Pediatric Adrenaline Dosing Guidelines

Correct Dosing by Indication

• The American Academy of Allergy, Asthma, and Immunology recommends an adrenaline dose of 0.01 mg/kg of 1:1000 concentration (maximum 0.3-0.5 mg) for anaphylaxis, administered via intramuscular injection into the lateral thigh, with a frequency of every 5-15 minutes as needed 1
• The American Heart Association recommends an initial adrenaline dose of 0.01 mg/kg of 1:10,000 solution (maximum 0.3 mg initially) for cardiac arrest, administered via intravenous or intraosseous route, with a frequency of every 3-5 minutes during ongoing arrest 1

Special Considerations for Anaphylaxis Progressing to Cardiac Arrest

• If anaphylaxis causes cardiac arrest, the American Academy of Allergy, Asthma, and Immunology and the American Heart Association recommend immediately switching to cardiac arrest dosing protocols, with standard resuscitative measures and immediate epinephrine administration taking priority 1, 2
• For pediatric cardiac arrest from anaphylaxis, the American Academy of Allergy, Asthma, and Immunology recommends an adrenaline dose of 0.01 mg/kg (0.1 mL/kg of 1:10,000) every 3-5 minutes, with higher doses (0.1-0.2 mg/kg of 1:1000) for refractory arrest 1

Preventing Medication Errors

• The American Heart Association recommends that hospitals stock clearly labeled, pre-filled intramuscular epinephrine syringes that are easily distinguished from IV formulations, with the 1:1000 concentration (1 mg/mL) for IM use in anaphylaxis and the 1:10,000 concentration (0.1 mg/mL) for IV use in cardiac arrest 2

Epinephrine Dosing for Anaphylaxis and Cardiac Arrest

Anaphylaxis Management

• The American Heart Association recommends an intramuscular dose of 0.2-0.5 mg (0.2-0.5 ml of 1:1000 concentration) for anaphylaxis management in adults, administered into the anterolateral aspect of the thigh 3, 4
• The American Heart Association suggests that intramuscular injection into the thigh provides rapid peak plasma epinephrine concentrations and is the preferred initial route due to ease of administration, effectiveness, and safety 4
• The frequency of intramuscular epinephrine administration can be repeated every 5-15 minutes as needed for anaphylaxis management 3, 4
• For intravenous administration of epinephrine in anaphylaxis, the recommended dose is 0.05-0.1 mg (5-10% of the cardiac arrest dose) using a 0.1 mg/ml (1:10,000) solution 3, 4, 5

Cardiac Arrest Management

• The American Heart Association recommends a standard dose of 1 mg IV/IO every 3-5 minutes during cardiac arrest, using a 1:10,000 (0.1 mg/ml) concentration 6
• Standard-dose epinephrine (1 mg) improves return of spontaneous circulation compared to placebo in cardiac arrest management 6

Monitoring and Special Considerations

• Close hemodynamic monitoring is essential in patients receiving epinephrine, especially those with anaphylactic shock, as recommended by the American Heart Association 3, 4
• If extravasation occurs with IV administration, infiltrate the site with phentolamine to prevent tissue necrosis 7

Epinephrine Dosing and Administration for Anaphylaxis and Cardiac Arrest

Anaphylaxis Management (Intramuscular Epinephrine)

• The first‑line treatment for anaphylaxis is 0.3–0.5 mg of epinephrine 1:1000 administered intramuscularly into the anterolateral thigh; this dose may be repeated every 5–15 minutes if symptoms persist【8】【9】.
• Intramuscular delivery provides rapid peak plasma concentrations and is preferred because it is easy, effective, and safe in the setting of anaphylaxis【9】.

Cardiac Arrest Management (Intravenous/Intraosseous Epinephrine)

• During cardiac arrest, the recommended dose is 1 mg of epinephrine 1:10 000 (0.1 mg/mL) given intravenously or intraosseously every 3–5 minutes throughout resuscitation【9】.
• The intravenous or intraosseous route is essential for cardiac arrest because it ensures immediate systemic delivery despite compromised peripheral perfusion【9】.
• Intramuscular epinephrine is not appropriate for cardiac arrest; absorption is unpredictable in the low‑flow state and the dose is insufficient【9】.

