13.2 Epinephrine Dosing in Depth

AHA PALS Provider Pediatric Advanced Life Support

Track your progress as you read

Finished sections get a check mark.

1 Chapter 1: Course Overview & Exam Logistics

1.1 Current Exam Facts 1.2 Audience, Prerequisites & Study Plan

2 Chapter 2: Systematic Pediatric Assessment

2.1 Pediatric Assessment Triangle (PAT) 2.2 Evaluate–Identify–Intervene Sequence 2.3 Primary Assessment: ABCDE 2.4 Secondary Assessment, SAMPLE & Vitals by Age

3 Chapter 3: Respiratory Distress & Failure

3.1 Respiratory Distress vs Failure 3.2 Recognition & Immediate Intervention Priorities 3.3 Oxygen Delivery & Basic Airway Support

4 Chapter 4: Airway Problems & Ventilation Strategies

4.1 Upper Airway Obstruction 4.2 Lower Airway, Lung Tissue Disease & Disordered Control 4.3 Bag-Mask Ventilation & Advanced Airways During CPR

5 Chapter 5: Shock Fundamentals & Hypovolemia

5.1 Compensated vs Hypotensive (Decompensated) Shock 5.2 Hypovolemic Shock 5.3 Isotonic Fluid Bolus 10–20 mL/kg & Reassessment

6 Chapter 6: Distributive, Cardiogenic & Obstructive Shock

6.1 Distributive & Septic Shock Pathway 6.2 Cardiogenic Shock 6.3 Obstructive Shock

7 Chapter 7: Pediatric BLS & High-Quality CPR

7.1 High-Quality CPR Metrics 7.2 Compression-Ventilation Ratios 7.3 CPR Quality Monitoring: ETCO2 & Diastolic BP

8 Chapter 8: Pediatric Cardiac Arrest Algorithm

8.1 Arrest Recognition & Systematic Approach 8.2 VF/pVT & Defibrillation Energy 8.3 Asystole & PEA 8.4 Epinephrine in Arrest: Dose & Timing

9 Chapter 9: Bradycardia & Narrow-Complex Tachycardia

9.1 Bradycardia with Poor Perfusion 9.2 Sinus Tachycardia vs SVT 9.3 Stable SVT: Vagal Maneuvers & Adenosine

10 Chapter 10: Unstable Tachycardia & Wide-Complex Rhythms

10.1 Unstable Tachycardia & Synchronized Cardioversion 10.2 Wide-Complex Tachycardia & VT with Pulse 10.3 Antiarrhythmics for Tachycardia with Pulse

11 Chapter 11: Reversible Causes & Special Circumstances

11.1 Reversible Causes: The H's and T's 11.2 Special Circumstances at Exam Level 11.3 Extracorporeal CPR (ECPR) Overview

12 Chapter 12: Post–Cardiac Arrest Care

12.1 Post-ROSC Oxygenation & Ventilation 12.2 Post-Arrest Hemodynamic Support 12.3 Temperature Control & Glucose 12.4 Neuroprognostication & Transport

13 Chapter 13: Vascular Access & Core Pharmacology

13.1 IV and Intraosseous Access 13.2 Epinephrine Dosing in Depth 13.3 Amiodarone, Lidocaine & Adenosine 13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

14 Chapter 14: Team Dynamics & Megacode Readiness

14.1 High-Performance Team Roles 14.2 Closed-Loop Communication 14.3 Constructive Intervention, Debriefing & Exam Integration

13.2 Epinephrine Dosing in Depth

Key Takeaways Explain This Topic AI

Cardiac arrest epinephrine dose is 0.01 mg/kg IV/IO every 3–5 minutes , maximum single dose 1 mg (0.1 mL/kg of the 0.1 mg/mL concentration).

Concentration confusion between 0.1 mg/mL (arrest IV/IO volume math) and 1 mg/mL (often IM anaphylaxis) is a major medication-error trap.

Anaphylaxis IM epinephrine typically uses 0.01 mg/kg of 1 mg/mL IM with common teaching maxima about 0.3–0.5 mg —not the arrest push recipe.

For symptomatic pediatric bradycardia with poor perfusion, epinephrine is usually preferred over atropine as the primary drug.

