Adrenaline
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Last updated: June 2025
For educational purposes only
Clinical Reference
# 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.