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Date
February, 2018
Purpose Scope Author
To ensure a consistent procedural approach to Adrenaline (epinephrine). Applies to all QAS clinical staff. Clinical Quality & Patient Safety Unit, QAS
Review date
February, 2021
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URL
https://ambulance.qld.gov.au/clinical.html
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Adrenaline (epinephrine) February, 2018
Drug class
Contraindications
UNCONTROLLED WHEN PRINTED Sympathomimetic
Pharmacology
• Nil
Adrenaline (epinephrine) is a naturally occurring catecholamine which primarily acts on Alpha (α) and Beta (β) adrenergic receptors. The actions of these receptors cause an increase in heart rate (β1), increase in the force of myocardial contraction (β1), increase in the irritability of the ventricles (β1), bronchodilation (β2) and peripheral vasoconstriction (α1).[1–3]
Precautions • Hypertension
UNCONTROLLED WHEN PRINTED • Hypovolaemic shock
Metabolism
• Concurrent MAOI therapy
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.
Side effects • Anxiety
Indications
UNCONTROLLED WHEN PRINTED • Hypertension
• Anaphylaxis OR severe allergic reaction
• Palpitations/tachyarrhythmias
• Severe life-threatening bronchospasm OR silent chest (patients must only be able to speak in single words AND/OR have haemodynamic compromise AND/OR an ALOC)
• Pupil dilation • Tremor
Presentation
• Bradycardia with poor perfusion (unresponsive to atropine AND/OR TCP)
UNCONTROLLED WHEN PRINTED ,,..,
• Ampoule, 1 mg/1 mL (1:1,000) adrenaline (epinephrine)
• Cardiac arrest
• Ampoule, 1 mg/10 mL (1:10,000) adrenaline (epinephrine)
• Croup (with stridor at rest)
• Prefilled syringe EpiPen® Auto-injector, 300 mcg adrenaline (epinephrine)
• Shock unresponsive to adequate fluid resuscitation (excluding haemorrhagic cause) Figure 4.1
QUEENSLAND AMBULANCE SERVICE
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Adrenaline (epinephrine)
Onset
Duration
30 seconds (IV) 60 seconds (IM)
5–10 minutes
Half-life
Special notes • 1 : 1,000 (1 mg/mL) adrenaline (epinephrine) presentation should be used
for all nebuliser administration.
UNCONTROLLED WHEN PRINTED 2 minutes
• 1:10,000 (100 microg/1 mL ) or a 1 : 100,000 (10 microg/1 mL ) adrenaline (epinephrine) preparation should be used for all low dose IV injections
(e.g. paediatric cardiac arrest). Ensure all syringes are appropriately labelled.
Schedule • 1 mg/1 mL (1 : 1,000), S3 (therapeutic poison)
• If possible, all time critical adrenaline (epinephrine) IM injections
should be administered in the vastus lateralis (improved absorption).
• 1 mg/10 mL (1 :10,000), S3 (therapeutic poison) • 300 mcg EpiPen® Auto-injector, S3 (therapeutic poison)
UNCONTROLLED WHEN PRINTED • Suitably qualified officers should, where possible, administer adrenaline infusions through an appropriately placed CVL.
CCP
CCP
P
ACP1
FR
Nebuliser (NEB)
ACP2
ACP2
Routes of administration
• Suitably qualified officers should, where possible, utilise invasive pressure monitoring for patients being administered adrenaline (epinephrine) infusions. • Adrenaline (epinephrine) infusions must be administered through
a dedicated line.
Intraosseous injection (IO)
CCP
CCP
Intravenous injection (IV)
ACP2
UNCONTROLLED WHEN PRINTED Intramuscular injection (IM)
• Patients on adrenaline (epinephrine) infusions without continuous IBP
monitoring must have their NIBP measured regularly (every 5 mins at a minimum).
• All cannulae with adrenaline (epinephrine) infusions should be as proximal
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.
Intravenous infusion (IV INF)
E CCP
UNCONTROLLED WHEN PRINTED • All cannulae and IV lines must be flushed thoroughly with sodium chloride 0.9% following each medication administration.
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z
Adrenaline (epinephrine)
Adult dosages (cont.) Adult dosages
Bradycardia with poor perfusion
Anaphylaxis OR severe allergic reaction
(unresponsive to atropine AND/OR TCP)
NEB
5 mg Single dose only.
CCP
300 microg Repeated at 5 minute intervals.
No maximum dose.
20 – 50 microg Repeated at 1 minute intervals. No maximum dose.
CCP
IM
IV
IO
20 – 50 microg Repeated at 1 minute intervals. No maximum dose.
Cardiac arrest CCP
EpiPen® Auto-injector (300 microg)
Single dose only.
IV
1 mg Repeated at 3 – 5 minute intervals. No maximum dose.
CCP
CCP
P
CCP
ACP2
ACP2
ACP1
FR
UNCONTROLLED WHEN PRINTED IM
IO
1 mg Repeated at 3 – 5 minute intervals. No maximum dose.
