Class: alpha- and beta-Adrenergic Agonists
VA Class: AU100
CAS Number: 51-43-4
Brands: Adrenalin Chloride, EpiPen Auto-Injector, EpiPen Jr., Primatene
Introduction
Epinephrine is an endogenous catecholamine that is the active principle of the adrenal medulla; epinephrine acts directly on both α- and β-adrenergic receptors.
Uses for Epinephrine
Bronchospasm
Has been used as as a quick-relief bronchodilator for symptomatic treatment of acute symptoms and exacerbations of bronchial asthma and reversible bronchospasm associated with chronic bronchitis, emphysema, and other obstructive pulmonary diseases.a 160 162 166 168 However, generally should be used only when selective β2-agonists are not readily available, since excessive cardiac stimulation (e.g., increased heart rate, myocardial irritability, increased oxygen demand) can occur with nonselective agents, particularly at high doses.160 162 174 d
Orally inhaled selective β2-agonists currently are recommended for prehospital management of asthma exacerbations (e.g., in emergency medicine facilities and/or ambulances) and for acute asthma management in emergency rooms and hospitals.160 161 162 Reserve sub-Q epinephrine for severe exacerbations when selective agents are not readily available or are ineffective.160 161 162 174 d No proven advantage of systemically administered (e.g., sub-Q) epinephrine therapy over orally inhaled therapy for the acute management of asthma exacerbations.160 162 Parenteral epinephrine may be particularly useful in treating anaphylaxis and angioedema coexisting with asthma.174
Nebulized bronchodilator therapy generally should be reserved for patients who are unable to coordinate inhalation via an MDI because of their age, agitation, or exacerbation severity.160
Regular, daily use of a short-acting, inhaled β-agonist generally is no longer recommended for maintenance therapy of asthma.160 Current asthma guidelines emphasize long-term control with anti-inflammatory agents (e.g., corticosteroids), and concomitant anti-inflammatory therapy with an inhaled corticosteroid is recommended whenever inhaled β-agonist bronchodilators are used for maintenance.130 131 132 138 140 141 147 148
Sensitivity Reactions
Drug of choice in the emergency treatment of severe acute anaphylactic reactions, including anaphylactic shock, which can be profound and life-threatening.a 161 163 164 d
May relieve anaphylactic symptoms (e.g., urticaria, pruritus, angioedema, wheezing, dyspnea, hypotension, swelling of the lips, eyelids, and tongue) caused by reactions to drugs, contrast media, sera, insect stings or bites, foods (e.g., milk, eggs, fish, shellfish, peanuts, tree nuts), latex, or other allergens as well as idiopathic or exercise-induced anaphylaxis.a 161 163 d
Give to all patients with signs of shock, airway swelling, or definite breathing difficulty.161 d Drug of choice for the treatment of both vasodilation/hypotension and cardiac arrest associated with anaphylaxis.161 d
Parenteral administration (IM route favored)d is preferred for the treatment of anaphylaxis.a d Administer IV if anaphylaxis appears to be severe with immediate life-threatening manifestations.161 d Absorption and subsequent achievement of peak plasma concentrations after sub-Q injection is slower and may be substantially delayed in patients with shock.161 d
High IV doses (i.e., rapid progression to high dose) should be used without hesitation in any patient in full cardiac arrest.161 d
If necessary, institute other measures for management of cardiac arrhythmias, laryngeal edema, or bronchospasm.a Once adequate ventilation is ensured, maintenance of BP in anaphylactic shock should be achieved with other pressor agents (e.g., norepinephrine, metaraminol).a
Close monitoring critical; fatal overdose of epinephrine reported.d
Risk of paradoxical response to epinephrine in patients receiving β-adrenergic blocking agents; consider glucagon and/or ipratropium for treatment of anaphylaxis in these patients.d Increased incidence and severity of anaphylaxis in patients receiving β-adrenergic blocking agents.d
CPR and Cardiac Arrhythmias
Used for its α-adrenergic stimulatory effects to increase blood flow in ACLS during CPR.a 161 d The principal beneficial effects in patients with cardiac arrest result from increases in aortic diastolic blood pressure and in myocardial and cerebral blood flow during resuscitation.a 161 d The value and safety of the β-adrenergic effects are controversial because they may increase myocardial work and reduce subendocardial perfusion.161 d
