What are the recommended adrenaline (epinephrine) doses for adult and pediatric anaphylaxis, cardiac arrest, severe bronchospasm, and septic shock?

Adrenaline Dosing by Clinical Indication

Anaphylaxis

For anaphylaxis, administer 0.3–0.5 mg of 1:1000 adrenaline (1 mg/mL) intramuscularly into the anterolateral thigh in adults and children ≥30 kg, or 0.01 mg/kg (maximum 0.3 mg) in children <30 kg, repeating every 5–15 minutes as needed. 1, 2, 3

Adult Dosing

• Intramuscular (first-line): 0.3–0.5 mg of 1:1000 solution injected into the mid-anterolateral thigh 1, 2, 3
• Repeat interval: Every 5–15 minutes if symptoms persist or recur 1, 2, 3
• Route rationale: IM injection into the vastus lateralis produces faster peak plasma concentrations than subcutaneous or deltoid injection and avoids the risk of severe hypertension from IV overdose 4

Pediatric Dosing

• Children ≥30 kg: 0.3–0.5 mg IM (same as adult dose) 2, 3
• Children <30 kg: 0.01 mg/kg IM (maximum 0.3 mg) 1, 2, 3
• Infants: 0.15 mg auto-injector dose is widely prescribed when 0.1 mg formulations are unavailable, especially for infants >7.5 kg 1

Refractory Anaphylaxis (IV/Infusion)

• IV bolus (when IV already in place): 0.05–0.1 mg (50–100 mcg) of 1:10,000 solution, titrated slowly 2, 4
• IV infusion: 5–15 mcg/min (0.05–0.1 mcg/kg/min) with mandatory continuous hemodynamic monitoring 2, 4
• Alternative preparation: Add 1 mg (1 mL of 1:1000) to 250 mL D5W for 4 mcg/mL concentration; infuse at 1–4 mcg/min initially, maximum 10 mcg/min 4

Critical Pitfalls

• Delayed administration is associated with increased mortality—give epinephrine immediately upon recognizing anaphylaxis 2, 5
• Never use IV epinephrine as first-line unless the patient is already in anaphylactic shock with IV access established 4
• Concentration confusion: The 1:1000 (1 mg/mL) IM formulation is 10 times more concentrated than the 1:10,000 (0.1 mg/mL) IV formulation—mixing these causes fatal errors 2

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Cardiac Arrest

For cardiac arrest, administer 1 mg of 1:10,000 adrenaline (0.1 mg/mL) intravenously or intraosseously every 3–5 minutes during ongoing resuscitation. 2, 4, 6

Adult Dosing

• Standard dose: 1 mg IV/IO of 1:10,000 solution every 3–5 minutes 2, 4, 6
• Timing for non-shockable rhythms (asystole/PEA): Administer as soon as feasible after arrest recognition 4
• Timing for shockable rhythms (VF/VT): Give after initial defibrillation attempts have failed 4

Pediatric Dosing

• Standard dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO every 3–5 minutes, maximum 1 mg per dose 2, 4
• Refractory arrest: Consider higher doses of 0.1–0.2 mg/kg using 1:1000 solution for unresponsive asystole or PEA 2, 4

High-Dose Epinephrine

• Not recommended routinely: Doses >1 mg do not improve survival to discharge or neurological outcomes in adults 4
• Historical context: Early studies suggested benefit from high-dose epinephrine (0.2 mg/kg) in pediatric refractory arrest 7, but contemporary guidelines do not support routine use 4

Anaphylaxis Progressing to Cardiac Arrest

• Immediate protocol change: When a patient with anaphylaxis becomes pulseless, discontinue the 0.3–0.5 mg IM regimen and immediately start cardiac arrest dosing of 1 mg IV/IO every 3–5 minutes 2, 4, 6
• Escalated dosing for refractory anaphylactic arrest: Give 1–3 mg IV (1:10,000) over 3 minutes, followed by 3–5 mg IV over 3 minutes, then continuous infusion of 4–10 mg/min if needed 4
• 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 dose required for effective cardiac arrest therapy 2

