Epinephrine for Cardiac Arrest

• There are greater than 350,000 out-of-hospital cardiac arrests annually, and nearly 90% of them are

fatal.

• The effects of epinephrine on animal hemodynamics have been studied since the late 1800s.
• While the first advanced cardiac life support (ACLS) guidelines were first published in 1974, the role

of epinephrine remains controversial.

Epinephrine [Adrenalin®]

Dose

Cardiac arrest: 1 mg IV/IO every 3 to 5 minutes

Mechanism of Action

Receptor Activity

Pharmacological Action

Effect

α agonist

Peripheral

vasoconstriction

increased myocardial and cerebral blood

flow

β agonist

increased heart rate and

contractility

increased myocardial oxygen demand

Indications

Asystole/pulseless electrical activity (PEA)

Pulseless ventricular tachycardia/fibrillation

Onset: immediate

Distribution: 1-2 minutes to reach central circulation during CPR

Metabolism: rapid hepatic degradation

Elimination: urine (inactive metabolites)

Half-life: <5 minutes

Adverse Effects

Tachyarrhythmias, myocardial ischemia, may decrease cerebral perfusion,

mesenteric ischemia, extravasation leading to necrosis, lactic acidosis

Dosage Forms

Vial: 1 mg/mL (1 mL & 30 mL)

Pre-filled syringe: 1 mg/10 mL (10 mL)

Compatibility

Compatible with: NS, D5W, and LR

Incompatible with sodium bicarbonate

[email protected]; [email protected]

Author

(Year)

Study Design/Patient

Population

Intervention

Results

Pearson,

1963

Animal study (n=80)

Asphyxiated dogs with

asystole and ventricular

fibrillation

• Epinephrine 1 mg
• Positive-pressure breathing
• Chest compressions
• Defibrillation

increased ROSC in dogs that received epinephrine 5

min and 10 min after asystole

increased ROSC in dogs that received epinephrine 1

min after ventricular fibrillation

Ventricular fibrillation occurred only in the

epinephrine group

Stiell,

1992

RCT (650)

Out-of-hospital cardiac

arrest

• Epinephrine 7 mg every 5 min
• Epinephrine 1 mg every 5 min

No difference in survival to hospital

admission or discharge and neurologic

outcomes between low- and high-dose

epinephrine

Brown,

1992

RCT (n=1280)

Out-of-hospital cardiac

arrest

• Epinephrine 0.2 mg/kg
• Epinephrine 0.02 mg/kg

No difference in ROSC, survival to hospital

admission and discharge, or neurological

• The dose of epinephrine is based on animal studies from the 1960s, in which epinephrine was

administered immediately after the induction of cardiac arrest.

• There have been no differences found between standard and high-dose epinephrine.
• Epinephrine may lead to increased ROSC and survival to hospital admission but has not been found

to consistently improve long-term outcomes.

• Bottom Line: Quality chest compressions and early defibrillation continue to be the standard

of care in ACLS and should not be delayed for administration of epinephrine.

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Callaway C. Epinephrine for cardiac arrest. Current Opinion in Cardiology. 2013;28(1):36-42.

Epinephrine [package insert] Lake Forest, IL: Hospira, Inc.; 2019.

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Stiell IG, Hebert PC, Weitzman BN, et al. High-dose epinephrine in adult cardiac arrest. N Engl J Med.

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epinephrine in cardiac arrest outside the hospital. Resuscitation. 1995;29(1):3-9.

Sherman BW, Munger MA, Foulke GE, Rutherford WF, Panacek EA. High-dose versus standard-dose epinephrine

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arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-1143.

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patients with out-of-hospital cardiac arrest. JAMA. 2012;307(11):1161-1168.

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