What is the recommended dose of adrenaline (epinephrine) in Advanced Life Support (ALS) for cardiac arrest in adults and children?

Adrenaline Dose in Advanced Life Support

Adult Dosing

The recommended dose of epinephrine (adrenaline) in adult cardiac arrest is 1 mg IV/IO every 3-5 minutes, with no defined maximum cumulative dose, though cumulative doses above 3 mg may be associated with unfavorable neurological outcomes. 1, 2

Standard Administration Protocol

• Administer 1 mg IV/IO every 3-5 minutes during ongoing cardiac arrest (Class IIb recommendation) 1, 2
• No official maximum cumulative dose exists in current American Heart Association guidelines 1
• This dosing improves return of spontaneous circulation (ROSC) by 151 more patients per 1,000 compared to placebo (RR 2.80) 2
• Survival to hospital admission increases by 124 more patients per 1,000 (RR 1.95) 2

Timing Based on Rhythm

• For non-shockable rhythms (PEA/asystole): Administer epinephrine as soon as feasible after establishing IV/IO access (Class IIa recommendation) 2
• For shockable rhythms (VF/pVT): May administer after initial defibrillation attempts have failed (Class IIb recommendation) 2
• Delaying epinephrine in non-shockable rhythms is a critical pitfall to avoid 2

High-Dose Epinephrine: NOT Recommended

• High-dose epinephrine (0.1-0.2 mg/kg) is NOT recommended for routine use in adults (Class III: No Benefit) 1, 2
• While high-dose may increase ROSC rates, it does not improve survival to hospital discharge 1
• A large European trial of 3,327 patients showed no difference in hospital discharge survival between high-dose (5 mg) and standard-dose (1 mg): 2.3% vs 2.8% respectively 3
• High-dose may be considered only in exceptional circumstances such as β-blocker or calcium channel blocker overdose 1

---

Pediatric Dosing

For pediatric cardiac arrest, the recommended dose is 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO, with a maximum single dose of 1 mg, repeated every 3-5 minutes. 4, 1

Standard Pediatric Protocol

• Dose: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 concentration) 4
• Maximum single dose: 1 mg 4, 1
• Repeat every 3-5 minutes during ongoing cardiac arrest 4, 1
• High-dose epinephrine is not recommended for routine pediatric use 1

Alternative Route: Endotracheal Administration

If IV/IO access is not available, endotracheal administration may be used as a last resort:

• Endotracheal dose: 0.1 mg/kg (0.1 mL/kg of 1:1000 concentration) 4
• Maximum endotracheal dose: 2.5 mg 4
• This is 10 times the IV/IO dose due to reduced absorption via the endotracheal route 4
• After administration, flush with 5 mL normal saline and follow with 5 positive-pressure ventilations 4

Important caveat: Endotracheal epinephrine is controversial and may be less effective than vascular administration. Animal studies suggest lower concentrations achieved via endotracheal route may produce transient β2-adrenergic vasodilation, causing hypotension and reduced coronary perfusion 4. Three adult studies demonstrated reduced ROSC and survival with endotracheal versus vascular delivery 4.

---

Critical Considerations and Pitfalls

Evidence Limitations

• While epinephrine improves ROSC and short-term survival, it has NOT been proven to improve survival with favorable neurological outcome in high-quality randomized trials 2, 5
• Some evidence suggests an increase in survivors with poor neurological function at discharge in the epinephrine group 5
• The fundamental challenge is determining the likelihood of favorable versus unfavorable neurological outcome at the time of arrest 2

Dosing Interval Research

• A 2018 study comparing lower-dose protocols (0.5 mg) to standard dosing found no significant difference in survival or neurological outcomes 6
• A 2023 meta-analysis found that varying the epinephrine administration interval (<3 min or >5 min) was not associated with better outcomes compared to the recommended 3-5 minute interval 7
• These findings support the current guideline recommendations 7

Special Circumstances: Traumatic Cardiac Arrest

In traumatic cardiac arrest, epinephrine has minimal role because the primary problem is mechanical (hypovolemia, tension pneumothorax, tamponade) rather than electrical or metabolic 5. Priority interventions include:

• Bilateral needle decompression for suspected tension pneumothorax 5
• Emergency resuscitative thoracotomy within 10 minutes for penetrating thoracic trauma 5
• Massive transfusion protocol and hemorrhage control 5
• Pericardiocentesis for cardiac tamponade 5

Common Pitfalls to Avoid

• Using high-dose epinephrine routinely without specific indications (β-blocker/calcium channel blocker overdose) 1
• Delaying epinephrine administration in non-shockable rhythms 2
• Administering epinephrine in cardiac arrest associated with sympathomimetic drug overdose where it may be harmful 1
• Using endotracheal route when IV/IO access is achievable 4