epinephrine (adrenaline)

(ep i nef' rin)

epinephrine bitartrate
Aerosols:
Primatene Mist

epinephrine borate
Ophthalmic solution:
Epinal

epinephrine hydrochloride
Injection, OTC nasal solution:
Adrenalin Chloride
Ophthalmic solution:
Epifrin, Glaucon
Insect sting emergencies:
EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. Auto-
Injector (delivers 0.15 mg IM for children)
OTC solutions for nebulization:
AsthmaNefrin, microNefrin, Nephron, S2

Pregnancy Category C

Drug classes
Sympathomimetic
Alpha-adrenergic agonist
Beta1 and beta2-adrenergic agonist
Cardiac stimulant
Vasopressor
Bronchodilator
Antasthmatic drug
Nasal decongestant
Mydriatic
Antiglaucoma drug

Therapeutic actions
Naturally occurring neurotransmitter, the effects of which are mediated by alpha or beta
receptors in target organs. Effects on alpha receptors include vasoconstriction, contraction
of dilator muscles of iris. Effects on beta receptors include positive chronotropic and
inotropic effects on the heart (beta1 receptors); bronchodilation, vasodilation, and uterine
relaxation (beta2 receptors); decreased production of aqueous humor.

Indications
 • IV: In ventricular standstill after other measures have failed to restore circulation,
given by trained personnel by intracardiac puncture and intramyocardial injection;
treatment and prophylaxis of cardiac arrest and attacks of transitory AV heart
block with syncopal seizures (Stokes-Adams syndrome); syncope due to carotid
sinus syndrome; acute hypersensitivity (anaphylactoid) reactions, serum sickness,
urticaria, angioneurotic edema; in acute asthmatic attacks to relieve bronchospasm
not controlled by inhalation or SC injection; relaxation of uterine musculature;
additive to local anesthetic solutions for injection to prolong their duration of
action and limit systemic absorption
• Injection: Relief from respiratory distress of bronchial asthma, chronic bronchitis,
emphysema, other COPDs
• Aerosols and solutions for nebulization: Temporary relief from acute attacks of
bronchial asthma, COPD
• Topical nasal solution: Temporary relief from nasal and nasopharyngeal mucosal
congestion due to a cold, sinusitis, hay fever, or other upper respiratory allergies;
adjunctive therapy in middle ear infections by decreasing congestion around
eustachian ostia
• 0.25%–2% ophthalmic solutions: Management of open-angle (chronic simple)
glaucoma, often in combination with miotics or other drugs
• 0.1% ophthalmic solution: Conjunctivitis, during eye surgery to control bleeding,
to produce mydriasis

Contraindications and cautions

• Contraindicated with allergy or hypersensitivity to epinephrine or components of
preparation (many of the inhalant and ophthalmic products contain sulfites:
sodium bisulfite, sodium or potassium metabisulfite; check label before using any
of these products in a sulfite-sensitive patient); narrow-angle glaucoma; shock
other than anaphylactic shock; hypovolemia; general anesthesia with halogenated
hydrocarbons or cyclopropane; organic brain damage, cerebral arteriosclerosis;
cardiac dilation and coronary insufficiency; tachyarrhythmias; ischemic heart
disease; hypertension; renal dysfunction (drug may initially decrease renal blood
flow); COPD patients who have developed degenerative heart disease; diabetes
mellitus; hyperthyroidism; lactation. Opthalmic preparations are contraindicated
for those wearing contact lenses (drug may discolor the contact lens), aphakic
patients (maculopathy with decreased visual acuity may occur).
• Use cautiously with prostatic hypertrophy (may cause bladder sphincter spasm,
difficult and painful urination), history of seizure disorders, psychoneurotic
individuals, labor and delivery (may delay second stage of labor; can accelerate
fetal heart beat; may cause fetal and maternal hypoglycemia), children (syncope
has occurred when epinephrine has been given to asthmatic children).

Available forms
Solution for inhalation—1:100, 1:1,000, 1.125%, 1%; aerosol—0.35 mg, 0.5%, 0.22 mg;
injection—1, 5 mg/mL; solution for injection—1:1,000, 1:2,000, 1:10,000, 1:100,000;
suspension for injection—1:200; ophthalmic solution—0.1%, 0.5%, 1%, 2%
Dosages
ADULTS
Epinephrine injection
• Cardiac arrest: 0.5–1 mg (5–10 mL of 1:10,000 solution) IV or by intracardiac
injection into left ventricular chamber; during resuscitation, 0.5 mg q 5 min.
Intraspinal
0.2–0.4 mL of a 1:1,000 solution added to anesthetic spinal fluid mixture.
• Other use with local anesthetic: Concentrations of 1:100,000–1:20,000 are
usually used.
1:1,000 solution
• Respiratory distress: 0.3–0.5 mL of 1:1,000 solution (0.3–0.5 mg), SC or IM, q 20
min for 4 hr.
1:200 suspension (for SC administration only)
• Respiratory distress: 0.1–0.3 mL (0.5–1.5 mg) SC.
Inhalation (aerosol)
Begin treatment at first symptoms of bronchospasm. Individualize dosage. Wait 1–5 min
between inhalations to avoid overdose.
Inhalation (nebulization)
Place 8–15 drops into the nebulizer reservoir. Place nebulizer nozzle into partially opened
mouth. Patient inhales deeply while bulb is squeezed one to three times. If no relief in 5
min, give 2–3 additional inhalations. Use 4–6 times per day usually maintains comfort.
Topical nasal solution
Apply locally as drops or spray or with a sterile swab, as required.
Ophthalmic solution
Glaucoma: Instill 1–2 drops into affected eye or eyes daily–bid. May be given as
infrequently as every 3 days; determine frequency by tonometry. When used in
conjunction with miotics, instill miotic first.
Ophthalmic solution for vasoconstriction, mydriasis
Instill 1–2 drops into the eye or eyes; repeat once if necessary.
PEDIATRIC PATIENTS
Epinephrine injection
1:1,000 solution, children and infants except premature infants and full-term newborns:
0.01 mg/kg or 0.3 mL/m2 (0.01 mg/kg or 0.3 mg/m2) SC q 20 min (or more often if
needed) for 4 hr. Do not exceed 0.5 mL (0.5 mg) in a single dose. 1:200 suspension,
infants and children (1 mo–1 yr): 0.005 mL/kg (0.025 mg/kg) SC. Children < 30:
Maximum single dose is 0.15 mL (0.75 mg). Administer subsequent doses only when
necessary and not more often than q 6 hr.
Topical nasal solution
> 6 yr: Apply locally as drops or spray or with a sterile swab, as required.
Ophthalmic solutions
Safety and efficacy for use in children not established.
GERIATRIC PATIENTS OR PATIENTS WITH RENAL FAILURE
Use with caution; patients > 60 yr are more likely to develop adverse effects.

