What is the ideal time gap between adrenaline (epinephrine) injections during cardiopulmonary resuscitation (CPR)?

Epinephrine Dosing Interval During CPR

The ideal time gap between adrenaline (epinephrine) injections during CPR is every 3 to 5 minutes, as consistently recommended by the American Heart Association guidelines for both adult and pediatric cardiac arrest. 1

Standard Dosing Protocol

• Administer epinephrine 1 mg IV/IO every 3-5 minutes for adults during cardiac arrest, continuing until return of spontaneous circulation (ROSC) is achieved 1

• For pediatric patients, administer 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes, with a maximum single dose of 1 mg 1, 2

• The timing of drug administration is less important than minimizing interruptions in chest compressions—epinephrine should be administered during ongoing chest compressions 1

Evidence Supporting the 3-5 Minute Interval

The 3-5 minute interval represents a balance based on pharmacokinetics and clinical outcomes:

• More frequent dosing (<3 minutes) may be harmful: Pediatric data shows that dosing intervals less than 3 minutes were associated with lower 12-month survival compared to 3-5 minute intervals (adjusted OR 0.50; 95% CI, 0.24-1.06) 1

• Longer intervals (>5 minutes) may delay beneficial effects: While some observational data suggested potential benefit from longer intervals (5-8 minutes), this likely reflects resuscitation time bias rather than true therapeutic benefit 1

• Recent high-quality research confirms the guideline recommendation: A 2022 nationwide Japanese study of 10,965 OHCA patients found that neither shorter nor longer epinephrine dosing intervals compared to the standard 3-5 minute interval improved neurologically favorable survival 3

Critical Timing Considerations

Early administration of the first dose matters more than the interval between subsequent doses:

• For pediatric patients with nonshockable rhythms, every minute delay in the first epinephrine dose significantly decreases ROSC, 24-hour survival, and survival to discharge 1

• Patients receiving the first dose within 5 minutes of CPR initiation had significantly better outcomes than those receiving it after 5 minutes 1

• Prepare epinephrine doses in advance so administration can occur as soon as possible without interrupting chest compressions 1

Common Pitfalls to Avoid

• Do not give epinephrine more frequently than every 3 minutes in an attempt to improve outcomes—this may actually worsen survival, particularly in pediatric patients 1, 2

• Do not delay epinephrine administration beyond 5 minutes between doses unless there are specific contraindications—longer intervals do not improve outcomes 3

• Do not use high-dose epinephrine (>1 mg in adults or >0.01 mg/kg in children)—multiple studies show no survival benefit and potential harm, particularly in pediatric asphyxial arrest 1, 2

• Do not interrupt chest compressions to administer epinephrine—drug administration should occur during ongoing compressions 1

Route-Specific Considerations

• IV/IO administration is strongly preferred over endotracheal administration when possible, as it provides more predictable drug levels 1, 2

• If endotracheal administration is necessary, use a higher dose (0.1 mg/kg in pediatrics, 2-2.5 mg in adults) to compensate for reduced bioavailability 1, 2