Indications
Advanced Cardiac Life Support (ACLS) (see Advanced Cardiac Life Support, [[Advanced Cardiac Life Support]])
- Indications
- Asystole (see Asystole, [[Asystole]])
- Bradycardia (see Sinus Bradycardia, [[Sinus Bradycardia]]): symptomatic and unresponsive to atropine or pacing
- Pulseless Electrical Activity (PEA)
- Pulseless Ventricular Tachycardia (VT) (see Ventricular Tachycardia, [[Ventricular Tachycardia]])
- Ventricular Fibrillation (VF) (see Ventricular Fibrillation, [[Ventricular Fibrillation]])
Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]])
Asthma (see Asthma, [[Asthma]])
- Subcutaneous Use in the Setting of Status Asthmaticus is No Longer Recommended
Hemoptysis During Bronchoscopy (see Hemoptysis, [[Hemoptysis]] and Bronchoscopy, [[Bronchoscopy]])
Maintenance of Mydriasis During Ocular Surgery
- May Be Used for this Indication
Post-Extubation Laryngeal Edema/Stridor (see Stridor, [[Stridor]])
- Rationale: results in local vasoconstriction, decreasing laryngeal edema
- Clinical Efficacy: efficacy is unclear
- Pediatric Trial of Dexamthasone and Nebulized Epinephrine in Laryngeal Edema (Int J Pediatr Otorhinolaryngol, 2009) [MEDLINE]: dexamethasone and L-epinephrine did not reduce the clinical progression of airway obstruction due to laryngeal edema in the early post-extubation period
Septic Shock/Hypotension (see Sepsis, [[Sepsis]] and Hypotension, [[Hypotension]])
Pharmacology
Pharmacologic Effects at Adrenergic Receptors
- α1-Adrenergic Receptor Agonist (see α1-Adrenergic Receptor Agonists, [[α1-Adrenergic Receptor Agonists]])
- Vascular Smooth Muscle α1-Adrenergic Receptors
- β1-Adrenergic Receptor Agonist (see β1-Adrenergic Receptor Agonists, [[β1-Adrenergic Receptor Agonists]])
- Cardiac β1-Adrenergic Receptors
- Mediate Increased Atrioventricular Nodal Conduction Velocity
- Mediate Increased Chronotropy
- Mediate Increased Inotropy
- Renal Juxtaglomerular Cell β1-Adrenergic Receptors
- Mediate Increased Renin Release
- β2-Adrenergic Receptor Agonist (see β2-Adrenergic Receptor Agonists, [[β2-Adrenergic Receptor Agonists]])
- Bronchial Smooth Muscle β2-Adrenergic Receptors
- Gastrointestinal β2-Adrenergic Receptors
- Mediate Slowing of Peristalsis
- Mediate Slowing of Secretions
- Hepatic β2-Adrenergic Receptors
- Mediate Gluconeogenesis
- Mediate Glycogenolysis
- Mediate Lipolysis
- Ocular Ciliary Muscle β2-Adrenergic Receptors
- Mediate Flow of Aqueous Humor
- Mediate Accommodation
- Uterine Muscle β2-Adrenergic Receptors
- Mediate Uterine Relaxation (Tocolysis)
- Urinary Bladder Detrusor Muscle β2-Adrenergic Receptors
- Mediate Detrusor Muscle Relaxation
- Vascular Smooth Muscle β2-Adrenergic Receptors
- β3-Adrenergic Receptor Agonist
- Adipose Tissue β3-Adrenergic Receptors
Pharmacokinetics
- Half-Life: <5 min
- Distribution: epinephrine does not cross the blood-brain barrier
Metabolism
- Hepatic Metabolism of Circulating Epinephrine
- Urinary Excretion of Inactive Metabolites, Metanephrine, Sulfate and Hydroxy Derivatives of Mandelic Acid, and Small Amounts of Unchanged Drug
- Uptake by Adrenergic Neurons and Metabolism by Monoamine Oxidase (MAO) and Catechol-0-Methyltransferase
Administration
Advanced Cardiac Life Support (ACLS) (see Advanced Cardiac Life Support, [[Advanced Cardiac Life Support]])
Asystole/Pulseless Electrical Activity (PEA)/Pulseless Ventricular Tachycardia (VT)/Ventricular Fibrillation
- Intravenous (IV): 1 mg (1:10,000 Dilution = 0.1 mg/mL) q3-5 min
- Intraosseous (IO): 1 mg (1:10,000 Dilution = 0.1 mg/mL)
- Intratracheal (via Endotracheal Tube): 2-2.5 mg in 10 ml normal saline (1:10,000 Dilution = 0.1 mg/mL) q3-5 min
- May Cause False-Negative Readings with Exhaled Carbon Dioxide (CO2) Detectors
Symptomatic Bradycardia (Unresponsive to Atropine and/or Pacing)
- Intravenous (IV) Infusion: 2-10 μg/min
Septic Shock/Hypotension (see Sepsis, [[Sepsis]] and Hypotension, [[Hypotension]])
- Intravenous (IV) Infusion: 2-10 μg/min
Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]])
- Intramuscular (IM) (see Anaphylaxis, [[Anaphylaxis]]): 0.3 mg (1:1,000 Dilution = 1 mg/mL) into anterior middle third of the thigh