A drug of choice and a high priority for ACLS in cardiac arrest to facilitate return of spontaneous circulation (ROSC); generally used after failure of artificial ventilation, external or internal cardiac compression, and initial defibrillation to restore effective circulation.a 161 d
Cardiac arrest: May be administered IV, intraosseously, or intracardially or by direct instillation into the tracheobronchial tree via an endotracheal tube to restore cardiac rhythm as an adjunct in the management of cardiac arrest.a 161 169 170 d
Asystole: Restores cardiac electrical activity in asystole and, in some cases, restores myocardial contractility in electromechanical dissociation.a 161
Impending pulseless electrical activity: May produce beneficial vasopressor effects in patients who are not in cardiac arrest but who have other indications for vasopressor therapy161 (e.g., in those with severe bradycardia and hypotension who are close to pulseless electrical activity or even asystole).a
Bradycardia: Treatment of symptomatic bradycardia unresponsive to atropine, as a temporizing measure while awaiting availability of a pacemaker (e.g., out-of-hospital setting) or if pacing ineffective.d
Drug-induced cardiovascular emergencies or altered vital signs: May consider use in bradycardia or shock associated with β-adrenergic or calcium-channel blocking agent or tricyclic antidepressant toxicity.d
Anesthesia accidents: May be useful in treating cardiac arrest following anesthesia accidents, but should be used with extreme caution, if at all, in patients receiving cyclopropane or halogenated hydrocarbon general anesthetics.a (See General Anesthetics under Interactions.)
Heart block: Has been used in the treatment of syncope and/or bradycardia resulting from AV nodal block, but has largely been replaced by isoproterenol.a Electrical cardiac pacemakers have largely replaced drug therapy in third-degree AV nodal block (complete heart block).a
Radiographic Uses
Has been given intra-arterially† as an adjunct to radiographic contrast media in arteriography†.a
GI and Renal Hemorrhage
Has been administered intra-arterially† via the celiac artery, inferior mesenteric artery, or superior mesenteric artery to control hemorrhage in patients with severe GI bleeding†.a
Has been administered intra-arterially† via the renal artery to control hemorrhage in patients with renal arterial bleeding†.a
Radiation Nephritis
Has been injected into a renal artery prior to and during irradiation of the abdominal area to protect the kidney from radiation nephritis†.a
Adjunct to Local Anesthesia
May be added to solutions of some local anesthetics to decrease the rate of their vascular absorption (to localize and prolong the duration of anesthesia and decrease the risk of systemic toxicity).a
Superficial Bleeding
May be applied topically to control superficial bleeding from arterioles or capillaries in the skin, mucous membranes, or other tissues.a Bleeding from larger vessels is not controllable by topical application.a
Cardiogenic, Hemorrhagic, and Traumatic Shock
Should not be used in cardiogenic shock (because it increases myocardial oxygen demand) or in hemorrhagic or traumatic shock.a
Premature Labor
Has been used to relax uterine musculature and inhibit uterine contractions in premature labor† (tocolysis); however, the cardiovascular and other adverse effects limit its usefulness.a (See Pregnancy under Cautions.) Other β-agonists (e.g., terbutaline) preferred.165 173
Hypoglycemia
Has been used parenterally to correct hypoglycemia† in insulin shock; however, dextrose and/or glucagon is more effective.a
Epinephrine Dosage and Administration
Administration
Administer by sub-Q, IM, or IV injection or by IV infusion.a 160 161 162 163 164 169 d Also may be administered intra-arterially† (e.g., for radiography, for local control of bleeding).a
In extreme cardiac emergencies, may be administered intracardially, via an endotracheal tube, or by intraosseous infusion†.a 161 169 170 Although endotracheal administration of epinephrine is possible, IV or intraosseous† administration is preferred because of more predictable drug delivery and pharmacologic effect.d
Rapid IV injection (bolus dose) or endotracheal administration of epinephrine may cause failure of exhaled carbon dioxide detectors (used to confirm endotracheal tube placement in the trachea during cardiac arrest) despite adequate placement (i.e., false-negative reading).d Use a second method to confirm tube placement.d
