Indications
Subcut, IM, IV: Management of severe allergic reactions.
IV, Intracardiac, Intratracheal, Intraosseous
(part of advanced cardiac life support
[ACLS] and pediatric advanced life support
[PALS] guidelines): Management of cardiac arrest
(unlabeled). Subcut, IM: Management of reversible
airway disease due to asthma or COPD (unlabeled).
Inhaln: Management of upper airway obstruction
and croup (racemic epinephrine). Local/Spinal:
Adjunct in the localization/prolongation of anesthesia.
Action
Results in the accumulation of cyclic adenosine monophosphate
(cAMP) at beta-adrenergic receptors. Affects
both beta1(cardiac)-adrenergic receptors and
beta2(pulmonary)-adrenergic receptor sites. Produces
bronchodilation. Also has alpha-adrenergic agonist
properties, which result in vasoconstriction. Inhibits
the release of mediators of immediate hypersensitivity
reactions from mast cells. Therapeutic Effects:
Bronchodilation. Maintenance of heart rate and BP. Localization/
prolongation of local/spinal anesthetic.
Pharmacokinetics
Absorption: Well absorbed following subcut administration;
some absorption may occur following repeated
inhalation of large doses.
Distribution: Does not cross the blood-brain barrier;
crosses the placenta and enters breast milk.
Metabolism and Excretion: Action is rapidly terminated
by metabolism and uptake by nerve endings.
Half-life: Unknown.
TIME/ACTION PROFILE (bronchodilation)
ROUTE ONSET PEAK DURATION
Inhaln 1 min unknown 1–3 hr
Subcut 5–10 min 20 min 1–4 hr
IM 6–12 min unknown 1–4 hr
IV rapid 20 min 20–30 min
Contraindications/Precautions
Contraindicated in: Hypersensitivity to adrenergic
amines; Some products may contain bisulfites and
should be avoided in patients with known hypersensitivity
or intolerance.
Use Cautiously in: Cardiac disease (angina, tachycardia,
MI); Hypertension; Hyperthyroidism; Parkinson’s
disease; Pheochromocytoma; Diabetes; Cerebral
arteriosclerosis; Glaucoma (except for ophthalmic
use); Excessive use may lead to tolerance and paradoxical
bronchospasm (inhaler); OB: Use only if potential
maternal benefit outweighs potential risks to fetus; Lactation:
High intravenous doses of epinephrine mightp
milk production or letdown. Low-dose epidural, topical,
inhaled, or ophthalmic epinephrine are unlikely to
interfere with breast feeding (NIH); Geri: More susceptible
to adverse reactions; may requirepdose.
Adverse Reactions/Side Effects
CNS: nervousness, restlessness, tremor, headache, insomnia.
Resp: PARADOXICAL BRONCHOSPASM (EXCESSIVE
USE OF INHALERS). CV: angina, arrhythmias, hypertension,
tachycardia. Derm: skin and soft tissue infections
(including necrotizing fasciitis and myonecrosis).
GI: nausea, vomiting. Endo: hyperglycemia.
Interactions
Drug-Drug: Concurrent use with other adrenergic
agents will have additive adrenergic side effects. Use
with MAO inhibitors may lead to hypertensive crisis.
Beta blockers may negate therapeutic effect. Tricyclic
antidepressants enhance pressor response to
epinephrine.
Drug-Natural Products: Use with caffeine-containing
herbs (cola nut, guarana, mate, tea, coffee)
qstimulant effect.
Route/Dosage
Subcut, IM (Adults and Children 30 kg): Severe
anaphylaxis—0.3–0.5 mg (single dose not to exceed
0.5 mg); may repeat every 10–15 min as needed.
Subcut (Children 30 kg): Severe anaphylaxis—
0.01 mg/kg (not to exceed 0.3 mg/dose); may repeat
every 10–15 min as needed.
IV (Adults): Severe anaphylaxis—0.1–0.25 mg
every 5–15 min; may be followed by 1–4 mcg/min
continuous infusion; cardiopulmonary resuscitation
(ACLS guidelines)—1 mg every 3–5 min; bradycardia
(ACLS guidelines)—2–10 mcg/min).
IV (Children): Severe anaphylaxis—0.1 mg (less in
younger children); may be followed by 0.1 mcg/kg/min
continuous infusion (may bequp to 1.5 mcg/kg/min);
symptomatic bradycardia/pulseless arrest (PALS
guidelines)—0.01 mg/kg, may be repeated every 3–5
min, higher doses (up to 0.1–0.2 mg/kg) may be considered;
may also be given by the intraosseous route.
May also be given by the endotracheal route in doses of
0.1–0.2 mg/kg diluted to a volume of 3–5 mL with
normal saline followed by several positive pressure ventilations.
Inhaln (Adults): Inhalation solution—1 inhalation
of 1% solution; may be repeated after 1–2 min; additional
doses may be given every 3 hr; racepinephrine—
Via hand nebulizer, 2–3 inhalations of
2.25% solution; may repeat in 5 min with 2–3 more inhalations,
up to 4–6 times daily.
Inhaln (Children 1 mo): 0.25–0.5 mL of 2.25%
racemic epinephrine solution diluted in 3 mL normal
saline.
IV, Intratracheal (Neonates): 0.01–0.03 mg/kg
every 3–5 min as needed.
Intracardiac (Adults): 0.3–0.5 mg.
Endotracheal (Adults): Cardiopulmonary resuscitation
(ACLS guidelines)—2–2.5 mg.
Topical (Adults and Children 6 yr): Nasal decongestant—
Apply 1% solution as drops, spray, or with a
swab.
Intraspinal (Adults and Children): 0.2–0.4 mL of
1:1000 solution.
With Local Anesthetics (Adults and Children): Use
1:200,000 solution with local anesthetic.
Availability (generic available)
Inhalation solution (racepinephrine): 2.25%.
Intranasal solution: 1 mg/mL (1:1000). Solution
for injection: 0.1 mg/mL (1:10,000), 1 mg/mL
(1:1000). Autoinjector (Auvi-Q, EpiPen): 0.15 mg/
0.15 mL (1:1000), 0.15 mg/0.3 mL (1:2000), 0.3 mg/
0.3 mL (1:1000).
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