Drug Therapy Protocols: Adrenaline (epinephrine)

Policy code DTP_ADR_0519

Date May, 2019
Purpose To ensure a consistent procedural approach to adrenaline (epinephrine) administration.
Scope Applies to Queensland Ambulance Service (QAS) clinical staff.
Health care setting Pre-hospital assessment and treatment.
Population Applies to all ages unless stated otherwise.
Source of funding Internal – 100%
Author Clinical Quality & Patient Safety Unit, QAS
Review date May, 2022
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 Adrenaline (epinephrine)
May, 2019

Drug class
Contraindications
Sympathomimetic

Pharmacology

U NC O NTR O L L ED WH E N PR IN T ED
Adrenaline (epinephrine) is a naturally occurring catecholamine which
primarily acts on Alpha (α) and Beta (β) adrenergic receptors. The actions
• Nil

of these receptors cause an increase in heart rate (β1), increase in the

Precautions
force of myocardial contraction (β1), increase in the irritability of the
ventricles (β1), bronchodilation (β2) and peripheral vasoconstriction (α1).[1–3] • Hypertension
• Hypovolaemic shock
Metabolism

U N C O NTR O L L ED WH E N PR IN T ED
The majority of circulating adrenaline (epinephrine) is metabolised by
sympathetic nerve endings. It is subject to the process of mitochondrial
enzymatic breakdown by monoamine oxidase at the synaptic level.
• Concurrent MAOI therapy

Side effects

Indications • Anxiety
• Hypertension

U N C O NT R O L L ED WH E N PR IN T ED
• Anaphylaxis OR severe allergic reaction
• Severe life-threatening bronchospasm
OR silent chest (patients must only be able to speak
• Palpitations/tachyarrhythmias
• Pupil dilation
• Tremor
in single words AND/OR have haemodynamic
compromise AND/OR an ALOC)
Presentation
• Bradycardia with poor perfusion unresponsive to
atropine AND/OR transcutaneous pacing

U N C O NT R O L L ED WH E N
• Cardiac arrest
PR IN T ED
• Croup (with stridor at rest)
• Ampoule, 1 mg/1 mL (1:1,000) adrenaline (epinephrine)
• Ampoule, 1 mg/10 mL (1:10,000) adrenaline (epinephrine)
• Prefilled syringe EpiPen® Auto-injector, 300 mcg adrenaline
• Shock unresponsive to adequate fluid resuscitation (epinephrine)
(excluding haemorrhagic, obstructive and anaphylactic)
Figure 4.1

QUEENSLAND AMBULANCE SERVICE 854

Adrenaline (epinephrine)

Onset Duration Half-life Special notes

30 seconds (IV) • Ambulance officers must only administer medications for the listed indications
5–10 minutes 2 minutes
60 seconds (IM) and dosing range. Any consideration for treatment outside the listed scope of

U NC O NT
ScheduleR O L L ED WH E N PR IN T ED practice requires mandatory approval via the QAS Clinical Consult and Advice Line.
• 1 : 1,000 (1 mg/mL) adrenaline (epinephrine) presentation should be used 

for all nebuliser administration.
• 1 mg/1 mL (1 : 1,000), S3 (therapeutic poison)
• 1:10,000 (100 microg/1 mL ) or a 1 : 100,000 (10 microg/1 mL ) adrenaline
• 1 mg/10 mL (1 :10,000), S3 (therapeutic poison) (epinephrine) preparation should be used for all low dose IM/IV injections. 

• 300 mcg EpiPen® Auto-injector, S3 (therapeutic poison) Ensure all syringes are appropriately labelled.
• If possible, all time critical adrenaline (epinephrine) IM injections 


U N C O NTR O L L ED WH E N
Routes of administration PR IN T ED should be administered in the vastus lateralis (improved absorption).
• Suitably qualified officers should, where possible, administer adrenaline 

infusions through an appropriately placed central venous line.
ACP2
CCP
Nebuliser (NEB)
• Suitably qualified officers should, where possible, utilise invasive pressure
monitoring for patients being administered adrenaline (epinephrine) infusions.
E PTO

P
ACP2
ACP1

CCP
FR

AT

Intramuscular injection (IM) • Adrenaline (epinephrine) infusions must be administered through 


T ED
a dedicated line.

