Epinephrine*

• Epinephrine

• Adrenaline

Classification:

• Adrenergic agonist, Sympathomimetic

Mechanism of Action:

• Stimulates alpha and beta receptors
  • increases heart rate
  • increases AV conduction
  • increases force of myocardial contractility
  • increases vasoconstriction (increases SVR)
• Relaxes bronchial smooth muscle (↓ A/W resistance)
• Increases coronary and cerebral blood flow

Indications:

• Bronchoconstriction
• Stridor
• Symptomatic bradycardia
• Hypotension refractory to fluids
• Allergic reactions
• Cardiac arrest

Contraindications:

•  None in emergency setting

Precautions:

• Cardiovascular disease
• Elderly patients
• Hypertension
• Pregnancy

Adverse Effects:

• Anxiety
• Headache
• Hypertension
• Arrhythmias
• Palpitations
• Tachycardia
• Myocardial ischemia
• Nausea/vomiting
• Tremors

Dose:

• Cardiac arrest:  1.0 mg 1:10,000 IV repeat q 4 mins PRN
• Symptomatic Bradycardia:
  • 2 mcg/min via infusion pump, titrated to effect (max 10 mcg/min)
    • To prepare this epinephrine infusion, use the 0.1 mg/mL (1:10,000) formulation. Add 0.5
      mg (5 mL of the 1:10,000 epinephrine) to a 500 mL normal saline bag. This results in a 1
      mcg/mL solution.
• Anaphylaxis: 
  • 0.3-0.5 mg 1:1,000 IM repeated q 5-20 mins PRN or
  • 0.1mg 1:10,000 IV repeated q 5 minutes PRN
• Near-death anaphylaxis (after 3 IM doses of epinephrine):
  • 2 mcg/min via infusion pump, titrated to effect to a max of 10 mcg/min.
    
    • To prepare this epinephrine infusion, use the 0.1 mg/mL (1:10,000) formulation. Add 0.5
      mg (5 mL of the 1:10,000 epinephrine) to a 500 mL normal saline bag. This results in a 1
      mcg/mL solution.
• Near-death asthma
  • 0.01 mg/kg to a maximum of 0.5 mg of 1 mg/mL (1:1000) IM (lateral thigh), repeated q 5-10 minutes as needed.
• Stridor:
  • 5.0 mg 1:1,000 NEB repeat PRN
  • Infusion: 2-10 mcg/min PRN

• For cardiac arrest: 0.01 mg/kg (0.1 mL/kg) of 0.1 mg/mL (1:10 000) IV/IO OR 0.1 mg/kg (0.1 mL/kg) of 1 mg/mL (1:1000) ETT mixed with 3 mL sterile saline, q 4 minutes as needed.
• Non-hemorrhagic shock (pediatric patients ≤ 16 years):
  • 0.1 mcg/kg/min via infusion pump, titrated by 0.02 mcg/kg/min every 2-5 minutes until the desired effect is achieved to a max of 1 mcg/kg/min.
    • To prepare this epinephrine infusion, use the 1 mg/mL (1:1000) formulation. Add 8 mg (8 mL of the 1:1000 epinephrine) to a 500 mL normal saline bag. This results in a 16 mcg/mL solution.
• For symptomatic bradycardia: 0.01 mg/kg (0.1 mL/kg) of 0.1 mg/mL (1:10 000) IV/IO OR 0.1 mg/kg (0.1 mL/kg) of 1 mg/mL (1:1000) ETT mixed with 3 mL sterile saline, q 4 minutes as needed.
• For anaphylaxis: 0.01 mg/kg (0.01 mL/kg) of 1 mg/mL (1:1000) IM (anterior lateral thigh) (maximum of 0.5 mg), repeated q 5-10 minutes as needed (see Pediatric IM Anaphylaxis Dosing Guide below). See dosing for near-death anaphylaxis below if patient refractory to 3 IM doses.

Pediatric IM Anaphylaxis Dosing Guide

• For near-death anaphylaxis (after 3 IM doses of epinephrine):
  • 0.05 mcg/kg/min via infusion pump, titrated by 0.02 mcg/kg/min every 2-5 minutes until the desired effect is achieved, to a max of 1 mcg/kg/min.
    • To prepare this epinephrine infusion, use the 1 mg/mL (1:1000) formulation. Add 8 mg (8
      mL of the 1:1000 epinephrine) to a 500 mL normal saline bag. This results in a 16
      mcg/mL solution.
• For near-death asthma: 0.01 mg/kg (0.01 mL/kg) of 1 mg/mL (1:1000) IM in anterior lateral thigh (maximum of 0.5 mg), repeated q 5-10 minutes as needed (see Pediatric IM Anaphylaxis Dosing Guide above).
• For stridor: 0.5 mg/kg (0.5 mL/kg) of 1 mg/mL (1:1000) nebulized (maximum of 5 mg) mixed with normal saline to a maximum of 5 mL total volume, repeat as needed.

• IM, NEB, IV, IO

• 1 mg in a 10 mL preloaded syringe (1:10,000 concentration)
• 1 mg in a 1 mL ampoule (1:1,000 concentration)

• Most shock patients require fluid administration prior to vasopressors therefore normal saline should be initiated prior to epinephrine administration.
• It is recommended to administer a normal saline infusion by gravity with any epinephrine infusion. 
• To do this:
  • A.    Initiate a normal saline infusion at a rate appropriate to patient condition via gravity (i.e., not through the pump)
  • B.   Connect the epinephrine infusion (via the pump) to the access port of the normal saline infusion line proximal to the patient
  • C.    This will help as a driver when volumes of medication being infused are small
• Never give epinephrine 1 mg/mL (1:1,000) formulation via the IV or IO route.
• Pregnancy category C [if the patient will benefit from a Category C drug, it is generally used]

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