CCP CCP
IV
IO
20 – 50 microg Repeated at 1 minute intervals.
No maximum dose. 20 – 50 microg Repeated at 1 minute intervals.
No maximum dose.
ACP2
UNCONTROLLED WHEN PRINTED May be administered for facial or tongue swelling
thought to be allergic in origin – IM or IV adrenaline
(epinephrine) must first be administered.
Shock unresponsive to adequate fluid resuscitation (excluding haemorrhagic cause) CCP
IV
20 – 50 microg Repeated at 1 minute intervals. No maximum dose.
CCP
IO
20 – 50 microg Repeated at 1 minute intervals. No maximum dose.
E CCP
UNCONTROLLED WHEN PRINTED IV
INF
Commence infusion at 2 microg/minute (2 mL/hour)
and increase by 1 – 2 microg/minute (1–2 mL/hour)
every 3 – 5 minutes as determined by MAP.
Severe life-threatening bronchospasm OR silent chest
CCP
ACP2
ACP1
(patients must only be able to speak in single words AND/OR have haemodynamic compromise AND/OR an ALOC) IM
300 microg Repeated at 5 minute intervals.
No maximum dose.
CCP
IV
20 – 50 microg Repeated at 1 minute intervals.
No maximum dose.
CCP
UNCONTROLLED WHEN PRINTED IO
20 – 50 microg Repeated at 1 minute intervals.
No maximum dose.
Syringe preparation: Mix 3 mg of 1 : 1,000 adrenaline
(3 mL) with 47 mL of sodium chloride 0.9% in a 50 mL syringe to achieve a final concentration of 60 microg/ mL. Ensure all syringes are appropriately labelled. Administer via syringe driver.
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Adrenaline (epinephrine)
Paediatric dosages (cont.)
Paediatric dosages Anaphylaxis OR severe allergic reaction
Severe life-threatening bronchospasm OR silent chest
CCP
ACP2
ACP1
IM
≥ 6 years – 300 microg
Repeated at 5 minute intervals.
No maximum dose. < 6 years – 150 microg
Repeated at 5 minute intervals.
No maximum dose.
CCP
1–5 years – EpiPen® Jr Auto-injector (150 microg)
Single dose only.
(patients must only be able to speak in single words AND/OR have haemodynamic compromise AND/OR an ALOC) ACP2
P
≥ 6 years – EpiPen® Auto-injector (300 microg)
Single dose only.
ACP1
FR
UNCONTROLLED WHEN PRINTED IM
IM
≥ 6 years – 300 microg
Repeated at 5 minute intervals. No maximum dose. < 6 years – 150 microg
Repeated at 5 minute intervals. No maximum dose.
NEB
CCP
5 mg Single dose only. May be administered for facial or tongue
swelling thought to be allergic in origin
– IM or IV adrenaline (epinephrine) must first be administered.
CCP
CCP
ACP2
UNCONTROLLED WHEN PRINTED IV
2 microg/kg Single dose not to exceed 50 microg.
Repeated at 2 minute intervals. No maximum dose.
IO
2 microg/kg Single dose not to exceed 50 microg.
Repeated at 2 minute intervals. No maximum dose.
CCP
IO
2 microg/kg Single dose not to exceed 50 microg.
Repeated at 2 minute intervals.
No maximum dose.
2 microg/kg Single dose not to exceed 50 microg.
Repeated at 2 minute intervals.
No maximum dose.
CCP
IV
Cardiac arrest ACP2
CCP
UNCONTROLLED WHEN PRINTED IV
≥ 10 kg (≥ 1 year ) – 10 microg/kg
Repeated at 3 – 5 minute intervals.
No maximum dose. < 10 kg (< 1 year ) – 100 microg
Repeated at 3 – 5 minute intervals.
No maximum dose.
CCP
UNCONTROLLED WHEN PRINTED IO
≥ 10 kg (≥ 1 year ) – 10 microg/kg
Repeated at 3 – 5 minute intervals.
No maximum dose. < 10 kg (< 1 year ) – 100 microg
Repeated at 3 – 5 minute intervals.
No maximum dose.
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Adrenaline (epinephrine)
Paediatric dosages (cont.) Croup (with stridor at rest) CCP
ACP2
UNCONTROLLED WHEN PRINTED NEB
5 mg
Single dose only.
Shock unresponsive to adequate fluid resuscitation
CCP
IV
2 microg/kg Single dose not to exceed 50 microg.
Repeated at 2 minute intervals. No maximum dose.
CCP
(excluding haemorrhagic cause)
IO
2 microg/kg Single dose not to exceed 50 microg.
Repeated at 2 minute intervals. No maximum dose.
UNCONTROLLED WHEN PRINTED UNCONTROLLED WHEN PRINTED Bradycardia with poor perfusion
CCP
(unresponsive to atropine AND/OR TCP) IV
QAS Clinical Consultation and Advice Line
approval required in all situations.
UNCONTROLLED WHEN PRINTED QUEENSLAND AMBULANCE SERVICE
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