For bronchodilation, administer by oral inhalation via a metered-dose inhaler (MDI), nebulization, or intermittent positive-pressure breathing (IPPB) apparatus or inject sub-Q or IM.a 160 162 166 168
Apply topically to the skin and mucous membranes for local hemostasis.a
Sub-Q Injection
Injections containing 1 mg/mL preferably are administered sub-Q.a 160 162 169 However, absorption and subsequent achievement of peak plasma concentrations is slower and may be substantially delayed if shock is present.a 161 d
IM Injection
Injections containing 1 mg/mL also may be injected IM, but IM injection into the buttocks should be avoided.a 160 161 162 169 172 d
For self-medication, instruct patients and their caregivers about proper administration techniques using the auto-injector provided by the manufacturer.163 164 d First aid providers should be familiar with the auto-injector in order to assist patients having an anaphylactic reaction with self-medication, and they should be able to administer the auto-injector, if a patient is unable to self-administer, provided that state law permits it and valid prescription exists.d
Technique for Using Auto-injector
Inject the age-appropriate dose IM only into the anterolateral aspect of the thigh.163 164
The patient should grasp the prefilled auto-injector with the black tip pointed downward; the grey activation cap should be removed.164 Point the black tip toward the outer thigh, swing and jab it firmly into the outer thigh so that the auto-injector is perpendicular (90° angle) to the thigh, and hold firmly in the thigh for several seconds until the dose is delivered.164 Administer through clothing if necessary.163 Massage injection area for several seconds.164 If the needle is not exposed at the black tip, repeat administration.164
Never put thumb, fingers, or hand over the black tip.164
Do not remove the grey activation cap until ready to use.164
The auto-injector is overfilled and most of the solution (90%) will remain after injection of the age-approriate dose and cannot be reused.164
After use, bend the needle back against a hard surface.164 Then, deliver the used auto-injector to a health-care provider for proper disposal.164
IV Administration
Emergency situations: Inject very slowly IV as a dilute solution or infuse slowly IV.a When injected peripherally, 1–2 minutes generally are required to reach central circulation.161 d
Severe asthma or anaphylaxis: IV therapy may be necessary (e.g., for severe anaphylactic shock with immediate life-threatening manifestations) when drug absorption from sub-Q or IM injection is likely to be impaired.a d
CPR: When a vein has not been cannulated prior to the arrest, a peripheral vein (antecubital or external jugular in adults and the largest most accessible vein that does not interrupt resuscitation in pediatric patients) is preferred since central venous access requires interruption of chest compressions, is technically more difficult, and is associated with an increased risk of complications.161 Venous access can be challenging in infants and children during an emergency, whereas intraosseous access can be easily achieved.d Limit the time attempting venous access; if reliable access cannot be achieved quickly, establish intraosseous access.d
If a central venous catheter is already in place at the time of arrest, it can be used because of more rapid onset (in adults), more secure access to circulation, and avoidance of tissue infiltration.161 d Tissue infiltration may lead to local ischemia, tissue injury, and ulceration.d Avoid central venous line placement in patients who are candidates for pharmacologic reperfusion (e.g., with thrombolytic therapy).161 d
Dilution
Prepare infusion solutions containing 2 or 4 mcg/mL by adding 1 mg to 500 or 250 mL of a compatible IV solution, respectively.a 101 d
Prepare solutions containing 0.05 mg/mL by adding 0.5 mg (0.5 mL of a 1:1000 injection) to 10 mL of 0.9% sodium chloride injetion.169
Prepare a 1:10,000 solution (0.1 mg/mL) by diluting 1 mL of a commercially available 1:1000 injection (1 mg/mL) with 10 mL of water for injection or 0.9% sodium chloride injection.a Alternatively, a commercially available 1:10,000 (0.1 mg/mL) injection can be used.170
Prepare a 1:100,000 solution (0.01 mg/mL) by diluting 0.1 mL of a commercially available 1:1000 injection (1 mg/mL) with 10 mL of 0.9% sodium chloride injection.a
Rate of Administration
Severe asthma or anaphylaxis: Inject IV slowly (e.g., over 5–10 minutes) or administer by rapid IV injection (i.e., bolus).a 101
