ADRENALINE

Last Updated 20 AUG 09

DRUG THERAPY PROTOCOL 1.003
Version 1.4.5
S3
Page

1 of 5
Any material that is printed is regarded
as an uncontrolled copy
OFFICERS ARE ONLY TO PERFORM PROCEDURES FOR WHICH THEY HAVE
RECEIVED SPECIFIC TRAINING AND AUTHORISATION BY THE QAS
Presentation

1mg in 1mL ampoule (1:1000)


Pharmacology

Adrenaline is a naturally occurring catecholamine which primarily acts on Alpha () and Beta () adrenergic
receptors, which are located mainly in tissues innervated by sympathetic nerves. The actions of these receptors
cause an increase heart rate (1), increase the force of myocardial contraction (1), increases the irritability of the
ventricles (1), bronchodilation (2) and peripheral vasoconstriction (1) (1)


Metabolism

The majority of circulating adrenaline is metabolised by sympathetic nerve endings. It is subject to the process of
mitochondrial enzymatic breakdown by mono-amine oxidase (MAO) at synaptic level (2)


Indications

Anaphylaxis
Asthma or severe bronchospasm with imminent arrest cardiac arrest
Bradycardia with poor perfusion unresponsive to Atropine and / or pacing
Cardiac arrest
Cardiogenic shock
Croup with life threatening airway compromise
Shock (excluding haemorrhagic causes) that is unresponsive to adequate fluid resuscitation


Contra-Indications

Known severe adverse reaction


Precautions

Patients taking monoamine oxidase inhibitors (MAOIs) (2)
Hypovolaemic shock
Hypertension


Side Effects

Anxiety
Hypertension
Palpitations
Tachyarrhythmias
Pupillary dilation


Routes of Administration

Intramuscular- anterolateral aspect of deltoid or quadricep
Intravenous
Nebulised
Endotracheal
Intraosseous


Drug Effect


Onset 30 90 seconds
Intramuscular Peak 4 10 minutes
Duration 5 10 minutes
Onset 30 seconds
Intravenous Peak 2 minutes
Duration 5 10 minutes
ADRENALINE

Last Updated 20 AUG 09
DRUG THERAPY PROTOCOL 1.003
Version 1.4.5
S3
Page

2 of 5
Any material that is printed is regarded
as an uncontrolled copy
OFFICERS ARE ONLY TO PERFORM PROCEDURES FOR WHICH THEY HAVE
RECEIVED SPECIFIC TRAINING AND AUTHORISATION BY THE QAS

DOSE













P1 - Paramedic Not authorised for use
P2 - Advanced Skills Paramedic Not authorised for use
P3 - Advanced Care Paramedic

ADULT
Anaphylaxis
I.M.I. 250 - 500mcg (0.25 - 0.5mg)
May be repeated at 5 minute intervals only whilst patient continues to have life-threatening presentation
No maximum dose

Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise)
I.M.I. 250 500mcg (0.25 - 0.5mg)
May be repeated at 5 minute intervals only whilst patient continues to have a life-threatening presentation
No maximum dose

Cardiac arrest
I.V.I. 1mg as a bolus
To be repeated by 1mg every 3-5 minutes if required

No adult doses to be diluted




DILUTION FOR CHILD ADRENALINE DOSES (IV) for P3

1mg (1mL) of Adrenaline to be drawn up in a 10ml syringe with 9mL Normal Saline (1:10,000)

This gives 1ml solution = 100mcg

CHILD
Anaphylaxis
I.M.I. 10mcg / kg. Single dose not to exceed 250mcg (0.25mg)
May be repeated at 5 minute intervals whilst patient has a life threatening presentation
No maximum dose

Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise)
I.M.I. 10mcg / kg. Single dose not to exceed 250mcg (0.25mg)
May be repeated at 5 minute intervals whilst patient has a life threatening presentation
No maximum dose

Cardiac arrest
I.V.I. If child <10kgs (1 year) then 100mcg as a bolus
If child >10kgs (1 year) then 10mcg/kg
To be repeated every 3-5 minutes if required

Croup (with life threatening airway compromise)
Nebulised 2mg
Single dose only






ADRENALINE

Last Updated 20 AUG 09
DRUG THERAPY PROTOCOL 1.003
Version 1.4.5
S3
Page

3 of 5
Any material that is printed is regarded
as an uncontrolled copy
OFFICERS ARE ONLY TO PERFORM PROCEDURES FOR WHICH THEY HAVE
RECEIVED SPECIFIC TRAINING AND AUTHORISATION BY THE QAS
DOSE




















