Transition When Anaphylaxis Progresses to Cardiac Arrest

• If anaphylaxis evolves into cardiac arrest, clinicians must abandon the 0.3–0.5 mg IM protocol and immediately switch to the cardiac‑arrest regimen of 1 mg IV/IO epinephrine 1:10 000 every 3–5 minutes【9】.
• Standard resuscitative measures and prompt epinephrine administration take priority over continued IM dosing in this scenario【9】.

Importance of Correct Concentration and Route (Error Prevention)

• The 1:1000 concentration (1 mg/mL) used for IM anaphylaxis is ten times more concentrated than the 1:10 000 formulation (0.1 mg/mL) required for IV cardiac‑arrest dosing; confusing the two can lead to severe iatrogenic cardiac complications【9】.
• Hospitals should stock clearly labeled, pre‑filled syringes that differentiate IM (1:1000) from IV/IO (1:10 000) epinephrine to reduce dosing errors【9】.

Clinical Algorithm Summary (Key Action Points)

• Anaphylaxis without arrest: Give 0.3–0.5 mg IM epinephrine 1:1000 into the thigh; repeat every 5–15 minutes as needed【8】【9】.
• Refractory anaphylaxis: Consider a slow IV push or infusion of 0.05–0.1 mg epinephrine 1:10 000【9】.
• Cardiac arrest (any cause): Administer 1 mg IV/IO epinephrine 1:10 000 every 3–5 minutes until return of spontaneous circulation or termination of efforts【9】.
• Anaphylaxis → cardiac arrest: Immediately transition to the 1 mg IV/IO 1:10 000 protocol; do not continue IM dosing【9】.

All statements are based on recommendations from the American Heart Association (circulation guidelines) and the American Academy of Allergy, Asthma & Immunology (allergy guidelines).*

Management of Anaphylaxis‑Induced Cardiac Arrest

Pre‑Arrest Anaphylaxis Management

• First‑line therapy – The American Heart Association (AHA) recommends intramuscular epinephrine 0.3–0.5 mg (1 : 1000) into the anterolateral thigh for patients with systemic anaphylaxis, hypotension, airway swelling, or respiratory distress. Class I, Level B 10.
• Pharmacokinetic advantage – IM administration yields rapid peak plasma concentrations and is preferred for its ease, effectiveness, and safety while the patient is still perfusing. Class I, Level B 10.
• Repeat dosing – If symptoms persist, repeat the IM dose every 5–15 minutes as needed. Class I, Level B 10.

Immediate Transition When Cardiac Arrest Occurs

• Switch to ACLS protocol – The moment a patient becomes pulseless, IM epinephrine must be abandoned and standard Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) protocols initiated, with immediate IV/IO epinephrine at cardiac‑arrest dosing. Class I, Level B 10.
• Cardiac‑arrest dosing – Administer 1 mg epinephrine (1 : 10 000) IV or intra‑osseously every 3–5 minutes during ongoing resuscitation. Class I, Level B 10.
• Rationale for abandoning IM route – During arrest peripheral perfusion is essentially absent, making IM absorption unpredictable; the 0.3–0.5 mg IM dose provides only 30–50 % of the dose required for effective cardiac‑arrest therapy. Class I, Level B 10.
• Witnessed on‑scene arrest – For EMTs who witness an anaphylaxis arrest:
• Evidence base – No randomized controlled trials support alternative treatment algorithms; standard BLS/ACLS with early IV/IO epinephrine remains the cornerstone of care. Class I, Level C‑LD [10][11]12.

