Adrenaline 1:10,000 / 1:100,000 for ROSC

Question 1

What clinical situation would you administer adrenaline 1:10,000 for? (2)

Answer 1

Cardiac arrest

Management of patients (18 and over) after the return of spontaneous circulation (ROSC) to prevent the frequent post-ROSC decrease in blood pressure.

Question 2

Inclusion criteria for adrenaline 1:10,000 administration? (2)

Answer 2

Cardiac arrest

Patients (18 and over) in whom ROSC has been achieved and SBP <100mmHg and pulse rate <100 beats per minute AFTER a 250ml sodium chloride bolus

Question 3

Exclusion criteria for adrenaline 1:10,000 administration?

Answer 3

Newborn (infants requiring transition support at time of birth)

Question 4

Why is adrenaline 1:10,000 administered during cardiac arrest / ROSC? (3)

Answer 4

Adrenaline stimulates both alpha and beta adrenoreceptors, which causes vasoconstriction.

This increases peripheral resistance, enhancing myocardial and cerebral blood flow.

This increases the chance of achieving ROSC and helps to maintain blood pressure.

Question 5

Cautions for adrenaline 1:10,000 administration? (4)

Answer 5

Where hypothermia is considered as the cause of the cardiac arrest and the core body temperature is 30-35 degrees celsius double the intervals of adrenaline in cardiac arrest.

The alpha-adrenergic actions of adrenaline cause vasoconstriction, which increases myocardial and cerebral perfusion pressure. The higher coronary blood flow increases the frequency and amplitude of the VF waveform and should improve the chance of restoring a circulation when defibrillation is attempted.

Although adrenaline improves short-term survival, it impairs the microcirculation and can cause postcardiac-arrest myocardial dysfunction, both of which might impact on long-term outcome.

Management of patients who achieve ROSC aims to address post-arrest brain injury and myocardial dysfunction, systemic ischemia/reperfusion response and any persistent precipitating pathology.

Question 6

Side effects of adrenaline 1:10,000 administration? (3)

Answer 6

The potentially severe adverse effects of adrenaline arise from its effect upon blood pressure and cardiac rhythm - Ventricular fibrillation may occur and severe hypertension may lead to cerebral haemorrhage and pulmonary oedema.

Symptomatic adverse effects are anxiety, dyspnoea, restlessness, palpitations, tachycardia, anginal pain, tremor, weakness, dizziness, headache and cold extremities.

Biochemical effects include inhibition of insulin secretion, stimulation of growth hormone secretion, hyperglycaemia (even with low doses), gluconeogenesis, glycolysis, lipolysis and ketogenesis.

Question 7

Route of administration for adrenaline 1:10,000? (2)

Answer 7

Intravenous

Intraosseous

Question 8

Frequency of adrenaline 1:10,000 administration in non-shockable (PEA/Asystole) cardiac arrest in adults and children?

Answer 8

Adrenaline is given initially as soon as vascular access is available and then every 3-5 min

Question 9

Frequency of adrenaline 1:10,000 administration in VF/pulseless VT cardiac arrest in adults and children?

Answer 9

adrenaline is given once chest compressions have restarted after the third shock and then every 3-5 min (during alternate cycles of CPR).

Question 10

Frequency of adrenaline 1:10,000 administration in the hypothermic patient?

Answer 10

Where the primary cause of arrest is hypothermia, double intervals between drugs should be used e.g. adrenaline every 6-10 minutes.

Question 11

Dose of adrenaline 1:10,000 to be given to adults and children ≥ 12?

Answer 11

1mg

1mg in 10ml presentation

Question 12

Is there a max dose of adrenaline 1:10,000 that can be given to patients in cardiac arrest?

Answer 12

No

Question 13

How do you create adrenaline 1:100,000 solution to be used in ROSC?

Answer 13

To make Dilute Adrenaline, draw-up 1mL of Adrenaline 1:10,000 (100mcg/mL) from a pre-filled syringe into a 10mL syringe and then add an additional 9mL 0.9% sodium Chloride, shake the syringe to ensure the adrenaline has mixed; this makes Dilute Adrenaline 1:100,000 solution (10mcg/mL).

Label the syringe Dilute Adrenaline 1:100,000.

Question 14

When would you administer adrenaline 1:100,000 to a patient and what dose and dose interval would you use? (4)

Answer 14

If 18+ ROSC patient remains hypotensive and heart rate is less than 100bpm after 250ml fluid bolus administer dilute adrenaline solution

Every 2 minutes, reassess the SBP and pulse.

If below 100bpm or 100mmHg then administer a dose of 10mcg Adrenaline (1mL of Dilute Adrenaline 1:100,000).

Continue until cessation or ED arrival