What are the recommended epinephrine (adrenaline) doses and dilution instructions for adult and pediatric cardiac arrest during ACLS CPR, including intravenous/intra‑osseous and endotracheal administration?

Epinephrine Dosing and Dilution in ACLS CPR

For adult cardiac arrest, administer 1 mg of epinephrine IV/IO every 3-5 minutes using a 1:10,000 dilution (0.1 mg/mL), and for pediatric cardiac arrest, give 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes with a maximum single dose of 1 mg. 1, 2, 3

Adult Dosing

Standard IV/IO Administration

• Dose: 1 mg every 3-5 minutes during cardiac arrest 1, 2
• Dilution: Use 1:10,000 concentration (0.1 mg/mL) 4, 5
• Timing: In shockable rhythms (VF/pVT), administer epinephrine after initial CPR and defibrillation attempts are unsuccessful; in nonshockable rhythms (asystole/PEA), give as soon as feasible 2
• Route preference: IV is preferred, but IO is acceptable if IV access cannot be established quickly 2

Continuous Infusion (Alternative)

For refractory shock or post-arrest hypotension, epinephrine infusion may be prepared: 6

• Add 1 mg (1 mL of 1:1000) to 250 mL D5W = 4 mcg/mL concentration 6
• Infuse at 1-4 mcg/min initially, titrate up to maximum 10 mcg/min 6
• Alternative: 1 mg in 100 mL saline (1:100,000) at 30-100 mL/h (5-15 mcg/min) 6

Pediatric Dosing

Standard IV/IO Administration

• Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) 7, 3
• Maximum single dose: 1 mg (10 mL) 7
• Frequency: Every 3-5 minutes 7, 3
• Timing: Administer during chest compressions to minimize interruptions 7

Endotracheal Route (If IV/IO Unavailable)

• Dose: 0.1 mg/kg (0.1 mL/kg of 1:1000 concentration) - 10 times the IV dose 7
• Administration technique: Stop compressions briefly, instill medication deep into airway, flush with 5 mL normal saline, follow with 5 positive-pressure ventilations 7
• Important caveat: Endotracheal administration is significantly less effective than IV/IO routes and should only be used when vascular access is not available 7, 8

Critical Pitfalls and Considerations

Route Selection

The endotracheal route is substantially inferior to IV/IO administration. Studies demonstrate that endotracheal epinephrine produces reduced return of spontaneous circulation (ROSC) and lower survival compared to vascular delivery 7. One study showed that endotracheal doses up to 10 mcg/kg (one-third of recommended resuscitation dose) had no effect on blood pressure or heart rate, while IV doses of 0.1 mcg/kg produced significant hemodynamic effects 8. The lower concentrations achieved via endotracheal route may paradoxically cause transient β2-adrenergic vasodilation, potentially lowering coronary perfusion pressure 7.

High-Dose Epinephrine

High-dose epinephrine (>1 mg in adults, >0.01 mg/kg in children) is NOT recommended for routine use. Multiple trials show no benefit for survival to discharge or favorable neurologic outcomes, despite improved ROSC rates 1, 2. In pediatric patients, high-dose epinephrine may be harmful, particularly in asphyxial arrest 7. Consider high-dose only in exceptional circumstances such as β-blocker or calcium channel blocker overdose 7.

Timing Considerations

• In adults with shockable rhythms, prioritize rapid defibrillation over epinephrine administration 2
• One observational study found 10% lower survival in hospitals with highest rates of epinephrine before initial defibrillation 2
• For nonshockable rhythms, early epinephrine (within first 3-9 minutes) is associated with improved survival 1
• Recent evidence suggests cumulative doses >3 mg during ECPR may be associated with worse neurologic outcomes 9

Preparation and Administration

• Prepare drug doses before rhythm checks to enable immediate administration 7
• Administer during chest compressions; timing of drug administration is less important than minimizing compression interruptions 7
• Avoid central venous access attempts that delay compressions or defibrillation unless performed by highly trained personnel 2

Evidence Limitations

Despite decades of use, epinephrine improves ROSC and survival to hospital admission but has not been shown to improve survival with favorable neurologic outcome. 1, 2, 10 The 2020 AHA guidelines acknowledge this limitation but maintain epinephrine as standard therapy because short-term survival is a prerequisite for meaningful recovery, and no feasible intra-arrest method exists to predict neurologic outcome 2.