (0.1 mg/mL) IV for cardiac arrest. 2, 3
Administering the cardiac arrest dose IV to anaphylaxis patients causes severe systolic dysfunction and potentially lethal cardiac complications. 6
Hospitals should stock clearly labeled, pre-filled IM epinephrine syringes that are easily distinguished from IV formulations to prevent this iatrogenic error. 2, 6
The risk of error is amplified by the need for rapid decision-making in critically ill patients. 6
Special Scenario: Anaphylaxis Progressing to Cardiac Arrest
If anaphylaxis causes cardiac arrest, immediately switch to cardiac arrest dosing protocols (1 mg IV/IO every 3-5 minutes) with standard resuscitative measures taking priority. 1, 2
Standard cardiac arrest doses should be used rather than the lower anaphylaxis doses once arrest occurs. 1
Epinephrine remains the cornerstone of treatment and should be administered immediately. 1
Route-Specific Considerations
Intramuscular is preferred for anaphylaxis due to ease of administration, effectiveness, safety, and avoidance of severe hypertension and cardiac complications from IV overdose. 1, 3, 7
Intraosseous (IO) epinephrine is likely effective at comparable doses to IV, though not specifically studied in anaphylaxis. 1
If IV extravasation occurs, infiltrate the site with phentolamine to prevent tissue necrosis. 2, 3
Patients on Beta-Blockers
Patients taking beta-blockers may have refractory hypotension despite epinephrine and may require glucagon 1-5 mg IV over 5 minutes followed by infusion at 5-15 mcg/min. 3