Adrenaline Dosing Chart
Administer intramuscular adrenaline 0.3–0.5 mg (1:1000 concentration) into the anterolateral thigh immediately for anaphylaxis in adults, and use 1 mg IV/IO (1:10,000 concentration) every 3–5 minutes for cardiac arrest—these are the only evidence-based first-line doses that prevent death in their respective indications. 1, 2, 3
Anaphylaxis Dosing (Intramuscular Route)
Adult Dosing
- Adults ≥30 kg: Administer 0.3–0.5 mg of 1:1000 adrenaline (1 mg/mL) intramuscularly into the mid-anterolateral thigh 1, 2, 3
- Repeat interval: Every 5–15 minutes if symptoms persist or recur 1, 2, 3
- Injection site rationale: The vastus lateralis achieves peak plasma concentrations in 8±2 minutes versus 34±14 minutes for subcutaneous administration 2, 4
Pediatric Dosing
- Children <30 kg: Administer 0.01 mg/kg (maximum 0.3 mg) of 1:1000 adrenaline intramuscularly into the anterolateral thigh 1, 2, 3
- Autoinjector dosing:
- 0.15 mg for children 10–25 kg
- 0.3 mg for individuals ≥25 kg
- 0.1 mg for infants where available (if unavailable, 0.15 mg is appropriate for infants >7.5 kg) 2
- Repeat interval: Every 5–15 minutes as needed 2, 3
Critical Safety Points
- Never delay intramuscular adrenaline while establishing IV access—IM injection achieves therapeutic levels faster than waiting for IV placement 2
- No absolute contraindications exist for adrenaline in anaphylaxis, even in elderly patients with cardiovascular disease 2
- 10–20% of patients require more than one dose—prepare for repeat administration 2
Cardiac Arrest Dosing (Intravenous/Intraosseous Route)
Adult Dosing
- Standard dose: 1 mg IV/IO (1:10,000 concentration = 0.1 mg/mL) every 3–5 minutes during ongoing resuscitation 1, 2
- Timing for non-shockable rhythms (asystole/PEA): Administer as soon as feasible after arrest recognition 1
- Timing for shockable rhythms (VF/VT): Administer after initial defibrillation attempts have failed 1
Pediatric Dosing
- Children: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO every 3–5 minutes, maximum 1 mg per dose 1, 2
- Higher doses for refractory arrest: 0.1–0.2 mg/kg (0.1 mL/kg of 1:1000 solution) may be considered for unresponsive asystole or pulseless electrical activity 1
High-Dose Epinephrine (NOT Recommended)
- High-dose epinephrine (>1 mg) is NOT recommended for routine cardiac arrest—it does not improve survival to discharge or neurological outcomes 1
Anaphylaxis Progressing to Cardiac Arrest
Immediately abandon the 0.3–0.5 mg IM protocol and switch to cardiac arrest dosing of 1 mg IV/IO (1:10,000) every 3–5 minutes the moment the patient becomes pulseless. 1, 2
Transition Protocol
- Witnessed anaphylaxis arrest: Begin high-quality CPR, obtain IV/IO access, and give 1 mg adrenaline (1:10,000) as soon as access is secured 1, 2
- Rationale: During arrest, peripheral perfusion is absent, making IM absorption unpredictable; the 0.3–0.5 mg IM dose provides only 30–50% of the required cardiac arrest dose 2
- Anaphylaxis-specific cardiac arrest dosing: For refractory anaphylactic arrest, consider high-dose IV adrenaline with rapid escalation: 1–3 mg (1:10,000) IV slowly over 3 minutes, then 3–5 mg IV over 3 minutes, then 4–10 mg/min infusion 1, 2
Refractory Anaphylaxis (IV Adrenaline)
When to Use IV Adrenaline
- Consider IV route when: An IV line is already in place AND the patient has anaphylactic shock unresponsive to multiple IM doses 1, 2