U N C O NT R O L L ED WH E N PR IN • Patients on adrenaline (epinephrine) infusions without continuous IBP 


ACP2
CCP

Intravenous injection (IV)

monitoring must have their NIBP measured regularly (every 5 mins at a minimum).
• All cannulae with adrenaline (epinephrine) infusions should be as proximal 

CCP

Intraosseous injection (IO) as possible, be freely flowing, and be watched closely for extravasation.
• NIBP cuffs are only to be placed on limbs without infusion as not to 

obstruct the flow.
CCP

D
Intravenous infusion (IV INF)

U N C O NT R O L L ED WH E N PR IN T E • All cannulae and IV lines must be flushed thoroughly with sodium chloride 0.9%
following each medication administration.
CCP

Intaosseous infusion (IO INF)

QUEENSLAND AMBULANCE SERVICE 855

Adrenaline (epinephrine)

Adult dosages
Anaphylaxis OR severe allergic reaction Anaphylaxis OR severe allergic reaction
IM EpiPen® Auto-injector (300 microg)
 NEB 5 mg

P
E PTO

ACP2
CCP
FR

AT

Single dose only. Single dose only.

U NC O NTR O L L ED WH E
IM
N PR IN T ED
500 microg (300 microg if known pregnancy)
May be administered for upper airway obstruction
thought to be allergic in origin - IM adrenaline 

ACP2
ACP1

CCP

Repeated at 5 minute intervals. (epinephrine) must first be administered.

No maximum dose.

IV
 Commence infusion at 6 microg/minute (1 drop/second) Severe life-threatening bronchospasm OR silent chest 

CCP

INF and increase by 6 microg/minute (1 drop/second) every (patients must only be able to speak in single words AND/OR
3-5 minutes − titrate accordingly to indication and 
 have haemodynamic compromise AND/OR an ALOC)
patient’s physiological response to treatment.
IM 500 microg (300 microg if known pregnancy)

ACP2
ED

ACP1

CCP
U N C O NTR O L L ED WH E N PR IN T
May be administered for refractory anaphylaxis

(unresponsive to 3 x 500 microg (300 microg if known
pregnancy) adrenaline (epinephrine) IM) and adequate
fluid resuscitation).
IV

Repeated at 5 minute intervals.
No maximum dose.

Commence infusion at 6 microg/minute (1 drop/second)

CCP
Infusion preparation: Inject 1 mg of 1:1000 adrenaline INF and increase by 6 microg/minute (1 drop/second) every
(epinephrine) in 500 mL of sodium chloride 0.9% to 3-5 minutes − titrate accordingly to indication and 

achieve a final concentration of 2 microg/mL Ensure 
 patient’s physiological response to treatment.
bag is appropriately labelled. Administer infusion via 

May be administered for severe life-threatening 

a SmartSite® add-on burette set (with ball valve drip 

bronchospasm or silent chest (unresponsive to 


U N C O NT R O L L ED WH E
IO
N PR IN T ED
chamber) through a dedicated IV cannula.

Commence infusion at 6 microg/minute (1 drop/second)

3 x 500 microg (300 microg if known pregnancy) 

adrenaline (epinephrine) IM).
CCP

INF and increase by 6 microg/minute (1 drop/second) every Infusion preparation: Inject 1 mg of 1:1000 adrenaline
3-5 minutes − titrate accordingly to indication and 
 (epinephrine) in 500 mL of sodium chloride 0.9% to
patient’s physiological response to treatment. achieve a final concentration of 2 microg/mL Ensure 

May be administered for refractory anaphylaxis
 bag is appropriately labelled. Administer infusion via 

(unresponsive to 3 x 500 microg (300 microg if known a SmartSite® add-on burette set (with ball valve drip 

pregnancy) adrenaline (epinephrine) IM) and adequate chamber) through a dedicated IV cannula.

