Epinephrine

Question 1

What is the trade name for epinephrine?

Answer 1

Adrenalin

Question 2

What is the drug classification of epinephrine?

Answer 2

adrenergic agonist (Sympathomimetic)

Question 3

How is epinephrine supplied?

Answer 3

Preload syringes 1 mg/10mL (1:10,000)
Multi-dose vial 30 mg/30mL (1:1000)
Ampule 1 mg/mL (1:1000)

Question 4

Describe the MOA (pharmacodynamics) for epinephrine.

Answer 4

❑ A catecholamine that stimulates the alpha and beta-adrenergic receptors in the sympathetic nervous system.
❑ Alpha1 Receptors: causes vasoconstriction used to delay absorption of local anesthetics, control superficial bleeding, suppress glottal edema and elevate blood pressure by increasing peripheral vascular resistance. Alpha1 receptors on the iris produces mydriasis during ophthalmologic procedures
❑ Beta1 Receptors: produces inotropic (strength of contraction), chronotropic (rate of contraction) and dromotropic (speed of conduction) effects, increasing cardiac output and myocardial oxygen consumption.
❑ Beta2 Receptors: Relaxes bronchial smooth muscle increasing tidal volume and vital capacity.
❑ Activation of these three types of adrenergic receptors can reverse the degranulation of the anaphylactic reaction caused largely by the release of leukotrienes with histamine.

Question 5

List the indications for use of epinephrine.

Answer 5

❑ Cardiac Arrest – V-fib, Pulseless V-Tach, Asystole, PEA
❑ Symptomatic bradycardia, particularly if associated with hypotension, for whom atropine may be inappropriate or after atropine fails
❑ Used to treat severe hypotension (e.g., systolic blood pressure < 70 mm Hg)
❑ Maintain cardiac output during Post-Cardiac Arrest Care
❑ Anaphylaxis
❑ Severe status asthmaticus
❑ Beta Blocker/Ca+ channel Blocker overdose

Question 6

What is the dose of epinephrine in cardiac arrest?

Answer 6

Adult: 1 mg (1:10,000) IVP q 3-5 minutes

Pediatric: 0.01mg/kg to a max of 1mg (1:10,00) IVP q3-5 minutes

Question 7

What is the ADULT dose of epinephrine for symptomatic bradycardia with hypotension?

Answer 7

Adult: 2 to 10 mcg/minute IV infusion

Mix 4 mg of Epinephrine (1:1000) in 250 ml of N/S (concentration 16 mcg/ml)

Question 8

What is the PEDIATRIC dose of epinephrine for symptomatic bradycardia with hypotension?

Answer 8

Pediatric: 0.01mg/kg to a max of 1mg (1;10,00) IVP q3-5 minutes

Question 9

What is the dose for racemic epinephrine used in Croup / Anaphylaxis?

Answer 9

Adult/Pediatric: 5mg neb (1:1000). Repeat q5 minutes to a max of 10mg.

Question 10

What is the ADULT dose of epinephrine for use in Anaphylactic Shock / Severe bronchospasm, and Asthma (refractory to initial treatment)?

Answer 10

0.2 to 0.5 mg IM q5 min prn (repeat only in absence of clinical improvement); Max of 1.5 mg.

(AHS protocols - 0.3mg IM q5 min prn Max 0.9mg)

Question 11

What is the PEDIATRIC dose of epinephrine for use in Anaphylactic Shock / Severe bronchospasm, and Asthma (refractory to initial treatment)?

Answer 11

0.01mg/kg to a single max dose of 0.3mg q 5min prn

AHS protocols:

• less than 30kg = 0.15mg IM q5min prn Max 0.45mg
• greater than 30kg = 0.3mg IM q5min prn Max 0.9mg

Question 12

What is the dosage for Push Dose Epinephrine?

Answer 12

Adult: 20 to 50 mcg. Repeat q 2 minutes PRN
Pediatric: 1mcg/kg to single max dose 50 mcg, q 2 min

Question 13

What is the dosage for an epinephrine infusion? How do you mix it?

Answer 13

Adult and Pediatric: 0.1 to 1 mcg/kg/min IV infusion (titrate to desired effect)

*Mix 4 mg of Epinephrine (1:1000) in 250 ml of
N/S (concentration 16 mcg/ml)

Question 14

What are the contraindications to epinephrine administration?

Answer 14

None in the emergent setting.

Question 15

List some precautions to the use of epinephrine.

Answer 15

• Caution when administering for asthma in patients with a history of cardiac problems or over age 35 due to its marked cardiac effects.
• In patients with a perfusing rhythm, epinephrine causes tachycardia; it may also cause ventricular ectopy, tachyarrhythmias, vasoconstriction, and hypertension.

Question 16

When is push dose epinephrine used?

Answer 16

In an acutely deteriorating patient as a temporary measure while initiating an infusion.

Question 17

How do you draw up push dose epinephrine?

Answer 17

There are a few ways, and all give you a concentration of 10mcg/mL.

• Draw up 1mL of 0.1mg/mL (from 1:10,000 preload) into a 10mL syringe and top up with 9mL normal saline.
• Add 10mL of 0.1mg/mL (from a 1:10,000 preload) to a 100mL bag of normal saline (after wasting 10mL saline from the bag)
• Draw up 1mL from an ampule of 1mg/mL (1:1000) and add to a 100mL bag of normal saline (after wasting 1mL from bag).

Question 18

Can epinephrine be mixed with alkaline solutions?

Answer 18

DO NOT mix with alkaline solutions (i.e. sodium bicarbonate) –precipitate will form in IV tubing

Question 19

How does epinephrine affect myocardial oxygen requirements?

Answer 19

Will increase myocardial oxygen requirements as it raises HR and BP (May induce dysrhythmias)

Question 20

To avoid extravasation, what is preferred when using epinephrine?

Answer 20

The use of an infusion pump or 60gtt set in combination with a central vein.

Question 21

Is there an age requirement for using epinephrine in patients with severe, life-threatening asthma?

Answer 21

There is little evidence to withhold epinephrine (even if it must be given IV) from patients with severe, life-threatening asthma solely because of their age.

Question 22

Why might an epinephrine infusion be used?

Answer 22

• Post Resuscitation Care (supports cardiac output)
• Severe Hypotension
• Shock refractory to fluid resuscitation
• Cardiogenic shock with refractory hypotension
• Anaphylaxis
• Bronchospasm Asthma
• Ca & Beta Blocker OD
• Digoxin OD
• Non-Cyclic Antidepressant OD
• Salicylate OD