Post-arrest or shock support may use epinephrine infusions titrated to perfusion and blood-pressure goals—know the concept without inventing nonstandard concentration recipes.

Last updated: August 2026

Arrest Dose: Numbers You Must Own Cold

Chapter 8 introduced epinephrine timing in the arrest algorithm. This section owns the dose math, concentration traps, and non-arrest uses that generate medication errors and exam distractors.

Standard pediatric cardiac arrest dose

Parameter Value
Dose 0.01 mg/kg IV or IO
Preferred concentration for volume math 0.1 mg/mL (older label 1:10,000)
Volume at 0.1 mg/mL 0.1 mL/kg
Interval Every 3–5 minutes during arrest
Maximum single dose 1 mg
Route preference IV/IO ; not routine high-dose; ET only if no IV/IO
The 1 mg ceiling

The 2025 Pediatric Cardiac Arrest Algorithm and the Pediatric Bradycardia With a Pulse Algorithm both cap the epinephrine dose at a maximum of 1 mg , which is also the standard adult push dose. Weight-based math and the ceiling cross at 100 kg (0.01 mg/kg × 100 kg = 1 mg), so the cap only binds for large adolescents:

A 60 kg adolescent gets 0.6 mg (6 mL of 0.1 mg/mL)—weight-based, no cap needed.

A 120 kg adolescent does not get 1.2 mg; the dose is capped at 1 mg (10 mL of 0.1 mg/mL).

Exam stems that hand you an adolescent weight above 100 kg are testing whether you know the ceiling exists. Everything else about the dose—interval, concentration, flush—stays the same.

Worked examples (arrest IV/IO, 0.1 mg/mL)

Weight Dose (mg) Volume of 0.1 mg/mL
5 kg 0.05 mg 0.5 mL
10 kg 0.1 mg 1 mL
15 kg 0.15 mg 1.5 mL
20 kg 0.2 mg 2 mL
30 kg 0.3 mg 3 mL
110 kg 1 mg (capped, not 1.1 mg) 10 mL

Announce both mg/kg and the drawn volume in closed-loop communication so another team member can catch a ten-fold error before it reaches the patient.

Why α-effects matter in arrest

During CPR, epinephrine’s α-adrenergic vasoconstriction raises aortic diastolic pressure and coronary perfusion pressure . That is the primary benefit in true arrest. β-effects increase heart rate and contractility but also raise myocardial oxygen demand—one reason high-dose epinephrine is not routinely recommended for standard pediatric arrest. Stick to 0.01 mg/kg unless a specific special circumstance and medical direction say otherwise.

Flush, time, and continue CPR

Every dose: push → flush → note clock time → continue compressions and the rhythm algorithm. Do not create a prolonged pause to "see if the dose worked" on the monitor alone.

Concentration Confusion: The Highest-Yield Med Error

Two epinephrine concentrations appear constantly in pediatric care. Mixing them is a classic pathway to ten-fold underdose or overdose .

Concentration Older ratio label Typical emergency uses
0.1 mg/mL 1:10,000 Cardiac arrest IV/IO volume = 0.1 mL/kg for 0.01 mg/kg
1 mg/mL 1:1,000 IM anaphylaxis ; some infusion compounding and nebulized uses per protocol
Trap patterns

Using 1 mg/mL volume as if it were 0.1 mg/mL: Drawing 0.1 mL/kg of 1 mg/mL delivers 0.1 mg/kg — ten times the standard arrest dose.

Using 0.1 mg/mL for IM anaphylaxis volume math incorrectly: IM anaphylaxis teaching is built around the 1 mg/mL product in many systems.

Saying "give epi 1:10,000" without checking the vial in hand. Always read the mg/mL on the label; ratio labels are being phased down in many hospitals for safety.

Quick verification habit

Before any push:

Confirm indication (arrest vs anaphylaxis vs infusion).

Confirm concentration on the vial/syringe.

Confirm weight-based mg dose.

Confirm mL that matches that mg at that concentration.

Independent double-check when time allows; closed-loop always.