CHILD
Cardiac arrest
I.V.I. / I.O. If child <10kgs (1 year) 100mcg as a bolus.
If child >10kgs (1 year) then 10mcg / kg
To be repeated every 3-5 minutes if required

E.T.T. route all doses 100mcg/kg

Anaphylaxis
I.M.I. 5 - 10mcg / kg. Single dose not to exceed 500mcg (0.5mg)
May be repeated at 5 minute intervals

I.V.I. / I.O. 1 - 2mcg / kg. Single dose not to exceed 50mcg (0.05mg)
May be repeated at 2 minute intervals

E.T.T. Double the I.V.I. dose

Asthma or severe bronchospasm with imminent arrest (Altered consciousness or haemodynamic compromise)
I.M.I. 5 - 10mcg / kg. Single dose not to exceed 500mcg (0.5mg)
May be repeated at 5 minute intervals

I.V.I. / I.O. 1 - 2mcg / kg. Single dose not to exceed 50mcg (0.05mg)
May be repeated at 2 minute intervals

E.T.T. Double the I.V.I. dose

Croup (with life threatening airway compromise)
Nebulised 2mg
Single dose only


P4 - Intensive Care Paramedic


DOSE DILUTIONS FOR P4

1mg adrenaline to be drawn up with 9mL Normal Saline in a 10mL syringe (1:10,000)
This gives 1mL solution = 100mcg

To double dilute, draw off 1mL of above solution (100mcg) and add 9mL Normal Saline in a 10mL syringe (1:100,000)
This gives 1mL solution = 10mcg

ENSURE ALL DOSES and SYRINGES LABELLED APPROPRIATELY


ADULT
Anaphylaxis
I.M.I. 250 - 500mcg (0.25 0.5mg)
May be repeated at 5 minute intervals until perfusion and respiratory status normalises
No maximum dose

I.V.I. 20 - 50mcg (0.02 0.05mg)
May be repeated every 60 seconds until perfusion and respiratory status normalises
No maximum dose

E.T.T. Double the I.V.I dose

Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise)
I.M.I. 250 500mcg (0.25 -0.5mg)
May be repeated at 5 minute intervals until perfusion and respiratory status normalises
No maximum dose

I.V.I. 20 - 50mcg (0.02 0.05mg)
May be repeated every 60 seconds until perfusion and respiratory status normalises
No maximum dose

E.T.T. Double the I.V.I. dose

Bradycardia with poor perfusion that is unresponsive to Atropine / pacing
I.V.I. 20 - 50mcg (0.02 0.05mg)
May be repeated every 60 seconds until perfusion improves
No maximum dose

E.T.T. Double the I.V.I. dose

Cardiac arrest
I.V.I. 1mg as a bolus
To be repeated by 1mg every 3-5 minutes if required

E.T.T. Double the I.V.I dose

Cardiogenic shock
I.V.I. 20 -50mcg (0.02 - 0.05mg)
May be repeated every 60 seconds until perfusion improves
No maximum dose

E.T.T. Double the I.V.I. dose


ADRENALINE

Last Updated 20 AUG 09
DRUG THERAPY PROTOCOL 1.003
Version 1.4.5
S3
Page

4 of 5
Any material that is printed is regarded
as an uncontrolled copy
OFFICERS ARE ONLY TO PERFORM PROCEDURES FOR WHICH THEY HAVE
RECEIVED SPECIFIC TRAINING AND AUTHORISATION BY THE QAS
DOSE

















































P4 - Intensive Care Paramedic

CHILD
Anaphylaxis
I.M.I. 10 mcg/kg. Single dose not to exceed 250mcg (0.25mg)
May be repeated at 5 minute intervals
No maximum dose

I.V.I. / I.O. 2 mcg/kg. Single dose not to exceed 50mcg (0.05mg)
May be repeated at 2 minute intervals
No maximum dose

E.T.T. Double the I.V.I. dose

Asthma or severe bronchospasm with imminent arrest (altered consciousness or haemodynamic compromise)
I.M.I. 10 mcg/kg. Single dose not to exceed 250mcg (0.25mg)
May be repeated at 5 minute intervals
No maximum dose