U N C O NT R O L L ED WH E N PR IN T ED
fluid resuscitation).
Infusion preparation: Inject 1 mg of 1:1000 adrenaline
(epinephrine) in 500 mL of sodium chloride 0.9% to
achieve a final concentration of 2 microg/mL Ensure 

bag is appropriately labelled. Administer infusion via 

a SmartSite® add-on burette set (with ball valve drip 

chamber) through a dedicated IV cannula.
QUEENSLAND AMBULANCE SERVICE 856
Adrenaline (epinephrine)

Adult dosages (cont.) Adult dosages (cont.)

Severe life-threatening bronchospasm OR silent chest 
 Shock unresponsive to adequate fluid resuscitation 

(patients must only be able to speak in single words AND/OR (excluding haemorrhagic, obstructive and anaphylactic )
have haemodynamic compromise AND/OR an ALOC)

U NC O NTR O L L ED WH E N PR IN T ED IV
 Commence infusion at 6 microg/minute (1 drop/second)

CCP
IO
 Commence infusion at 6 microg/minute (1 drop/second) INF
 and increase by 6 microg/minute (1 drop/second) every
CCP

INF
 and increase by 6 microg/minute (1 drop/second) every 3-5 minutes – titrate accordingly to indication and 

3-5 minutes − titrate accordingly to indication and 
 patient’s physiological response to treatment.
patient’s physiological response to treatment.
Infusion preparation: Inject 1 mg of 1:1000 adrenaline 

May be administered for severe life-threatening 
 (epinephrine) in 500 mL of sodium chloride 0.9% to
bronchospasm or silent chest (unresponsive to 
 achieve a final concentration of 2 microg/mL. Ensure 

3 x 500 microg (300 microg if known pregnancy) 
 bag is appropriately labelled. Administer infusion via 

adrenaline (epinephrine) IM).

D
a SmartSite® add-on burette set (with ball valve drip 


U N C O NTR O L L ED WH E N PR IN T E
Infusion preparation: Inject 1 mg of 1:1000 adrenaline
(epinephrine) in 500 mL of sodium chloride 0.9% to
achieve a final concentration of 2 microg/mL Ensure 
 IO

chamber) through a dedicated IV cannula.

Commence infusion at 6 microg/minute (1 drop/second)

CCP
bag is appropriately labelled. Administer infusion via 
 INF and increase by 6 microg/minute (1 drop/second) every
a SmartSite® add-on burette set (with ball valve drip 
 3-5 minutes – titrate accordingly to indication and 

chamber) through a dedicated IV cannula. patient’s physiological response to treatment.
Infusion preparation: Inject 1 mg of 1:1000 adrenalin 

Bradycardia with poor perfusion 
 (epinephrine) in 500 mL of sodium chloride 0.9% to

U N C O NT R O L
IVL ED WH E N PR IN
20 – 50 microgT ED
unresponsive to atropine AND/OR transcutaneous pacing achieve a final concentration of 2 microg/mL. Ensure 

bag is appropriately labelled. Administer infusion via 

a SmartSite® add-on burette set (with ball valve drip 

CCP

Repeated at 1 minute intervals. No maximum dose. chamber) through a dedicated IV cannula.

IO 20 – 50 microg IV
 Commence infusion at 6 microg/minute (6 mL/hour)

E CCP
CCP

Repeated at 1 minute intervals. No maximum dose. INF and increase by 6 microg/minute (6 mL/hour) 

every 3-5 minutes as determined by MAP.
Infusion preparation: Mix 3 mg of 1:1000 

Cardiac arrest

U N C O NT R O L
IV
L ED WH
1 mg
E N PR IN T ED adrenaline (3 mL) with 47 mL of sodium chloride 

0.9% in a 50 mL syringe to achieve a final 

ACP2
CCP

Repeated at 3 – 5 minute intervals. No maximum dose. concentration of 60 microg/mL. Ensure all 

syringes are appropriately labelled. 

1 mg Administer via syringe driver.
IO
CCP

Repeated at 3 – 5 minute intervals. No maximum dose.

