Anaphylaxis Treatment Guidelines

Adult and Pediatric Dosing

The American Heart Association recommends administering 0.3 to 0.5 mL of 1:1000 epinephrine (equivalent to 0.3 to 0.5 mg) intramuscularly into the anterolateral aspect of the thigh for adults and children weighing ≥30 kg, with doses repeated every 5 to 15 minutes for persistent or recurrent symptoms 1
For children weighing less than 30 kg, the recommended dose is 0.01 mL/kg of 1:1000 epinephrine (0.01 mg/kg), up to a maximum of 0.3 mL (0.3 mg) per injection, with a 0.15 mg autoinjector recommended for children weighing 7.5 to 25 kg and a 0.3 mg autoinjector for children weighing ≥25 kg 3
Approximately 6-19% of patients require a second dose of epinephrine 2

Intramuscular injection into the anterolateral thigh (vastus lateralis muscle) is the preferred route, producing rapid peak plasma concentrations compared to subcutaneous administration 2
IV epinephrine should be reserved for patients in anaphylactic shock when an IV line is already in place, or for cardiac arrest or profound hypotension unresponsive to IM epinephrine and fluid resuscitation 2

The standard concentration for intramuscular/subcutaneous use in anaphylaxis is 1:1000, meaning 1 mg per 1 mL, with 0.3 mL equivalent to 0.3 mg and 0.5 mL equivalent to 0.5 mg 3, 2
For IV administration, 0.05 to 0.1 mg (0.5 to 1 mL of 1:10,000 solution) should be used, with a continuous IV infusion prepared by adding 1 mg (1 mL of 1:1000) to 1000 mL of 0.9% normal saline, starting at 2 μg/min (120 mL/h) and titrating up to 10 μg/min (600 mL/h) based on blood pressure, heart rate, and oxygenation 1, 4

There are no absolute contraindications to epinephrine use in anaphylaxis, even in elderly patients with cardiovascular disease or other comorbidities, as the benefits far outweigh the risks 4, 2