Alternatively in adults, infuse IV at an initial rate of 1 mcg/minute, increasing to 4 mcg/minute as needed.a
In children after an initial 1-mcg/kg IV bolus, infuse IV at an initial rate of 0.1 mcg/kg per minute, increasing gradually up to 1.5 mcg/kg per minute as needed.101
CPR: Inject doses by IV push in adults, repeating at 3- to 5-minute intervals as needed;161 170 d follow each dose injected peripherally with a 20-mL flush of IV fluid to ensure distribution into the central compartment;161 d if injected IV in an extremity, elevate the extremity for 10–20 seconds.d
In children, infuse IV at an initial rate of 0.1 mcg/kg per minute, increasing gradually to a maximum of 1 mcg/kg per minute as needed for CPR.a d
Bradycardia or hypotension (i.e., nonarrest rate): In adults, infuse IV at an initial rate of 1 mcg/minute, titrating to hemodynamic response at rates ranging from 2–10 mcg/minute.161 d Assess intravascular volume and support as needed.d
In children, infuse IV at a rate of 0.1–0.2 mcg/kg per minute for refractory bradycardia.161
Intra-arterial Administration
Injections have been administered intra-arterially† for local effects (e.g., to control local bleeding, prevent radiation nephritis, as an adjunct to arteriography).a
Rate of Administration
GI hemorrhage: 8–20 mcg/minute infused into the celiac or inferior or superior mesenteric artery†.a
Renal hemorrhage: 10 mcg/minute infused into the renal artery†.a
Radiation nephritis: 3–7.6 mcg/minute infused into the renal artery†.a
Adjunct to arteriography: 8–12 mcg/minute infused into the celiac or superior mesenteric artery†.a
Intracardiac Injection
Limit intracardiac injection to personnel well trained in the technique and generally use only during open cardiac massage or when other routes of administration are persistently inaccessible.a 161 170
Inject into the left ventricular chamber.170
Follow intracardiac administration by external cardiac massage to ensure entry of the drug into the coronary circulation.a
Suspensions must not be administered intracardially.a
Administration Risks
Hazards include coronary artery laceration, cardiac tamponade, pneumothorax, and the need to interrupt external chest compressions and ventilation during the period of administration.a 161
Endotracheal Administration
Limit endotracheal administration to personnel well trained in the technique.a 161
In intubated patients, doses can be instilled directly into the bronchial tree via the endotracheal tube.170
Pass a catheter beyond the tip of the tracheal tube, stop chest compressions, inject the drug solution directly into the tracheal tube, follow immediately with several quick insufflations to create a rapidly absorbed aerosol, and then resume compressions.161 d
For pediatric patients, flush with a minimum of 5 mL of 0.9% sodium chloride injection after each dose.d
For pediatric patients, administration via a tracheal tube is preferred to a catheter or feeding tube because these latter 2 methods often are cumbersome and depend on finding the correct-size catheter to place through the tracheal tube.161
Dilution
Adults: Dilute dose in 5–10 mL of 0.9% sodium chloride or sterile water.a d Systemic absorption may be increased by diluting in sterile water instead of 0.9% sodium chloride;a d however, sterile water may have a more negative effect on arterial oxygen pressure (PaO2) than sodium chloride.a Alternatively, a commercially available 1:10,000 (0.1 mg/mL) injection may be administered undiluted via the endotracheal tube.170
Intraosseous Administration
When IV administration is not possible, epinephrine may be given by intraosseous administration for emergency uses such as CPR.161 d
Limit intraosseous administration to personnel well trained in the technique.a 161
Place a cannula in a noncollapsible marrow venous plexus; such access often can be achieved in 30–60 seconds.161
Use a rigid needle, preferably a specially designed intraosseous or Jamshidi-type bone marrow needle; a styleted needle is preferred to prevent obstruction of the needle with cortical bone.161
Insert the intraosseous needle into the anterior tibial bone marrow; alternatively, the distal femur, medial malleolus, or anterior superior iliac spine can be used.161
In older children and adults, intraosseous cannulas also have been inserted successfully into the distal radius or ulna as well as the proximal tibia.161