- Critical concentration: Use only 1:10,000 concentration (0.1 mg/mL) for IV administration—never use 1:1000 concentration IV, as it can cause fatal arrhythmias 2
IV Bolus Dosing
- Adults: 50–100 mcg (0.05–0.1 mg) IV bolus using 1:10,000 concentration, titrated slowly to response 1, 2
- Children: 1 mcg/kg IV bolus 2
- Repeat interval: Every 5–15 minutes as needed 2
IV Infusion Dosing
- Adults: 0.05–0.1 mcg/kg/min (approximately 1–4 mcg/min, maximum 10 mcg/min) 1, 2
- Alternative preparation: Add 1 mg (1 mL of 1:1000) to 250 mL D5W for a 4 mcg/mL concentration, infuse at 1–4 mcg/min initially 2
- Mandatory monitoring: Continuous cardiac monitoring and frequent blood pressure checks are required 1, 2
Severe Bronchospasm/Asthma
Adrenaline is NOT recommended for severe asthma exacerbations—use nebulized albuterol 2.5–5 mg in 3 mL saline (repeated as necessary) as the bronchodilator of choice. 1, 2
Bronchospasm Resistant to Epinephrine (in Anaphylaxis Context)
- After adequate adrenaline doses for anaphylaxis: Consider inhaled β-agonist (nebulized albuterol 2.5–5 mg in 3 mL saline, repeat as necessary) 1, 2
- Rationale: Albuterol treats bronchospasm but does NOT address airway edema or cardiovascular collapse 2
Special Populations & Modifiers
Patients on Beta-Blockers
- May be refractory to adrenaline—administer glucagon 1–5 mg IV over 5 minutes (20–30 mcg/kg in children, maximum 1 mg), followed by infusion of 5–15 mcg/min 1, 2
- Be aware: Glucagon may cause vomiting 2
Pregnant Patients
- Position: Perform left uterine displacement to avoid aortocaval compression 2
- Dosing: Standard adult anaphylaxis dosing applies 2
Fluid Resuscitation (Essential Adjunct)
- Adults: Administer 5–10 mL/kg of isotonic crystalloid rapidly in first 5 minutes (approximately 1–2 L total); up to 20–30 mL/kg may be needed 2
- Children: Give up to 30 mL/kg within the first hour 2
- Rationale: Anaphylaxis causes massive vasodilation and capillary leak, with up to 35% of intravascular volume shifting extravascularly within minutes 2
Concentration & Route Error Prevention
Critical Distinctions
| Indication | Concentration | Route | Dose | Frequency |
|---|---|---|---|---|
| Anaphylaxis | 1:1000 (1 mg/mL) | IM (thigh) | 0.3–0.5 mg (adults) | Every 5–15 min |
| Cardiac Arrest | 1:10,000 (0.1 mg/mL) | IV/IO | 1 mg | Every 3–5 min |
| Refractory Anaphylaxis | 1:10,000 (0.1 mg/mL) | IV (slow push) | 50–100 mcg | Every 5–15 min |
Safety Strategies
- Pre-filled syringes: Hospitals should stock clearly labeled, color-coded pre-filled syringes that differentiate IM (1:1000) from IV/IO (1:10,000) adrenaline 2
- Double-check protocol: Before administration, verify (1) indication (anaphylaxis vs. cardiac arrest), (2) concentration (1:1000 vs. 1:10,000), (3) route (IM thigh vs. IV/IO), and (4) weight-based dose for children 2
- Physical separation: Store IM and IV preparations in distinct locations on the emergency cart with different color codes 2
Common Pitfalls to Avoid
- Do NOT delay IM adrenaline while establishing IV access in anaphylaxis—IM achieves therapeutic levels in 8 minutes 2, 4
- Do NOT use 1:1000 concentration for IV administration—only 1:10,000 is safe for IV route 2
- Do NOT rely on antihistamines or corticosteroids to treat airway obstruction or cardiovascular collapse—they are second-line adjuncts only 1, 2
- Do NOT continue IM dosing once cardiac arrest occurs—immediately switch to 1 mg IV/IO cardiac arrest protocol 2
- Do NOT administer repeated injections at the same site—resulting vasoconstriction may cause tissue necrosis 3