Epinephrine
Classification
high alert medication
Sympathomimetic
Indications
FR: Anaphylaxis via autoinjector
⚠️ EMR: Requires completion of scope expansion education. Anaphylaxis
PCP: Anaphylaxis
PCP: Severe bronchospasm
PCP: Stridor (secondary to croup or other infectious cause)
ACP: Cardiac arrest
ACP: Severe anaphylaxis or asthma/bronchospasm refractory to IM administration
ACP: Significant bradycardia
ACP: Shock/hypotension (distributive/cardiogenic)
Contraindications
Contraindications:
- There are no absolute contraindications to epinephrine use in life-threatening situations such as anaphylaxis
Cautions:
- Cardiovascular disease, hypertension, diabetes, hyperthyroid, cerebrovascular disease
Adult dosages
FR: Anaphylaxis
- 1 dose via autoinjector to lateral thigh as directed by device instructions
- If no response after 5 minutes, may be repeated once via new autoinjector.
EMR: Anaphylaxis
- ⚠️ EMR requires completion of scope expansion education:
- 0.5 mg IM every 5 minutes; may repeat up to 3 times
PCP: Severe Asthma or Bronchospasm or impending respiratory arrest
- CliniCall consultation recommended prior to administration.
- 0.5 mg IM every 5-20 minutes
ACP: Severe anaphylaxis or Asthma and Bronchospasm refractory to IM administration
- 50-100 mcg IV/IO q 2-5 minutes prn
ACP: Cardiac arrest
- 1 mg IV/IO every 3-5 minutes
ACP: Significant bradycardia
- Infusion: 2-10 mcg/minute IV/IO infusion
ACP: Shock or Hypotension (distributive, cardiogenic) to achieve a MAP greater than 65 mmHg or adequate perfusion
- Infusion: starting 5mcg/min, usual range 2 - 20mcg/min (max 80mcg/min)
OR
- Direct: 10mcg IV q 2-5 minutes prn
Pediatric Considerations And Dosing
FR: Anaphylaxis
- 1 dose via autoinjector to lateral thigh as directed by device instructions
- If no response after 5 minutes, may be repeated once via new autoinjector.
EMR: Anaphylaxis
- ⚠️ EMR requires completion of scope expansion education:
- 0.01 mg/kg IM to a maximum of 0.5 mg; may repeat up to 3 times
- If no response after 5 minutes, may be repeated once via new autoinjector.
PCP: Severe Asthma or Bronchospasm with impending respiratory arrest
- CliniCall consultation recommended prior to administration.
- 0.01 mg/kg IM (maximum 0.5 mg)
PCP: Stridor (secondary to croup or other infectious process) Westley Croup Score
- 5 mg by nebulizer mask over 10-15 minutes, may repeat in 3 hours if required
- CliniCall consultation recommended to discuss care planning options.
- Requires additional training
ACP: Cardiac arrest
Non-neonatal cardiac arrest
- 0.01 mg/kg IV/IO (maximum 1mg) in non-neonatal cardiac arrest
- 0.02 mg/kg IV/IO for initial dose; escalate to 0.03 mg/kg IV/IO for subsequent doses where required if heart rate does not increase above 60 bpm
ACP: Severe anaphylaxis or asthma/bronchospasm refractory to IM administration
- 5 mcg/kg IV/IO
ACP: Autonomic stability during intubation
- 1 mcg/kg slow push IV/IO every 2-5 minutes
ACP: Shock (cardiogenic, distributive) to maintain MAP greater than 65 mmhg
- Infusion: 0.01 – 1 mcg/kg/min
OR
- Direct: 1 mcg/kg IV/IO q 2-5 minutes prn
Preparation and Administration
Infusion
Adult
Standard solution concentrations:
- 4 mcg/mL: dilute 1mg in 250 mL NS
- 12 mcg/mL: dilute 3 mg in 250 mL NS
Pediatric
Standard solution concentrations:
- 4mcg/mL: dilute 1mg in 250mL NS
- 25 mcg/mL: dilute 1.25mg in 50mL NS
Direct
Standard concentration adult and pediatric
- 10mcg/mL : dilute 0.1mg in 9mL of NS
- Withdraw 0.1mg (1mL) of 1mg/10mL prefilled syringe in 20mL syringe
- Dilute with 9mL of NS
Mechanism Of Action
epinephrine acts on alpha and beta-adrenergic receptors. Alpha-adrenergic activity produces vasoconstriction and reduces vascular permeability; beta-adrenergic activity results in bronchial smooth muscle relaxation, increased heart rate, and increased force of cardiac contractility. Epinephrine also inhibits histamine release.
Pharmacokinetics
IV
Onset: 30 seconds
Peak: 3-5 minutes
Duration 5-10 minutes
IM
Onset: 30-90 seconds
Peak: 4-10 minutes
Duration: 5-10 minutes
Adverse Effects
- Common reactions to systemically administered epinephrine include anxiety, tremor, dizziness, sweating, palpitations, headache, and nausea
- Increase heart rate and blood pressure and risk of arrhythmias
- Accidental injection of epinephrine into a digit, hands, or feet may result in a loss of blood flow to the area
- Extravasation may cause ischemia or tissue necrosis
Overdose
Epinephrine overdose may produce significantly elevated blood pressures and heart rate, which may in turn cause cerebral hemorrhage.
Warning And Precautions
Warning: EPINEPHrine vials must be stored in specially marked containers and never co-mingled with other medications in kits or bins. Inadvertent administration of EPINEPHrine to patients has the potential to cause serious harm or death.
Patients with underlying coronary artery disease may develop signs and symptoms of angina or myocardial ischemia. Caution should be exercised in these cases.
Caution should be used in patients with significant tachydysrhythmias or in the context of hypothermia.
Drug Interactions
Arrhythmias can develop in patients taking antiarrhythmic medications. Beta-adrenergic blocking drugs can limit the effectiveness of EPINEPHrine’s bronchodilating and inotropic effects.