The Rescue & Code Drug
First-line for anaphylactic shock and cardiac arrest. Second-line rescue in sepsis. Higher risk of lactic acidosis and arrhythmias compared to Norepinephrine.
- Mechanism: Potent non-selective agonist: , , and .
- Dosing:
- Anaphylaxis: 0.3-0.5 mg IM.
- Cardiac Arrest: 1 mg IV q3-5min.
- Sepsis (Rescue): 0.05-0.5 mcg/kg/min IV infusion.
- PK: Onset: Immediate. Half-life: < 5 mins.
indications
- Anaphylactic Shock – First-line
- Cardiac Arrest (ACLS) – First-line
- Sepsis (Rescue) – Second-line if Norepinephrine + Vasopressin (ADH) insufficient, or if significant myocardial dysfunction exists
evidence & efficacy
- Cardiogenic Shock: Associated with higher rates of refractory shock and lactic acidosis compared to Norepinephrine.
- Mortality: Some meta-analyses suggest a threefold increased risk of death in cardiogenic shock compared to norepi.
cautions
- Highly arrhythmogenic
- Type B Lactic Acidosis: Stimulates aerobic glycolysis via receptors. Causes a rise in lactate without tissue ischemia. This confuses the clinical picture (“Is the patient getting worse, or is it just the Epi?“)
clinical pearl
“Dirty Epi”: Push-dose epinephrine (10-20 mcg) is useful for transient hypotension in the ED/OR, but rarely used for maintenance in the ICU.