Adult Epinephrine Dosing for Anaphylaxis

Standard Intramuscular Dosing

Approximately 6-19% of patients require a second dose of epinephrine 1
Intramuscular injection into the vastus lateralis (lateral thigh) is the preferred route, producing more rapid peak plasma concentrations compared to subcutaneous administration or injection into the deltoid 1, 2
There are no absolute contraindications to epinephrine use in anaphylaxis, even in elderly patients with cardiovascular disease—the benefits far outweigh the risks 1, 2

IV epinephrine should only be used in specific situations: cardiac arrest, profound hypotension unresponsive to IM epinephrine and IV fluids, or failure to respond to several injected doses 1, 3

For graded perioperative allergic reactions, the British Journal of Anaesthesia consensus recommends the following IV bolus dosing:
Starting dose for IV infusion: 1-4 mcg/min, titrated up to a maximum of 10 mcg/min based on clinical response and side effects 2, 3
Preparation method: Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL of D5W to yield 4.0 mcg/mL concentration, infuse at 15-60 drops/min with microdrop apparatus 2, 3
Alternative preparation: Add 1 mg (1 mL) of 1:1000 epinephrine to 100 mL of saline (1:100,000 solution), infuse at 30-100 mL/hr (5-15 mcg/min) 2, 3
Continuous hemodynamic monitoring is essential when administering IV epinephrine 3

Delayed epinephrine administration is associated with more serious anaphylaxis and fatalities 2, 6
Antihistamines and corticosteroids are not substitutes for epinephrine and should only be used as adjunctive therapy 6
Do not use the 1:1000 concentration intravenously—if IV administration is necessary, use 1:10,000 dilution (0.05-0.1 mg or 0.5-1 mL) 1

Call emergency medical services (9-1-1) immediately when caring for a person with suspected anaphylaxis 7