Anaphylaxis IM dose (contrast—do not conflate with arrest)

For anaphylaxis , intramuscular epinephrine into the mid-outer thigh is first-line while airway and fluid support proceed (see special circumstances content). Teaching commonly used on PALS-aligned exams:

Approximately 0.01 mg/kg IM of the 1 mg/mL concentration

Common maximum single IM doses taught around 0.3 mg (many pediatric auto-injector ranges) to about 0.5 mg depending on size/protocol teaching

May repeat per anaphylaxis protocols if symptoms persist

Setting Route Typical teaching dose concept
Cardiac arrest IV/IO 0.01 mg/kg of 0.1 mg/mL (= 0.1 mL/kg ) q3–5 min
Anaphylaxis IM ~0.01 mg/kg of 1 mg/mL , max ~ 0.3–0.5 mg teaching
Bradycardia (poor perfusion) IV/IO 0.01 mg/kg (same order as arrest push dosing framework)

Exam stem tip: if the child has hives, wheeze, and shock from allergy , think IM epi first for the allergic reaction pathway—not an automatic arrest concentration discussion. If the child is pulseless , you are in the arrest IV/IO pathway.

Loading diagram... Epinephrine Use Map (Exam-Level)

Bradycardia Preference and Infusion Concepts
Bradycardia with poor perfusion

As Chapter 9 detailed, pediatric symptomatic bradycardia is usually driven by hypoxia . After airway, oxygen, and ventilation—and CPR when HR remains <60/min with poor perfusion — epinephrine is the preferred medication . Typical IV/IO dose teaching remains 0.01 mg/kg , repeated about every 3–5 minutes while indicated. Atropine is reserved for increased vagal tone , AV block , or when epinephrine is unavailable—not the automatic first drug as in many adult ACLS bradycardia pathways.

Infusions for shock and post-arrest care (concept level)

After ROSC or in vasodilated/cardiogenic shock, teams often start a continuous epinephrine infusion because it can provide combined inotropic and vasopressor effects across a dosing range. PALS written exams emphasize:

Treat hypotension and poor perfusion aggressively (post-arrest: keep SBP and MAP above the 10th percentile for age and sex—Chapter 12).

Use infusions when intermittent pushes are no longer the right tool.

Titrate to clinical perfusion and blood-pressure goals , not to a vanity heart-rate number alone.

Follow institutional concentration and pump protocols ; do not freestyle bedside mixing outside approved charts.

Some systems also discuss "push-dose" dilute epinephrine as a bridge while an infusion is prepared. That practice is protocol-specific. For exam purposes, know that bolus arrest dosing , IM anaphylaxis dosing , and infusion titration are three different workflows that share a drug name but not a single syringe recipe.

What not to do

Error Why it is wrong
Routine high-dose IV epinephrine in standard arrest Not recommended; risk of harm
Giving IM anaphylaxis concentration/volume as the arrest IV push without conversion Ten-fold errors

Choosing atropine first for hypoxic pediatric bradycardia while skipping ventilation Wrong physiology and algorithm

Leaving post-ROSC hypotension untreated because "the pulse is back" Violates post-arrest hemodynamic goals
Inventing an unapproved infusion concentration under stress Medication safety failure
Clinical synthesis scenarios

Arrest math: 8 kg infant in asystole, IO in. Arrest epi = 0.08 mg = 0.8 mL of 0.1 mg/mL , flush, q3–5 min.

Anaphylaxis: 20 kg child with stridor, urticaria, and hypotension after a peanut exposure, pulses present. Give IM epinephrine ~0.01 mg/kg of 1 mg/mL (0.2 mg IM in many teachings, respecting device/protocol maxima), support airway, give fluids, and prepare for possible refractory therapy—not an automatic 2 mL of 0.1 mg/mL IV "because that is the arrest volume."

Bradycardia: 6 kg infant, HR 50 after effective ventilation, poor perfusion → CPR + epinephrine 0.01 mg/kg IV/IO .

Post-ROSC: ROSC achieved but SBP/MAP below 10th percentile with cool extremities → fluids as indicated + epinephrine (or other) infusion per protocol, titrated to goals.

Bottom line for 13.2: Arrest epi = 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL) q3–5 min ; never confuse with 1 mg/mL IM anaphylaxis dosing; prefer epi for pediatric bradycardia after ABC support; use infusions conceptually for ongoing shock/post-arrest support without inventing nonstandard recipes.