Start with a bolus
The ideal dose of epinephrine is unknown, potentially depending on how close the patient is to death. Moitra 2012 recommended a bolus of 10-100 mcg epinephrine. A 20-40 mcg IV bolus seems reasonable for most patients.
The best way to achieve this is push-dose epinephrine, a solution of 10 mcg/ml epinephrine which may be formulated as shown below (Weingart 2015). 2-4 ml of push-dose epinephrine will provide a 20-40 mcg epinephrine bolus.
Mixing Epinephrine for Push-Dose Pressors from Scott from EMCrit on Vimeo.
A quick and dirty approach is to push 1/2 ml of 100 mcg/ml epinephrine (cardiac epinephrine). If no push-dose epinephrine is available, this may be faster because it requires no dilution. For a patient whose heart rate is rapidly dropping and is about to arrest, this may be a reasonable maneuver (5). However, there is a risk of inaccurate dosing.
Continue with an infusion
If the patient responds to a bolus of epinephrine, an epinephrine infusion should be started immediately. An epinephrine infusion at 2-10 mcg/min is generally recommended for bradycardia. For bradycardic periarrest, it may be best to start at 10 mcg/min and then wean down once the patient is stabilized (6).
Epinephrine requires respect. It is prone to dosing errors, which can be dangerous. However, this shouldn’t lead us to epinephrophobia: irrational fear of epinephrine, even in situations where it is life-saving (e.g. anaphylaxis).
Resuscitationists must become comfortable with epinephrine in its various forms (intramuscular, push-dose, and IV infusion). When dosed appropriately, this is a safe medication. Please note, however, that intracardiac epinephrine is no longer recommended (7):