Cardiopulmonary Resuscitation Guidelines

Introduction to Epinephrine Administration

• The American Heart Association recommends administering epinephrine in adult cardiopulmonary resuscitation (CPR) at a dose of 1 mg IV/IO every 3-5 minutes throughout the resuscitation effort, with a preferred route of administration being intravenous (IV) or intraosseous (IO) 1
• Epinephrine should be given as soon as possible for non-shockable rhythms, or after the first shock for shockable rhythms if the rhythm remains shockable, with subsequent doses continued every 3-5 minutes regardless of rhythm 1

Epinephrine Dosing and Administration

• The standard dose of epinephrine is 1 mg IV/IO, which has been the standard practice since the 1960s, and this recommendation is supported by the 2020 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care 1
• If IV/IO access is not available, the endotracheal (ET) route can be used as a temporary alternative, although the ET dose should be 2-2.5 times the IV dose (approximately 2-2.5 mg) 1
• The following table summarizes the American Heart Association's recommendations for epinephrine and antiarrhythmic administration:

1

High-Quality CPR and Defibrillation

• High-quality CPR with minimal interruptions should be maintained while administering medications, and chest compressions should not be interrupted for drug administration 1
• After one defibrillation shock and a dose of epinephrine in a patient with pulseless ventricular tachycardia, the next step is to immediately deliver a second shock at the same or higher energy level, using a biphasic dose of 120-200J or maximum available energy, or a monophasic dose of 360J, as recommended by the American Heart Association 1
• High-quality CPR should be performed immediately after shock, with compressions that are at least 2 inches/5 cm deep and 100-120/min fast, allowing complete chest recoil, and minimizing interruptions in compressions, as recommended by the American Heart Association 1

Advanced Airway Management and Ventilation

• Advanced airway management can be performed during CPR without interrupting chest compressions, and should include endotracheal intubation or supraglottic advanced airway, with confirmation of placement using waveform capnography, as recommended by the American Heart Association 1
• Ventilation should be delivered at a rate of 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions once the advanced airway is placed, avoiding excessive ventilation, as recommended by the American Heart Association 1

Avoiding Incorrect Practices and Reversible Causes

• High-dose epinephrine should be avoided, as large clinical trials have shown no improvement in survival rates with high-dose regimens 1
• Repeated injections at the same site should not be administered, as this can cause tissue necrosis due to vasoconstriction 1
• Consider reversible causes, including Hypovolemia, Hypoxia, Hydrogen ion/acidosis, Hypo/hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Toxins, Thrombosis-pulmonary, and Thrombosis-coronary, as suggested by the American Heart Association 1