Adrenaline

# Adrenaline ## Overview - **Classification**: Alpha- and beta-adrenergic agonist, sympathomimetic. - **Mechanism**: Stimulates alpha-1, beta-1, and beta-2 adrenergic receptors. Causes vasoconstriction (alpha-1), increased heart rate/contractility (beta-1), and bronchodilation (beta-2). ## Primary Indications 1. **Anaphylaxis** - Severe allergic reactions including angioedema, bronchospasm, and hypotension. 2. **Cardiac Arrest** - For non-perfusing rhythms (asystole, pulseless electrical activity, ventricular fibrillation/tachycardia). 3. **Severe Croup** - To reduce laryngeal edema and improve airflow. ## Adult Dosing ### Standard Dosing **Anaphylaxis** - **Dose**: **0.3 mg** to **0.5 mg** (1:1000 dilution) - **Frequency**: Every 5-15 minutes as needed - **Route**: Intramuscular (IM) into anterolateral thigh - **Special Considerations**: Administer immediately upon recognition of anaphylaxis. **Cardiac Arrest (ACLS)** - **Dose**: **1 mg** (1:10,000 dilution) - **Frequency**: Every 3-5 minutes - **Route**: Intravenous (IV) or Intraosseous (IO) - **Special Considerations**: Follow IV/IO dose with a **20 mL IV fluid flush**. **Severe Croup (Off-label for L-epinephrine, often racemic used)** - **Dose**: **0.5 mL** of 1:1000 solution (equal to **0.5 mg**) - **Frequency**: Single dose; may repeat after 30 minutes if needed. - **Route**: Nebulized - **Maximum**: **0.5 mg** per dose for L-epinephrine. ### Dose Adjustments - **Renal Impairment**: No specific dose adjustments required. - **Hepatic Impairment**: No specific dose adjustments required. - **Elderly Patients**: Use with caution. Consider lower starting doses if pre-existing cardiovascular disease is present. Monitor closely for adverse effects. ## Pediatric Dosing ### Neonates (0-28 days) **Cardiac Arrest (ACLS)** - **Dose**: **0.01 mg/kg** (1:10,000 dilution) - **Frequency**: Every 3-5 minutes - **Route**: IV or IO - **Maximum**: No specific max dose per administration; titrated to effect. - **Special Notes**: Administer rapidly. Follow with 0.5-1 mL normal saline flush. ### Infants (1-12 months) **Anaphylaxis** - **Dose**: **0.01 mg/kg** (1:1000 dilution) - **Frequency**: Every 5-15 minutes as needed - **Route**: IM into anterolateral thigh - **Maximum**: **0.3 mg** per dose. - **Special Notes**: Pre-filled auto-injectors (e.g., EpiPen Jr. 0.15 mg) may be used for infants weighing ≥ **15 kg**. **Cardiac Arrest (ACLS)** - **Dose**: **0.01 mg/kg** (1:10,000 dilution) - **Frequency**: Every 3-5 minutes - **Route**: IV or IO - **Maximum**: No specific max dose per administration; titrated to effect. ### Children (1-12 years) **Anaphylaxis** - **Dose**: **0.01 mg/kg** (1:1000 dilution) - **Frequency**: Every 5-15 minutes as needed - **Route**: IM into anterolateral thigh - **Maximum**: **0.3 mg** per dose for children <30 kg. **0.5 mg** per dose for children ≥30 kg. - **Special Notes**: EpiPen Jr. (0.15 mg) for 15-30 kg. EpiPen (0.3 mg) for >30 kg. **Cardiac Arrest (ACLS)** - **Dose**: **0.01 mg/kg** (1:10,000 dilution) - **Frequency**: Every 3-5 minutes - **Route**: IV or IO - **Maximum**: No specific max dose per administration; titrated to effect. ### Adolescents (13-18 years) **Anaphylaxis** - **Dose**: **0.3 mg** to **0.5 mg** (1:1000 dilution) - **Frequency**: Every 5-15 minutes as needed - **Route**: IM into anterolateral thigh - **Maximum**: **0.5 mg** per dose. - **Special Notes**: Dosing approaches adult recommendations. **Cardiac Arrest (ACLS)** - **Dose**: **1 mg** (1:10,000 dilution) - **Frequency**: Every 3-5 minutes - **Route**: IV or IO - **Maximum**: Adult dose. ## Safety Information ### Contraindications - **Absolute**: No absolute contraindications in life-threatening emergencies (e.g., anaphylaxis, cardiac arrest) where benefits outweigh risks. - **Relative**: Closed-angle glaucoma, non-anaphylactic shock, during labor (may delay uterine involution), patients on non-selective beta-blockers. ### Common Adverse Effects - **Very Common (>10%)**: Palpitations, anxiety, tremor, headache, dizziness, sweating. - **Common (1-10%)**: Tachycardia, arrhythmias, hypertension, dyspnea, pallor, weakness. - **Serious but Rare**: Myocardial ischemia/infarction, cerebral hemorrhage, ventricular arrhythmias (fibrillation), pulmonary edema. ### Key Drug Interactions - **Non-selective Beta-blockers (e.g., Propranolol)**: May cause severe hypertension and reflex bradycardia due to unopposed alpha-adrenergic effects. - **Tricyclic Antidepressants (TCAs), MAOIs, COMT Inhibitors**: Potentiate pressor effects of adrenaline, increasing risk of arrhythmias and hypertension. - **Halogenated Hydrocarbon Anesthetics (e.g., Halothane)**: May sensitize the heart to arrhythmias. ## Monitoring & Follow-up - **Before Treatment**: Assess airway, breathing, circulation (ABCs). Baseline vital signs (BP, HR, RR, SpO2). - **During Treatment**: Continuous monitoring of heart rate, rhythm (ECG), blood pressure, respiratory status (SpO2). - **Clinical Signs**: Resolution of allergic symptoms (hives, wheezing, swelling), return of spontaneous circulation (ROSC). ## Clinical Pearls - 💡 **Anaphylaxis**: Always administer **IM** into the anterolateral thigh for fastest absorption. Pinch skin and inject straight in. - 💡 **Auto-injectors**: Instruct patients to carry **two** auto-injectors and to seek immediate medical attention after any dose. - 💡 **Cardiac Arrest**: Administer IV/IO push, followed by a **20 mL fluid flush** and elevate extremity for 10-20 seconds to facilitate central circulation. - 💡 **Dilution Critical**: Verify correct dilutions for route: **1:1000** (1 mg/mL) for IM, **1:10,000** (0.1 mg/mL) for IV/IO. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.