QUEENSLAND AMBULANCE SERVICE 857

Adrenaline (epinephrine)

Paediatric dosages Paediatric dosages (cont.)

Anaphylaxis OR severe allergic reaction Severe life-threatening bronchospasm OR silent chest 

(patients must only be able to speak in single words AND/OR 

IM ≥ 6 years – EpiPen® Auto-injector (300 microg)

E PTO

P
FR

have haemodynamic compromise AND/OR an ALOC)

AT

Single dose only.

U NC O NTR O L L ED WH E N PR IN T ED
1–5 years – EpiPen® Jr Auto-injector (150 microg)
 IM ≥ 6 years – 300 microg


ACP2
ACP1

CCP
Single dose only. Repeated at 5 minute intervals. 

No maximum dose.
IM ≥ 6 years – 300 microg

ACP2

1 – < 6 years – 150 microg


ACP1

CCP

Repeated at 5 minute intervals. 
 Repeated at 5 minute intervals. 


No maximum dose. No maximum dose.
1 – < 6 years – 150 microg
 6 months – 1 year – 100 microg

Repeated at 5 minute intervals. 
 Repeated at 5 minute intervals. 


U N C O NTR O L L ED WH E N PR IN T ED
No maximum dose.
6 months – 1 year – 100 microg

Repeated at 5 minute intervals. 

No maximum dose.
No maximum dose.
< 6 months – 50 microg

Repeated at 5 minute intervals. 

No maximum dose.
< 6 months – 50 microg

Repeated at 5 minute intervals. 
 IV
 QAS Clinical Consultation and Advice Line 


CCP
No maximum dose. INF consultation and approval required in all situations.

IV
 QAS Clinical Consultation and Advice Line 


E N PR IN T ED
CCP

U N C O NT R O L L ED WH
INF IO
 QAS Clinical Consultation and Advice Line 


CCP
consultation and approval required in all situations.
INF consultation and approval required in all situations.

IO
 QAS Clinical Consultation and Advice Line 


CCP

INF consultation and approval required in all situations.

NEB 5 mg

ACP2
CCP

Single dose only.

U N C O NT R O L L ED WH E N PR IN T ED
May be administered for upper airway obstruction
thought to be allergic in origin - IM adrenaline 

(epinephrine) must also be administered.

QUEENSLAND AMBULANCE SERVICE 858

Adrenaline (epinephrine)

Paediatric dosages (cont.) Paediatric dosages (cont.)

Cardiac arrest Bradycardia with poor perfusion 


IV ≥ 10 kg (≥ 1 year ) – 10 microg/kg
 unresponsive to atropine AND/OR transcutaneous pacing

T ED
ACP2

R IN
CCP

U NC O NTR O L L ED WH E N P
Repeated at 3 – 5 minute intervals. 

No maximum dose. IV
 QAS Clinical Consultation and Advice Line 


CCP
< 10 kg (< 1 year ) – 100 microg
 consultation and approval required in all situations.
Repeated at 3 – 5 minute intervals. 

No maximum dose. IO QAS Clinical Consultation and Advice Line 


CCP
consultation and approval required in all situations.
IO ≥ 10 kg (≥ 1 year ) – 10 microg/kg

CCP

Repeated at 3 – 5 minute intervals. 


U N C O NTR O L L ED WH E N P T ED
No maximum dose.

R IN
< 10 kg (< 1 year ) – 100 microg

Repeated at 3 – 5 minute intervals. 

No maximum dose.

Croup (with stridor at rest)

NEB 5 mg

ACP2
CCP

Single dose only.

U N C O NT R O L L ED WH E N PR IN T ED
Shock unresponsive to adequate fluid resuscitation 

(excluding haemorrhagic, obstructive and anaphylatic)

IV
 QAS Clinical Consultation and Advice Line 


CCP

INF consultation and approval required in all situations.

U N C O NT R O L L
IO

ED WH E N PR IN T ED
QAS Clinical Consultation and Advice Line 

CCP

INF consultation and approval required in all situations.

QUEENSLAND AMBULANCE SERVICE 859