Adjunctive Therapies During Resuscitation

• Fluid resuscitation – Aggressive IV crystalloid (1–2 L normal saline in adults, or 20 mL/kg boluses in children) is mandatory; anaphylactic shock can result in loss of up to ~37 % of circulating blood volume. Class I, Level B 13.
• Airway protection – Secure the airway early when laryngeal edema is present; be prepared for surgical airway placement if needed. Class I, Level B [10][13].
• Non‑epinephrine drugs – Antihistamines, inhaled β‑agonists, and IV corticosteroids have no proven benefit during anaphylaxis‑induced cardiac arrest and should never delay epinephrine administration. Class III (no benefit), Level C‑LD [10][11]12.

Post‑Arrest Management

• Epinephrine infusion – If return of spontaneous circulation (ROSC) is achieved and the patient remains in shock, an IV epinephrine infusion of 5–15 µg/min may be considered. Class IIa, Level B [10][11].
• Hemodynamic monitoring – Continuous, close hemodynamic monitoring is required after ROSC because cardiovascular status can change rapidly. Class I, Level B 10.

Adrenaline Dosing and Safety in Anaphylaxis and Cardiac Arrest

Dosage Recommendations for Anaphylaxis

• Adults: Administer 0.3–0.5 mg (0.3–0.5 mL of a 1 mg/mL solution, 1:1000 concentration) intramuscularly into the mid‑anterolateral thigh using a needle inserted at 90°. 14
• Children: Administer 0.01 mg/kg (maximum 0.3 mg) intramuscularly using the same 1:1000 concentration and injection site; the adult maximum dose of 0.5 mg may be used for older children when appropriate. 14
• Repeat dosing: If anaphylactic symptoms persist, repeat the intramuscular dose every 5–15 minutes as needed. 14

Dosage Recommendations for Cardiac Arrest

• Adults: Give 1 mg of adrenaline (0.1 mg/mL, 1:10,000 concentration) intravenously or intra‑osseously every 3–5 minutes during resuscitation. 14
• Children: Give 0.01 mg/kg (0.1 mL/kg of the 1:10,000 solution), not exceeding 1 mg per dose, intravenously or intra‑osseously every 3–5 minutes. 14

Safety and Error‑Prevention Strategies

• Pre‑filled, colour‑coded syringes: Hospitals should stock pre‑filled syringes that are clearly labelled—“ANAPHYLAXIS – INTRAMUSCULAR ONLY” for 1:1000 preparations and “CARDIAC ARREST – IV/IO ONLY” for 1:10,000 preparations—to minimize selection errors. 14
• Survey finding: A recent survey indicated that 6 of 7 hospitals lacked pre‑filled intramuscular syringes, a gap associated with a higher risk of medication errors. 14
• Double‑check protocol: Before administration, clinicians must verify (1) whether the situation is anaphylaxis or cardiac arrest, (2) the correct concentration (1:1000 vs. 1:10,000), (3) the intended route (IM thigh vs. IV/IO), and (4) the dose appropriate for the patient’s weight (especially in children). 14
• Rapid decision algorithm:
  
  • Pulse present + anaphylaxis symptoms → 0.3–0.5 mg IM 1:1000 in the thigh.
  • No pulse (any cause) → 1 mg IV/IO 1:10,000 every 3–5 minutes.
  • Anaphylaxis progressing to arrest → immediately switch to the cardiac‑arrest protocol (1 mg IV/IO 1:10,000). 14
• Physical separation and colour coding: Store intramuscular and intravenous preparations in distinct locations on the emergency cart and use different colour codes for each to further reduce the chance of confusion. 14

Special Clinical Considerations

• No absolute contraindication: Adrenaline should be administered in anaphylaxis even in patients with known cardiovascular disease or who are taking β‑blockers, because the risk of death from untreated anaphylaxis outweighs potential drug‑related risks. 14
• Asthma comorbidity: Patients with asthma have a markedly higher risk of fatal anaphylaxis and therefore require prompt intramuscular adrenaline administration. 14
• Impact of delayed administration: Delaying the first dose of adrenaline in anaphylaxis is associated with increased mortality and morbidity. 14