Dose of iv adrenaline in cardiac arrest
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IV adrenaline epinephrine dose cardiac arrest ALS guidelines 2025
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IV Adrenaline (Epinephrine) in Cardiac Arrest
Standard Dose
1 mg IV/IO, repeated every 3–5 minutes — no maximum dose.
- Preparation: 1 mg diluted to 10 mL (10 mL of 1:10,000 solution)
- Route: IV or IO (intraosseous); endotracheal route is no longer recommended
When to Give It
| Rhythm | Timing |
|---|---|
| VF / Pulseless VT | After the 2nd shock (i.e., after the first shock fails and CPR resumes) |
| Asystole / PEA | As soon as IV/IO access is obtained |
High-Dose Epinephrine
Escalating doses of 2–5 mg IV every 3–5 minutes have not improved long-term survival and are not recommended as standard therapy.
- AHA 2025 guidelines explicitly recommend against high-dose epinephrine.
Key Points
- The benefit of epinephrine is primarily via alpha-adrenergic effects → increased peripheral vasoconstriction → improved coronary and cerebral perfusion pressure during CPR.
- Evidence shows improved ROSC and short-term survival, but not improved survival to discharge or neurologic outcome.
- A landmark 2018 RCT (PARAMEDIC2) showed improved ROSC with epinephrine, but survivors had a higher rate of severe neurologic disability.
- Best benefit is within the first 15–20 minutes of arrest; administration beyond 20 minutes may worsen myocardial ischemia and induce ventricular ectopy.
- Potential adverse effects: tachycardia, increased myocardial O₂ demand, pulmonary shunting, ventricular ectopy.
Current Guidelines Summary
| Guideline | Dose | Interval |
|---|---|---|
| AHA 2025 | 1 mg IV/IO | Every 3–5 min |
| ERC 2025 | 1 mg IV/IO | Every 3–5 min |
Sources: Tintinalli's Emergency Medicine, p. 4127; AHA 2025 ACLS Algorithm; ERC Guidelines 2025
What about amiodarone or lidocaine dosing in cardiac arrest?
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Amiodarone & Lidocaine in Cardiac Arrest
Both are used for shock-refractory VF / pulseless VT — given after defibrillation + epinephrine have failed.
Amiodarone
| Situation | Dose |
|---|---|
| 1st dose (pulseless VT/VF) | 300 mg IV/IO bolus + 20 mL flush |
| 2nd dose (if no response) | 150 mg IV/IO bolus |
| Maintenance after ROSC | 1 mg/min IV for 6 hours → then 0.5 mg/min for 18 hours |
| Hemodynamically stable VT | 150 mg IV over 10–15 min (not >30 mg/min), then infusion |
- AHA 2025 algorithm: first dose 300 mg, can repeat once.
- Adverse effects: hypotension, bradycardia (most common — slow infusion or use pressors).
Lidocaine
| Situation | Dose |
|---|---|
| 1st dose | 1–1.5 mg/kg IV/IO bolus |
| 2nd dose (if rhythm persists) | 0.5–0.75 mg/kg IV, repeat every 5–10 min; max total 3 mg/kg |
| Maintenance after ROSC | 1–4 mg/min IV infusion |
| If dysrhythmia recurs during infusion | 0.5 mg/kg bolus + increase infusion rate |
Amiodarone vs. Lidocaine — Which to Use?
- Amiodarone is preferred over lidocaine (guideline recommendation).
- Lidocaine is the alternative when amiodarone is unavailable.
- The 2016 ALPS trial (multicenter RCT) showed neither drug improved survival to discharge or neurologic outcome vs. placebo for out-of-hospital cardiac arrest — a key finding that has tempered enthusiasm for both agents.
- Both drugs still appear in AHA 2025 and ERC 2025 guidelines as options for shock-refractory VF/pVT.
Quick Comparison Table
| Drug | 1st Dose | 2nd Dose | Post-ROSC |
|---|---|---|---|
| Amiodarone | 300 mg IV/IO bolus | 150 mg IV/IO | 1 mg/min × 6 h, then 0.5 mg/min × 18 h |
| Lidocaine | 1–1.5 mg/kg IV/IO | 0.5–0.75 mg/kg q5–10 min (max 3 mg/kg) | 1–4 mg/min infusion |
Sources: Tintinalli's Emergency Medicine pp. 4134–4143; Rosen's Emergency Medicine p. 672; AHA 2025 ACLS Algorithm
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