Successful intraosseous placement outside the hospital (e.g., by emergency medical services) generally is more difficult in older than in younger children.161
Onset of action and systemic concentrations are comparable to those achieved with central venous administration.161 d
Administration Risks
Complications are uncommon (less than 1% of patients), and include tibial fracture, lower-extremity compartment syndrome, extravasation, and osteomyelitis; careful technique can minimize the risk.161 Local effects on bone marrow and bone growth appear to be minimal.161 Risk of microscopic pulmonary fat and bone marrow emboli does not appear to be increased.161
Oral Inhalation
Epinephrine base or hydrochloride may be administered via oral inhalation using a nebulizer, aerosol (metered-dose inhaler [MDI]), or intermittent positive-pressure breathing (IPPB) apparatus.a 166 168
For nebulization, use a glass or plastic nebulizer capable of delivering a very fine mist and that works effectively with a very small volume of solution.168 Place the dose in the nebulizer reservoir and then place the nozzle just inside the partially opened mouth.168 Squeeze the bulb once or twice, inhaling deeply to draw the vaporized solution into the lungs.168 Rinse mouth with water immediately to prevent oropharyngeal dryness.168
Solutions intended for oral inhalation are more concentrated than those intended for injection and must not be administered parenterally.a 168
Do not administer oral inhalation solutions intranasally.168
Topical Administration
Apply solutions topically as a spray or on cotton or gauze to the skin, mucous membranes, or other tissues.a
Dosage
Available as epinephrine and epinephrine hydrochloride; dosage expressed in terms of epinephrine.a 163 166 168
Pediatric Patients
Bronchospasm
Treatment of Acute Exacerbations of Asthma
Oral Inhalation
Children ≥4 years of age: 220 mcg (1 inhalation) of epinephrine via an MDI, repeated once if necessary after at least 1 minute; do not administer subsequent doses for at least 3 hours.a 166
Children ≥4 years of age: After placing approximately 10 drops of 1% (1:100) epinephrine in the nebulizer reservoir, administer 1–3 deep inhalations via the hand-bulb.a 168 Do not repeat more often than every 3 hours; use the least number of inhalations producing relief.a 168
Sub-Q
For severe asthma, inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection)a 160 162 or 0.3 mg/m2 (0.3 mL/m2 of a 1:1000 injection) sub-Q.a 169
Single pediatric doses should not exceed 0.3–0.5 mg every 20 minutes as needed for up to 3 consecutive doses.160 162 a 160 162 169
IV
Neonates: Inject 0.01 mg/kg IV.170 172
Infants: Inject 0.05 mg IV initially, repeated at 20- to 30-minute intervals as needed.170 172
Sensitivity Reactions
Anaphylaxis
IM
Inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection) (up to 0.5 mg/dose), repeated every 10–20 minutes as needed for up to 3 consecutive doses.101
For self-administration using a prefilled auto-injector (e.g., EpiPen), inject 0.15 or 0.3 mg, depending on body weight; a dose of 0.01 mg/kg generally is recommended.163 Clinicians may recommend higher or lower doses depending on individual patient needs and considering the life-threatening nature of anaphylaxis.163 The 0.15-mg dose may be more approriate for children <30 kg.163 If doses <0.15 mg are considered more appropriate, alternative injectable forms of the drug should be used.163 For severe persistent anaphylaxis, repeated doses may be needed.163
Sub-Q
Inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection) or 0.3 mg/m2 (0.3 mL/m2 of a 1:1000 injection) sub-Q.a 169 Single pediatric doses should not exceed 0.5 mg, repeated as needed at 20-minute to 4-hour intervals depending on the severity of the condition and the response of the patient.a 169
IV
In severe anaphylactic shock, IV administration may be necessary since absorption may be impaired with sub-Q or IM administration.a 101
If necessary, inject an initial dose of 10 mcg/kg (0.1 mL/kg of a 1:10,000 dilution), followed by a continuous IV infusion at an initial rate of 0.1 mcg/kg per minute (using a diluted solution containing 4 mcg/mL); the infusion may be increased as necessary to a maximum of 1.5 mcg/kg per minute to maintain BP.101
Neonates, alternatively: Inject 0.01 mg (10 mcg)/kg.170 172
Infants, alternatively: Inject 0.05 mg (50 mcg) initially, repeated at 20- to 30-minute intervals as needed.170 172
CPR and Cardiac Arrhythmias
Bradycardia and Pediatric Advanced Life Support
IV