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Severe Bronchospasm

Adrenaline is not recommended for severe asthma exacerbations; use nebulized albuterol 2.5–5 mg in 3 mL saline (repeated as needed) as the bronchodilator of choice. 4

When Epinephrine May Be Considered

• Anaphylaxis-related bronchospasm: Use standard anaphylaxis dosing (0.3–0.5 mg IM) 1, 6
• Refractory post-intubation bronchospasm (case report): 0.5 mg of 1:10,000 epinephrine in 10 mL normal saline administered endotracheally resulted in immediate improvement in one case 8
• Laryngeal edema with stridor (adjunct): Nebulized epinephrine 1 mg in 5 mL saline may reduce airway edema, but effect is transient (lasting only 2 hours) 9

Important Distinction

• Asthma vs. anaphylaxis: Patients with asthma have markedly higher risk of fatal anaphylaxis and require prompt IM epinephrine when anaphylaxis is the cause of bronchospasm 4
• Post-extubation stridor: Systemic corticosteroids (dexamethasone 0.5–1 mg/kg every 6 hours) are primary treatment, not epinephrine 9

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Septic Shock

Adrenaline is not a first-line vasopressor for septic shock; this guideline does not address septic shock management as the evidence provided focuses on anaphylaxis, cardiac arrest, and bronchospasm.

The evidence provided does not contain guideline recommendations for adrenaline dosing in septic shock. Standard sepsis guidelines typically recommend norepinephrine as the first-line vasopressor, with epinephrine reserved for refractory shock.

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Special Populations & Considerations

Patients on Beta-Blockers

• Potential refractoriness to epinephrine: 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 4
• Mechanism: Beta-blockers antagonize the cardiostimulating and bronchodilating effects of epinephrine 3

Medication Error Prevention

• Pre-filled, color-coded syringes: Hospitals should stock clearly labeled syringes—"ANAPHYLAXIS – INTRAMUSCULAR ONLY" for 1:1000 and "CARDIAC ARREST – IV/IO ONLY" for 1:10,000 2
• Physical separation: Store IM and IV preparations in distinct locations on emergency carts with different color codes 2
• Double-check protocol: Verify (1) clinical scenario (anaphylaxis vs. arrest), (2) correct concentration, (3) intended route, and (4) weight-based dose in children 2

Contraindications

• No absolute contraindication to epinephrine in anaphylaxis: Even in elderly patients with cardiovascular disease or those on beta-blockers, the risk of death from untreated anaphylaxis outweighs potential drug-related risks 1, 4
• Sulfite preservative: Presence of sulfite in epinephrine products should not deter use for anaphylaxis 3

Adverse Effects

• Common: Anxiety, tremor, palpitations, pallor, headache, dizziness 3
• Serious: Arrhythmias (including fatal ventricular fibrillation), rapid rises in blood pressure producing cerebral hemorrhage, angina 3
• Monitoring requirement: Close hemodynamic monitoring is mandatory for patients receiving IV epinephrine, especially in anaphylactic shock 4

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Dosing Algorithm Summary

Clinical Scenario	Route	Adult Dose	Pediatric Dose	Frequency
Anaphylaxis	IM (anterolateral thigh)	0.3–0.5 mg (1:1000)	0.01 mg/kg, max 0.3 mg (1:1000)	Every 5–15 min [1,2,3]
Refractory anaphylaxis	IV bolus	0.05–0.1 mg (1:10,000)	Weight-based	Titrate to response [2,4]
Refractory anaphylaxis	IV infusion	5–15 mcg/min	0.05–0.1 mcg/kg/min	Continuous [2,4]
Cardiac arrest	IV/IO	1 mg (1:10,000)	0.01 mg/kg, max 1 mg (1:10,000)	Every 3–5 min [2,4,6]
Anaphylaxis → arrest	IV/IO	1 mg (1:10,000), escalate to 1–3 mg then 3–5 mg	0.01 mg/kg, consider 0.1–0.2 mg/kg for refractory	Every 3–5 min [2,4]
Laryngeal edema (adjunct)	Nebulized	1 mg in 5 mL saline	1 mg in 5 mL saline	As needed [9]