8.4 Epinephrine in Arrest: Dose & Timing
Key Takeaways
- The standard pediatric cardiac arrest epinephrine dose is **0.01 mg/kg IV/IO** every **3–5 minutes**, to a **maximum single dose of 1 mg**.
- Using the **0.1 mg/mL** concentration, **0.01 mg/kg equals 0.1 mL/kg** IV/IO—memorize both the mg/kg and mL/kg expressions.
- Give epinephrine **early** for initial **nonshockable** rhythms (asystole/PEA) once access is available.
- For **shockable** rhythms, prioritize defibrillation when rapid shocks are possible; give epinephrine after defibrillation attempts as the algorithm directs (and sooner if defibrillation cannot be delivered immediately).
- Prefer **IV/IO over endotracheal** administration; **high-dose epinephrine is not routinely recommended** for standard pediatric arrest.
Why Epinephrine Matters in Pediatric Arrest
Epinephrine is the primary vasopressor of the pediatric cardiac arrest algorithm. Its most important arrest effect is α-adrenergic vasoconstriction, which raises aortic diastolic pressure during CPR and improves coronary perfusion pressure—the pressure gradient that fills the coronary arteries between compressions. Without adequate coronary perfusion pressure, defibrillation and ROSC are far less likely. β-adrenergic effects (increased heart rate and contractility) are secondary during true arrest and can increase myocardial oxygen demand, which is one reason dosing discipline matters.
Epinephrine does not replace high-quality CPR or timely defibrillation. It is a pharmacologic adjunct that optimizes the perfusion CPR generates while you treat the cause.
Standard arrest dose (exam-critical)
| Parameter | Value |
|---|---|
| Dose | 0.01 mg/kg IV or IO |
| Concentration commonly referenced | 0.1 mg/mL (also labeled 1:10,000 in older notation) |
| Volume at that concentration | 0.1 mL/kg |
| Interval | Every 3–5 minutes during arrest |
| Route preference | IV/IO first; ET only if IV/IO cannot be obtained |
Concentration math you must not mix up
Two epinephrine concentrations appear in hospitals:
| Concentration | Older ratio label | Typical use |
|---|---|---|
| 0.1 mg/mL | 1:10,000 | Cardiac arrest IV/IO dose volume = 0.1 mL/kg for 0.01 mg/kg |
| 1 mg/mL | 1:1,000 | IM anaphylaxis and some infusions—not the default arrest push volume math |
Worked examples (arrest IV/IO using 0.1 mg/mL):
- 5 kg infant: 0.01 mg/kg × 5 = 0.05 mg → volume 0.5 mL
- 10 kg: 0.1 mg → 1 mL
- 20 kg: 0.2 mg → 2 mL
Flush the line after the drug so it reaches central circulation; continue CPR during preparation and administration. Do not create a prolonged hands-off interval to “watch the monitor for drug effect.”
Timing: Nonshockable vs Shockable Paths
Epinephrine timing is rhythm-dependent. This is one of the highest-yield discriminators on PALS exams.
Initial nonshockable rhythm (asystole / PEA)
- Start CPR immediately.
- Obtain IV/IO access as soon as possible.
- Give epinephrine ASAP—do not wait for multiple defibrillation attempts that will never be indicated.
- Repeat every 3–5 minutes while arrest continues.
- Parallel tasks: ventilation/oxygenation and reversible causes.
Early epinephrine for nonshockable rhythms is associated with better outcomes in resuscitation evidence summaries used in PALS teaching. On a megacode, a team that delays the first epi for nonshockable arrest without access attempts is off-algorithm.
Shockable rhythm (VF / pVT)
- Defibrillation is the priority when the defibrillator can be applied and charged rapidly.
- Deliver shocks with immediate CPR between attempts (Section 8.2).
- Give epinephrine after defibrillation attempts as the algorithm directs—commonly integrated after shocks are underway (often after the second defibrillation attempt in standard course algorithms).
- If defibrillation is not immediately possible (device delayed, pads not yet on), continue CPR, secure access, and give epinephrine sooner rather than waiting indefinitely for a shock that has not happened yet.
- Once started, continue epinephrine every 3–5 minutes.
| Situation | First priorities | Epinephrine timing emphasis |
|---|---|---|
| Asystole/PEA | CPR, access, airway/O₂, causes | Early / ASAP |
| VF/pVT, defibrillator ready | Shock → CPR | After defibrillation priority per algorithm |
| VF/pVT, defibrillator delayed | CPR + access + airway | Give epi sooner while awaiting defib |
What epinephrine does not do
- It does not convert asystole by “electrical reset” the way defibrillation terminates VF.
- It does not substitute for volume in pure hypovolemic PEA.
- It does not fix tension pneumothorax or tamponade—those need mechanical relief.
- It does not justify pausing compressions for lengthy drug discussions.
Route Selection and High-Dose Epinephrine
Prefer IV/IO over endotracheal
IV or IO administration is preferred because drug delivery to the central circulation is more reliable during CPR. IO access is appropriate emergency access when IV placement is delayed—PALS expects rapid IO rather than prolonged IV attempts in arrest.
Endotracheal (ET) epinephrine is a last-resort route if IV/IO cannot be obtained. Absorption is unpredictable during arrest; doses and dilution differ from IV/IO and should follow current PALS/institutional charts if ET is ever used. Exam correct answers almost always prioritize getting IV/IO over planning an ET drug strategy.
High-dose epinephrine is not routine
High-dose epinephrine (orders of magnitude above 0.01 mg/kg) is not routinely recommended for standard pediatric cardiac arrest. Potential harm includes post-ROSC myocardial dysfunction and excessive vasoconstriction. Unless a specific special circumstance and medical direction dictate otherwise, stick to 0.01 mg/kg IV/IO every 3–5 minutes.
Integration with the full arrest package
Every epinephrine dose should occur on top of:
- High-quality CPR (rate, depth, recoil, minimal interruptions)
- Correct shock/no-shock decisions
- Airway and ventilation appropriate to the child
- Active reversible-cause treatment
- Planned 2-minute cycles and role clarity (Chapter 14)
Clinical scenario
Case A — Nonshockable: 8 kg infant, asystole. IO placed at 45 seconds of CPR. Give 0.01 mg/kg = 0.08 mg = 0.8 mL of 0.1 mg/mL, flush, continue CPR and ventilation; repeat epi in 3–5 minutes if still arrested.
Case B — Shockable with ready defibrillator: 16 kg child in VF. Shock 2 J/kg (32 J) → immediate CPR → still VF → shock 4 J/kg (64 J) → during CPR give epinephrine 0.01 mg/kg (0.16 mg = 1.6 mL of 0.1 mg/mL) and continue the cycle. Do not delay the first shocks to draw the drug.
Case C — Shockable with delayed device: Same child, pads not yet available. CPR ongoing; IO in. Give epinephrine sooner while the defibrillator is retrieved, then shock as soon as possible at 2 J/kg.
Bottom line for 8.4: Arrest epinephrine = 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL) every 3–5 minutes; early for nonshockable; after defibrillation priority for shockable when rapid defib is possible; IV/IO > ET; no routine high-dose epinephrine.
What is the standard IV/IO epinephrine dose and interval during pediatric cardiac arrest?
Using epinephrine 0.1 mg/mL, what IV/IO volume delivers the standard 0.01 mg/kg arrest dose?
A child is in VF and the defibrillator is charged and ready. Vascular access is not yet established. What is the best prioritization?