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Epinephrine

high alert medication

Sympathomimetic

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:

  • There are no absolute contraindications to epinephrine use in life-threatening situations such as anaphylaxis

Cautions:

  • Cardiovascular disease, hypertension, diabetes, hyperthyroid, cerebrovascular disease

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

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 

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

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

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

OR

  • Direct: 1 mcg/kg IV/IO q 2-5 minutes prn

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

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.

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

 

 

  • 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

Epinephrine overdose may produce significantly elevated blood pressures and heart rate, which may in turn cause cerebral hemorrhage. 

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.

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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