- Same Dose as Preloaded Epinephrine Injector Devices (EpiPen, Adrenaclick, Auvi-Q)
- Intravenous (IV): recommended only for patients with refractory hypotension and lack of response to multiple intramuscular epinephrine injections or if patient is in cardiopulmonary arrest
- Subcutaneous (SQ): no longer recommended (due to slower and less reliable absorption than intramuscular administration)
Post-Extubation Laryngeal Edema/Stridor (see Stridor, [[Stridor]])
- Nebulized Racemic Epinephrine: 1 mg in 5 mL of normal saline
Hemoptysis During Bronchoscopy (see Hemoptysis, [[Hemoptysis]] and Bronchoscopy, [[Bronchoscopy]])
- Intrabronchial (Topical Instillation via Bronchoscope)
- Dilute 10 mL of 1:10,000 Epinephrine (0.1 mg/mL) + 10 mL Normal Saline: yields 20 mL of 1:20,000 Epinephrine
- Instill 2 mL Intrabronchially (Via Bronchoscope) at a Time (Max Total Dose: 10 mL = 0.5 mg)
Dose Adjustment
- Hepatic: none
- Renal: none
Extravasation Management
- Epinephrine is a Vesicant: extravasation can cause tissue necrosis
- Technique to Manage Extravasation
- Discontinue Epinephrine Infusion and Gently Aspirate the Extravasated Solution
- Phentolamine (see Phentolamine, [[Phentolamine]]): dilute 5-10 mg in 10-15 mL of normal saline and administer into extravasation site as soon as possible after extravasation
- Topical Nitroglycerin 2% Ointment (see Nitroglycerin, [[Nitroglycerin]]): apply a 1 inch strip to the affected site
Drug Interactions
- Spironolactone (Aldactone) (see Spironolactone, [[Spironolactone]]): spironolactone may decrease the vasoconstrictor effect of α/β-adrenergic agonists
- Inhalational Anesthetics: may increase the arrhythmogenic effect of epinephrine
- MAO Inhibitors (see Monoamine Oxidase Inhibitors, [[Monoamine Oxidase Inhibitors]]): may enhance the hypertensive effect of vasopressors (epinephrine, etc) and other sympathomimetics
- Linezolid (Zyvox) (see Linezolid, [[Linezolid]])
- Lurasidone (Latuda) (see Lurasidone, [[Lurasidone]]): epinephrine may enhance the hypotensive effect of lurasidone
- Serotonin Norepinephrine Reuptake Inhibitors (SNRI) (see Serotonin Norepinephrine Reuptake Inhibitors, [[Serotonin Norepinephrine Reuptake Inhibitors]]): SNRI’s may enhance the vasopressor effects of α/β-adrenergic agonists
Adverse Effects
Cardiovascular Adverse Effects
- Arrhythmias
- Exacerbation of Myocardial Ischemia (see Coronary Artery Disease, [[Coronary Artery Disease]])
- Clinical
- Acute Myocardial Infarction
- Chest Pain/Angina (see Chest Pain, [[Chest Pain]])
- Extravasation-Associated Tissue Necrosis
- Epidemiology: associated with intravenous administration
- Hypertension (see Hypertension, [[Hypertension]])
- Palpitations (see Palpitations, [[Palpitations]])
- QT Prolongation without Definite Association with Torsade (see Torsade, [[Torsade]])
- Sinus Tachycardia (see Sinus Tachycardia, [[Sinus Tachycardia]])
Dermatologic Adverse Effects
Endocrinologic Adverse Effects
Gastrointestinal Aderse Effects
Neurologic Adverse Effects
Pulmonary Adverse Effects
- Pulmonary Edema (see Pulmonary Edema, [[Pulmonary Edema]])
- Pharmacology: due to peripheral vasoconstriction and cardiac stimulation
Renal Adverse Effects
- Decreased Urine Output
- Pharmcology: due to renal vasoconstriction
Rheumatologic/Orthopedic Adverse Effects
- Acute Limb Ischemia/Digital Ischemia (see Acute Limb Ischemia, [[Acute Limb Ischemia]])
- Pharmcology: due to vasoconstriction
References
- Adrenaline administered via a nebulizer in adult patients with upper airway obstruction. Anaesthesia. 1995;50:35–6 [MEDLINE]
- The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup. Intensive Care Med. 2008;34:138–47
- L-epinephrine and dexamethasone in postextubation airway obstruction: a prospective, randomized, double-blind placebo-controlled study. Int J Pediatr Otorhinolaryngol. 2009;73:1639–43 [MEDLINE]
- Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;10:CD006619 [MEDLINE]
- Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review. Crit Care. 2015 Sep 23;19:295. doi: 10.1186/s13054-015-1018-2 [MEDLINE]