I.V.I. / I.O. 2 mcg/kg. Single dose not to exceed 50mcg (0.05mg)
May be repeated at 2 minute intervals
No maximum dose

E.T.T. Double the I.V.I. dose

Cardiac arrest
I.V.I. / I.O. If child <10kgs (1 year) 100mcg as a bolus
If child >10kgs (1 year) then 10 mcg/kg
To be repeated every 3-5 minutes if required

E.T.T. route all doses 100 mcg/kg
Not to exceed the adult dose


Croup (with life threatening airway compromise)
Nebulised 2mg
TRIAL - AGL Action Rescue (Maroochydore base only)

Intensive Care Paramedic Extended Scope of Role (ESoR) - Aeromedical

(QCC CONSULT APPROVAL REQUIRED IN ALL SITUATIONS)

ADULT
Shock (excluding haemorrhagic causes) that is unresponsive to adequate fluid resuscitation.

Mix 3mg (3mL) of Adrenaline with 47mL of Normal Saline 0.9% or Glucose 5% in a 50mL syringe to achieve a final
concentration of 60mcg/mL. Ensure all syringes are appropriately labelled.

Commence infusion at 2 mcg/min (2 mL/hr) and increased by 1-2 mcg/min (1-2 mL/hr) every 3-5 minutes until patients blood
pressure returns to an appropriate level.

Rate
(mL/hr)
Concentration 3mg/50mL
(mcg/min)
1 1 mcg/min
2 2 mcg/min
3 3 mcg/min
CHILD
Not approved

Special notes:
Full cardiac monitoring is required for all patients on Adrenaline infusions.
Vasopressor and inotropic agents should be administered through a central venous line where possible.
Invasive pressure monitoring (ART) should be used for all patients receiving intravenous inotrope infusions.

ADRENALINE

Last Updated 20 AUG 09
DRUG THERAPY PROTOCOL 1.003
Version 1.4.5
S3
Page

5 of 5
Any material that is printed is regarded
as an uncontrolled copy
OFFICERS ARE ONLY TO PERFORM PROCEDURES FOR WHICH THEY HAVE
RECEIVED SPECIFIC TRAINING AND AUTHORISATION BY THE QAS

SUPPORTING EVIDENCE

Reference (1):
Australian Resuscitation Council 2006 Medication in adult advanced life support Guideline 11.6

Te OH 1997 Intensive Care Manual 4
th
ed


Reference (2):
When an adrenergic nerve is stimulated, the action potential travels along the axon until it reaches the nerve
terminal. Depolarisation of the terminal causes the release of chemical transmitter noradrenaline (NA) into the
synaptic gap. NA diffuses across the gap and interacts with adrenergic postsynaptic receptors, triggering an effector
response

The transmitter is removed from the synapse by an amine re-uptake pump and is restored to the synaptic vesicles.
Any excess transmitter within the terminal not restored to the vesicles is degraded by the mitochondrial enzyme
mono-amine oxidase (MAO)

Mono-amine oxidase inhibitors (MAOIs) are a group of anti-depressant drugs that act to raise the synaptic levels of
endogenous amines by preventing the degradation of excess transmitter (NA) after its release

Galbraith et al 2001 Fundamentals of pharmacology 3
rd
ed


Further reading:
Angelos et al 2007 Cardiovascular response to epinephrine varies with increasing duration of cardiac arrest J of
Resuscitation Vol 77

Australian Resuscitation Council 2006 Pharmacology Guidelines

There is no evidence that giving any anti-arrhythmic drug routinely during human cardiac arrest increases rate of
survival to discharge. Despite the lack of human long-term outcome data, it is reasonable to continue to use anti-
arrhythmic drugs on a routine basis. Consensus on Science and Treatment Recommendations Part 4: Advanced
Life Support Resuscitation 2005 Vol 67 No 2-2

Hollenberg et al 2008 Improved survival after out-of-hospital cardiac arrest is associated with an increase in
proportion of emergency crew-witnessed cases and bystander cardiopulmonary resuscitation J of Resuscitation
Science Vol 118 No 4

Nolan et al 2002 Advanced life support drugs: do they really work? J of Cardiopulmonary Resuscitation Vol 8 No 3

Woodhouse et al 1995 High dose and standard dose adrenaline do not alter survival, compared with placebo in
cardiac arrest J of Resuscitation Vol 30