8.4 Epinephrine in Arrest: Dose & Timing

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

8.4 Epinephrine in Arrest: Dose & Timing

Key Takeaways Explain This Topic AI

The standard pediatric cardiac arrest epinephrine dose is 0.01 mg/kg IV/IO every 3–5 minutes , to a maximum single dose of 1 mg .

Using the 0.1 mg/mL concentration, 0.01 mg/kg equals 0.1 mL/kg IV/IO—memorize both the mg/kg and mL/kg expressions.

Give epinephrine early for initial nonshockable rhythms (asystole/PEA) once access is available.

For shockable rhythms, prioritize defibrillation when rapid shocks are possible; give epinephrine after defibrillation attempts as the algorithm directs (and sooner if defibrillation cannot be delivered immediately).

Prefer IV/IO over endotracheal administration; high-dose epinephrine is not routinely recommended for standard pediatric arrest.

Last updated: August 2026

Why Epinephrine Matters in Pediatric Arrest

Epinephrine is the primary vasopressor of the pediatric cardiac arrest algorithm. Its most important arrest effect is α-adrenergic vasoconstriction , which raises aortic diastolic pressure during CPR and improves coronary perfusion pressure —the pressure gradient that fills the coronary arteries between compressions. Without adequate coronary perfusion pressure, defibrillation and ROSC are far less likely. β-adrenergic effects (increased heart rate and contractility) are secondary during true arrest and can increase myocardial oxygen demand, which is one reason dosing discipline matters.

Epinephrine does not replace high-quality CPR or timely defibrillation. It is a pharmacologic adjunct that optimizes the perfusion CPR generates while you treat the cause.

Standard arrest dose (exam-critical)

• Parameter Value
• Dose 0.01 mg/kg IV or IO
• Concentration commonly referenced 0.1 mg/mL (also labeled 1:10,000 in older notation)
• Volume at that concentration 0.1 mL/kg
• Interval Every 3–5 minutes during arrest
• Route preference IV/IO first ; ET only if IV/IO cannot be obtained
• Concentration math you must not mix up

Two epinephrine concentrations appear in hospitals:

• Concentration Older ratio label Typical use
• 0.1 mg/mL 1:10,000 Cardiac arrest IV/IO dose volume = 0.1 mL/kg for 0.01 mg/kg
• 1 mg/mL 1:1,000 IM anaphylaxis and some infusions— not the default arrest push volume math

Worked examples (arrest IV/IO using 0.1 mg/mL):

• 5 kg infant: 0.01 mg/kg × 5 = 0.05 mg → volume 0.5 mL
• 10 kg: 0.1 mg → 1 mL
• 20 kg: 0.2 mg → 2 mL

Flush the line after the drug so it reaches central circulation; continue CPR during preparation and administration. Do not create a prolonged hands-off interval to “watch the monitor for drug effect.”

Timing: Nonshockable vs Shockable Paths

Epinephrine timing is rhythm-dependent. This is one of the highest-yield discriminators on PALS exams.

Initial nonshockable rhythm (asystole / PEA)

Start CPR immediately.

Obtain IV/IO access as soon as possible.

Give epinephrine ASAP —do not wait for multiple defibrillation attempts that will never be indicated.

Repeat every 3–5 minutes while arrest continues.

Parallel tasks: ventilation/oxygenation and reversible causes.

Early epinephrine for nonshockable rhythms is associated with better outcomes in resuscitation evidence summaries used in PALS teaching. On a megacode, a team that delays the first epi for nonshockable arrest without access attempts is off-algorithm.

Shockable rhythm (VF / pVT)

Defibrillation is the priority when the defibrillator can be applied and charged rapidly.

Deliver shocks with immediate CPR between attempts (Section 8.2).

Give epinephrine after defibrillation attempts as the algorithm directs—commonly integrated after shocks are underway (often after the second defibrillation attempt in standard course algorithms).

If defibrillation is not immediately possible (device delayed, pads not yet on), continue CPR, secure access, and give epinephrine sooner rather than waiting indefinitely for a shock that has not happened yet.

Once started, continue epinephrine every 3–5 minutes .

• Situation First priorities Epinephrine timing emphasis
• Asystole/PEA CPR, access, airway/O₂, causes Early / ASAP
• VF/pVT, defibrillator ready Shock → CPR After defibrillation priority per algorithm
• VF/pVT, defibrillator delayed CPR + access + airway Give epi sooner while awaiting defib
• What epinephrine does not do

It does not convert asystole by “electrical reset” the way defibrillation terminates VF.

It does not substitute for volume in pure hypovolemic PEA.

It does not fix tension pneumothorax or tamponade—those need mechanical relief.

It does not justify pausing compressions for lengthy drug discussions.

Loading diagram... Epinephrine Timing by Pediatric Arrest Branch

• Route Selection and High-Dose Epinephrine
• Prefer IV/IO over endotracheal

IV or IO administration is preferred because drug delivery to the central circulation is more reliable during CPR. IO access is appropriate emergency access when IV placement is delayed—PALS expects rapid IO rather than prolonged IV attempts in arrest.

Endotracheal (ET) epinephrine is a last-resort route if IV/IO cannot be obtained. Absorption is unpredictable during arrest; doses and dilution differ from IV/IO and should follow current PALS/institutional charts if ET is ever used. Exam correct answers almost always prioritize getting IV/IO over planning an ET drug strategy.

High-dose epinephrine is not routine

High-dose epinephrine (orders of magnitude above 0.01 mg/kg) is not routinely recommended for standard pediatric cardiac arrest. Potential harm includes post-ROSC myocardial dysfunction and excessive vasoconstriction. Unless a specific special circumstance and medical direction dictate otherwise, stick to 0.01 mg/kg IV/IO every 3–5 minutes .

Integration with the full arrest package

Every epinephrine dose should occur on top of :

• High-quality CPR (rate, depth, recoil, minimal interruptions)
• Correct shock/no-shock decisions
• Airway and ventilation appropriate to the child
• Active reversible-cause treatment
• Planned 2-minute cycles and role clarity (Chapter 14)
• Clinical scenario

Case A — Nonshockable: 8 kg infant, asystole. IO placed at 45 seconds of CPR. Give 0.01 mg/kg = 0.08 mg = 0.8 mL of 0.1 mg/mL , flush, continue CPR and ventilation; repeat epi in 3–5 minutes if still arrested.

Case B — Shockable with ready defibrillator: 16 kg child in VF. Shock 2 J/kg (32 J) → immediate CPR → still VF → shock 4 J/kg (64 J) → during CPR give epinephrine 0.01 mg/kg (0.16 mg = 1.6 mL of 0.1 mg/mL) and continue the cycle. Do not delay the first shocks to draw the drug.

Case C — Shockable with delayed device: Same child, pads not yet available. CPR ongoing; IO in. Give epinephrine sooner while the defibrillator is retrieved, then shock as soon as possible at 2 J/kg .

Bottom line for 8.4: Arrest epinephrine = 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL) every 3–5 minutes ; early for nonshockable; after defibrillation priority for shockable when rapid defib is possible; IV/IO > ET ; no routine high-dose epinephrine.