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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)

Direct: 10mcg IV q 2-5 minutes prn

Pediatric Considerations And Dosing

Follow weight-based 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

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

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

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.

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Licence Level Filtering

Epinephrine

Classification

Indications

Contraindications

Adult dosages

Pediatric Considerations And Dosing

Preparation and Administration

Mechanism Of Action

Pharmacokinetics

Adverse Effects

Overdose

Warning And Precautions

Drug Interactions