Neonates: The usual dose is 0.01–0.03 mg/kg (0.1–0.3 mL/kg of a 1:10,000 injection),d repeated every 3–5 minutes if necessary for CPR or bradycardia.a 161 Higher IV doses are not recommended161 d because of risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function.d
Pediatric Patients: The usual initial dose is 0.01 mg/kg (0.1 mL/kg of a 1:10,000 injection), up to a maximum single dose of 1 mg, for CPR or bradycardia,a 161 d e repeated every 3–5 minutes as needed.161 d Higher IV doses not recommended; use a standard dose for the first and subsequent doses.d No survival benefit from routine use of high-dose epinephrine; may be harmful, particularly in asphyxia.d Risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function with high doses.d May consider high-dose epinephrine in certain circumstances (e.g., β-adrenergic blocking agent overdose).d
Pediatric Patients: Alternatively, infuse at an initial rate of 0.1 mcg/kg per minute; increase the rate in increments of 0.1 mcg/kg per minute, if necessary, to a maximum of 1 mcg/kg per minute.a d Low-dose infusions (<0.3 mcg/kg per minute) generally produce predominantly β-adrenergic effects,161 while higher-dose infusions (>0.3 mcg/kg per minute) generally result in α-adrenergic vasoconstriction, but there is substantial interindividual variation in catecholamine response, and infusion dosage should be titrated to the desired effect.d
Pediatric patients: For refractory bradycardia, consider continuous infusiond at a rate of 0.1–0.2 mcg/kg per minute.161
Intraosseous
Pediatric patients: The usual initial dose is 0.01 mg/kg (0.1 mL/kg of a 1:10,000 injection), up to a maximum single dose of 1 mg, for CPR or bradycardia,a 161 d e repeated every 3–5 minutes as needed.161 d Higher intraosseous doses are not recommended; use a standard dose for the first and subsequent doses.d No survival benefit from routine use of high-dose epinephrine; may be harmful, particularly in asphyxia.d Risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function with high doses.d May consider high-dose epinephrine in certain circumstances (e.g., β-adrenergic blocking agent overdose).d
Endotracheal
Optimum dose not established.a 161 d
Neonates: IV administration (of 0.01–0.03 mg/kg per dose [0.1–0.3 mL/kg of a 1:10,000 injection])161 is the preferred route.a d If the endotracheal route is used, doses of 0.01 or 0.03 mg/kg will likely be ineffective.d Although safety and efficacy have not been established, consider endotracheal administration of a higher dose (up to 0.1 mg/kg) while access is being obtained.a d
Pediatric patients: The usual initial dose is 0.1 mg/kg (0.1 mL/kg of a 1:1000 injection), up to a maximum single dose of 10 mg, for CPR or bradycardia,a 161 d e repeated every 3–5 minutes as needed.161 d
Generally flush the dose with a minimum of 5 mL of 0.9% sodium chloride injection followed by 5 assisted manual ventilations to promote absorption.161 a d
Intracardiac
Pediatric patients: 0.005–0.01 mg/kg (0.05–0.1 mL/kg of a 1:10,000 injection).a
Adults
Bronchospasm
Treatment of Acute Exacerbations of Asthma
Oral Inhalation
220 mcg (1 inhalation) of epinephrine via an MDI, repeated once if necessary after at least 1 minute; do not administer subsequent doses for at least 3 hours.a 166
After placing approximately 10 drops of 1% (1:100) epinephrine in the nebulizer reservoir, administer 1–3 deep inhalations via the hand-bulb.a 168 Do not repeat more often than every 3 hours; the least number of inhalations producing relief should be used.a 168
Sub-Q
For severe asthma, the usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a
May give at 20-minute to 4-hours intervals depending on the severity of the condition and patient response.a
Alternatively, may administer 0.01 mg/kg (concentration of 1:1000) divided into 3 doses of approximately 0.3 mg, given at 20-minute intervals.a d
IM
For severe asthma, the usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a
IV
0.1–0.25 mg injected slowly.170
Sensitivity Reactions
Anaphylaxis
IM
The usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a
For the treatment of reactions caused by drugs that were given IM, epinephrine may be administered at the site of injection of the other drug to minimize further absorption.a
Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a
Alternatively, inject 0.3–0.5 mg (0.3–0.5 mL of a 1:1000 injection),161 repeated every 15–20 minutes, as needed.d
For self-administration using a prefilled auto-injector (e.g., EpiPen), inject 0.3 mg.163 Clinicians may recommend higher or lower doses depending on individual patient needs and considering the life-threatening nature of anaphylaxis.163
