What is the recommended dose of adrenaline (epinephrine) in advanced life support for adults and children with cardiac arrest or anaphylaxis?

Adrenaline Dose in Advanced Life Support

For adult cardiac arrest, administer 1 mg IV/IO every 3-5 minutes without a defined maximum cumulative dose; for anaphylaxis, give 0.3-0.5 mg IM (1:1000 concentration) every 5-10 minutes, never confusing these vastly different doses and routes. 1, 2

Cardiac Arrest Dosing

Adult Dosing

• Administer 1 mg IV/IO (1:10,000 concentration) every 3-5 minutes during ongoing resuscitation 1, 2
• This represents a Class 1 (strong) recommendation from the American Heart Association based on Level B-R evidence 2
• No maximum cumulative dose is defined in current guidelines, though cumulative doses above 3 mg may be associated with unfavorable neurological outcomes 2, 3

Timing Considerations by Rhythm

• For non-shockable rhythms (PEA/asystole): Give epinephrine as soon as feasible (Class 2a recommendation) 2
• Early administration within 1-3 minutes improves ROSC, survival to discharge, and neurologically intact survival compared to delayed administration 1
• For shockable rhythms (VF/pVT): Administer after initial defibrillation attempts have failed (Class 2b recommendation) 2

Pediatric Cardiac Arrest Dosing

• Give 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes 2, 3
• Maximum single dose is 1 mg 2, 3
• Endotracheal dose is 0.1 mg/kg (0.1 mL/kg of 1:1000 concentration), maximum 2.5 mg, followed by 5 mL normal saline flush and 5 positive-pressure ventilations 2
• The endotracheal dose is 10 times the IV/IO dose due to reduced absorption 2

Anaphylaxis Dosing

Adult and Children ≥30 kg

• Administer 0.3-0.5 mg IM (1:1000 concentration) into the anterolateral thigh every 5-10 minutes 1, 4
• Maximum dose per injection is 0.5 mg 4
• Intramuscular injection into the vastus lateralis produces faster peak plasma concentrations than subcutaneous or deltoid injection 1

Children <30 kg

• Give 0.01 mg/kg IM (0.01 mL/kg of 1:1000 concentration) every 5-10 minutes 1, 4
• Maximum dose per injection is 0.3 mg 4

Anaphylactic Shock with IV Access

• For refractory anaphylactic shock, use dramatically lower IV doses than cardiac arrest: 0.05-0.1 mg (50-100 mcg) bolus using 1:10,000 concentration 1
• Infusion rate: 5-15 mcg/min (0.05-0.1 mcg/kg/min) 1
• Close hemodynamic monitoring is mandatory due to rapid cardiovascular changes 1

Critical Pitfalls to Avoid

Dosing Confusion Leading to Iatrogenic Overdose

• Never administer cardiac arrest doses (1 mg IV) to anaphylaxis patients—this causes severe systolic dysfunction and potentially lethal cardiac complications 5
• The anaphylaxis dose (0.3-0.5 mg IM) is fundamentally different in both concentration (1:1000 vs 1:10,000), route (IM vs IV), and absolute dose 5
• Prefilled, clearly labeled syringes should be stocked separately to prevent this life-threatening error 5

High-Dose Epinephrine

• High-dose epinephrine (0.1-0.2 mg/kg) is NOT recommended for routine cardiac arrest (Class 3: No Benefit) 2, 3
• While high-dose epinephrine may increase ROSC rates, it does not improve survival to discharge or neurological outcomes and may worsen post-arrest outcomes 1, 3, 6
• Consider high-dose epinephrine only in exceptional circumstances: beta-blocker overdose, calcium channel blocker overdose, or when titrated to real-time physiologically monitored parameters 3

Route-Specific Errors

• Do not inject IM epinephrine into buttocks, digits, hands, or feet—use only the anterolateral thigh 4
• Do not administer repeated injections at the same site due to risk of tissue necrosis from vasoconstriction 4
• IV administration requires close monitoring for extravasation and tissue necrosis; phentolamine may be necessary as an antidote 1

Special Populations

Patients on Beta-Blockers

• May have refractory hypotension despite epinephrine 1
• Consider glucagon 1-5 mg IV over 5 minutes followed by infusion (5-15 mcg/min) 1

Pregnancy and Elderly

• These populations may be at greater risk of developing adverse reactions when epinephrine is administered parenterally 4
• However, the presence of these risk factors should not deter use in life-threatening situations 1

Evidence Quality and Rationale

The 1 mg dose for cardiac arrest has remained standard since the 1960s despite extensive investigation into higher doses 7. Epinephrine significantly increases ROSC (151 more patients per 1,000 achieving ROSC, RR 2.80) and survival to hospital admission (124 more patients per 1,000, RR 1.95) 2. The mechanism likely involves β2-adrenergic receptor activation, which distinguishes epinephrine from other vasopressors by enhancing pacemaker cell function and restoring contractile function in ischemic cardiomyocytes 8. Lower-dose protocols (0.5 mg) have been studied but showed no significant difference in outcomes compared to standard dosing 9.