Adrenaline Dosing in ATLS Trauma Cardiac Arrest
In trauma patients with cardiac arrest, administer 1 mg of intravenous adrenaline every 3-5 minutes during resuscitation, which remains the standard dose despite lack of definitive evidence for improved survival. 1
Standard Dosing Protocol for Cardiac Arrest
Administer 1 mg IV/IO every 3-5 minutes during ongoing cardiac arrest, regardless of the arrest rhythm (ventricular fibrillation, asystole, or pulseless electrical activity). 1
The dose should be given as a 1:10,000 dilution (1 mg in 10 mL) for intravenous or intraosseous administration. 1
Flush with 20 mL of normal saline after each peripheral IV bolus to ensure drug delivery to central circulation. 2
Alternative Routes When IV/IO Access Unavailable
If intravenous or intraosseous access cannot be established, endotracheal administration of 2-3 times the standard IV dose (2-3 mg) can be used, diluted to at least 10 mL in 0.9% saline, followed by five ventilations. 1
However, endotracheal dosing is significantly less effective than IV administration and should only be used as a second-line approach when vascular access is delayed. 1, 3
Pediatric Trauma Dosing
For children in cardiac arrest, administer 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO, with a maximum single dose of 1 mg. 1
Repeat every 3-5 minutes during ongoing arrest. 1
The endotracheal dose for children is 0.1 mg/kg (0.1 mL/kg of 1:1,000 solution) if vascular access is unavailable. 1
High-Dose Adrenaline: Not Recommended
High-dose epinephrine regimens (>1 mg per dose) are NOT recommended for routine resuscitation, as multiple studies have shown no improvement in survival to hospital discharge or neurological outcomes despite occasionally achieving return of spontaneous circulation. 1, 4
Higher doses may be counterproductive by increasing myocardial oxygen consumption and inducing myocardial injury patterns. 1
Severe Hypotension Without Cardiac Arrest
For trauma patients with severe hypotension but preserved cardiac output:
Begin with aggressive volume resuscitation first—this is the priority in trauma-related hypotension. 1, 2
If hypotension persists despite adequate volume replacement, consider adrenaline infusion at 1-4 mcg/min (starting dose), titrated up to a maximum of 10 mcg/min. 2, 5
Prepare the infusion by adding 1 mg (1 mL of 1:1,000) to 250 mL D5W to yield 4 mcg/mL concentration. 5
Continuous hemodynamic monitoring is mandatory when administering adrenaline infusions. 2, 5
Critical Pitfalls in Trauma Resuscitation
Do not confuse 1:1,000 and 1:10,000 concentrations—verify the concentration before drawing up doses to avoid 10-fold dosing errors. 2
Exercise extreme caution in patients with cocaine or sympathomimetic drug intoxication, as adrenaline may precipitate severe arrhythmias in this population. 1
Prolonged resuscitation efforts are encouraged in trauma arrest, particularly in young patients with healthy cardiovascular systems, as outcomes may be better than in primary cardiac arrest. 1
Address reversible causes aggressively: In trauma, focus on tension pneumothorax, cardiac tamponade, and massive hemorrhage—adrenaline alone will not reverse these conditions. 1
Atropine 3 mg IV (single dose) should be considered for asystole or pulseless electrical activity in trauma arrest, as vagal tone may contribute to these rhythms. 1
Evidence Limitations
The recommendation for 1 mg every 3-5 minutes is based on decades of practice rather than high-quality evidence demonstrating improved survival or neurological outcomes. 1 No adequately powered randomized controlled trial has compared standard-dose adrenaline to placebo in humans. 1 Despite this, adrenaline remains the standard of care because it improves coronary and cerebral perfusion pressure experimentally and occasionally achieves return of spontaneous circulation clinically. 1
Human data suggest an inverse relationship between cumulative adrenaline doses and survival—no patients survived after receiving more than 10 doses in one large cohort. 6 This underscores the importance of addressing reversible causes rather than relying solely on repeated adrenaline administration.