For severe persistent anaphylaxis, repeated doses may be needed.163
Sub-Q
Consider the possibility that drug absorption from sub-Q injection may be inadequate in anaphylaxis, particularly with shock.161 d
The usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a For the treatment of reactions caused by drugs that were given sub-Q, epinephrine may be administered at the site of injection of the other drug to minimize further absorption.a
Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a
May be given at 20-minute to 4-hours intervals depending on the severity of the condition and patient response.a
Alternatively, inject 0.3–0.5 mg every 20 minutes as needed for up to 3 doses.160 162
IV
In severe or life-threatening anaphylaxis, IV administration may be necessary since absorption may be impaired with sub-Q or IM administration.a 101 161 d
If necessary, inject 0.1–0.25 mga 161 172 d (e.g., 1–2.5 mL of a 1:10,000 injection or dilution) slowly and cautiously (e.g., over 5–10 minutes), and repeat every 5–15 minutes as necessary or follow by a continuous infusion at an initial rate of 1 mcg/minute, increasing the rate to up to 4 mcg/minute as necessary.a 161 d Individual doses up to 0.5 mg also have been used.161
To optimally control administration, some clinicians recommend an initial dose of 0.1 mg (10 mL of a 1:100,000 injection or dilution) given over 5–10 minutes, followed by a continuous infusion as necessary.100
Alternatively, 0.025–0.05 mg (0.25–0.5 mL of a 1:10,000 injection) be given every 5–15 minutes following initial sub-Q or IM administration of 0.5 mg.a
CPR and Cardiac Arrhythmias
The optimum dose of epinephrine during CPR remains controversial.103 104 115 116 117 118 119 120 121 122 123 125 126 127 The usual dose of 0.5–1 mg has been questioned since it is not based on body weight103 104 117 119 120 and may be lower than necessary for optimum cardiovascular effects.103 104 117 119 121 127
CPR (Cardiac Arrest)
IV
Inject 1 mg every 3–5 minutes.161 d
Has been infused at an initial rate of 1 mcg/minute and, increased to 3–4 mcg/minute as needed, via a central line to reduce the risk of extravasation and ensure good bioavailability.161
Higher (>1-mg) doses may be indicated in certain circumstances, (e.g., β-adrenergic or calcium-channel blocking agent overdose).d
Intraosseous
Intraosseous doses generally are the same as those administered IV.a d
Usually, 1 mg every 3–5 minutes.d
Endotracheal
Optimum dose not established.a 161 d
If IV or intraosseous access is delayed or cannot be established,d endotracheal doses 2–2.5 times those administered IV (i.e., 2–2.5 mg) are recommended.a 161 d
Intracardiac
Inject 0.1–1 mg (usually as 1–10 mL of a 1:10,000 injection) into the left ventricular chamber.a 161 170 172
Sub-Q
Following initial IV administration, 0.3 mg may be injected sub-Q.a
Persistent or Recurrent Ventricular Fibrillation/Tachycardia
IV
Inject 1 mg by rapid injection (IV push) every 3–5 minutes.161 d
Pulseless Electrical Activity
IV
Inject 1 mg by rapid injection (IV push) every 3–5 minutes.161 d
Asystole
IV
Inject 1 mg by rapid injection (IV push) every 3–5 minutes.161 d
Bradycardia:
IV
For symptomatic bradycardia without cardiac arrest, infuse at an initial rate of 1 mcg/minute; subsequent dosage is adjusted according to the patient’s response and generally ranges from 2–10 mcg/minute.a 161 d
Radiographic Use
Arteriography
IV
As an adjunct in arteriography†, 16–24 mL of sodium chloride injection containing 1 mcg of epinephrine per mL has been infused into the celiac or superior mesenteric artery† over 2 minutes; the radiographic contrast medium was administered 7–10 minutes later.
Hemorrhage
GI
Intra-arterial
To control GI bleeding†, infuse into the celiac artery†, inferior mesenteric artery†, or superior mesenteric artery† at a rate of 8–20 mcg/minute for 4 minutes to 3 hours.
Renal
Intra-arterial
To control bleeding from the kidney†, infuse into the renal artery† at a rate of 10 mcg/minute for 10 minutes.a
Radiation Nephritis
Abdominal Irradiation
Intra-arterial
To prevent radiation nephritis†, infuse into the renal artery† at a rate of 3–7.6 mcg/minute for 4–10 minutes prior to and continued during the period of abdominal irradiation.a
Adjunct to Local Anesthesia
Local Injection
To localize and prolong the duration of local anesthesia, epinephrine may be used in concentrations of 1:500,000 to 1:50,000; 1:200,000 is used most commonly.a 172
Superfic