Pharmacokinetics
Route Onset Peak Duration
SC 5–10 min 20 min 20–30 min
IM 5–10 min 20 min 20–30 min
IV instant 20 min 20–30 min
Inhalation 3–5 min 20 min 1–3 hr
Eye < 1 hr 4–8 hr 24 hr

Metabolism: Neural
Distribution: Crosses placenta; enters breast milk

IV facts
Preparation: 0.5 mL dose may be diluted to 10 mL with sodium chloride injection for
direct injection; prepare infusion by mixing 1 mg in 250 mL D5W (4 mcg/mL).
Infusion: Administer by direct IV injection or into the tubing of a running IV, each 1 mg
over 1 min, or run infusion at 1–4 mcg/min (15–60 mL/hr).

Adverse effects
Systemic administration
• CNS: Fear, anxiety, tenseness, restlessness, headache, light-headedness,
dizziness, drowsiness, tremor, insomnia, hallucinations, psychological
disturbances, seizures, CNS depression, weakness, blurred vision, ocular
irritation, tearing, photophobia, symptoms of paranoid schizophrenia
• CV: Arrhythmias, hypertension resulting in intracranial hemorrhage, CV collapse
with hypotension, palpitations, tachycardia, precordial pain in patients with
ischemic heart disease
• GI: Nausea, vomiting, anorexia
• GU: Constriction of renal blood vessels and decreased urine formation (initial
parenteral administration), dysuria, vesical sphincter spasm resulting in difficult
and painful urination, urinary retention in males with prostatism
• Other: Pallor, respiratory difficulty, orofacial dystonia, sweating
Local injection
• Local: Necrosis at sites of repeat injections (due to intense vasoconstriction)
Nasal solution
• Local: Rebound congestion, local burning and stinging
Ophthalmic solutions
• CNS: Headache, brow ache, blurred vision, photophobia, difficulty with night
vision, pigmentary (adrenochrome) deposits in the cornea, conjunctiva, or lids
with prolonged use
• Local: Transitory stinging on initial instillation, eye pain or ache, conjunctival
hyperemia

Interactions
Drug-drug
• Increased sympathomimetic effects with other TCAs (eg, imipramine)
• Excessive hypertension with propranolol, beta-blockers, furazolidone
• Decreased cardiostimulating and bronchodilating effects with beta-adrenergic
blockers (eg, propranolol)
• Decreased vasopressor effects with chlorpromazine, phenothiazines
• Decreased antihypertensive effect of guanethidine, methyldopa
Nursing considerations
Assessment
• History: Allergy or hypersensitivity to epinephrine or components of drug
preparation; narrow-angle glaucoma; shock other than anaphylactic shock;
hypovolemia; general anesthesia with halogenated hydrocarbons or cyclopropane;
organic brain damage, cerebral arteriosclerosis; cardiac dilation and coronary
insufficiency; tachyarrhythmias; ischemic heart disease; hypertension; renal
dysfunction; COPD; diabetes mellitus; hyperthyroidism; prostatic hypertrophy;
history of seizure disorders; psychoneuroses; labor and delivery; lactation; contact
lens use, aphakic patients (ophthalmic preparations)
• Physical: Weight; skin color, temperature, turgor; orientation, reflexes, IOP; P,
BP; R, adventitious sounds; prostate palpation, normal urine output; urinalysis,
kidney function tests, blood and urine glucose, serum electrolytes, thyroid
function tests, ECG

Interventions
• Use extreme caution when calculating and preparing doses; epinephrine is a very
potent drug; small errors in dosage can cause serious adverse effects. Double-
check pediatric dosage.
• Use minimal doses for minimal periods of time; "epinephrine-fastness" (a form of
drug tolerance) can occur with prolonged use.
• Protect drug solutions from light, extreme heat, and freezing; do not use pink or
brown solutions. Drug solutions should be clear and colorless (does not apply to
suspension for injection).
• Shake the suspension for injection well before withdrawing the dose.
• Rotate SC injection sites to prevent necrosis; monitor injection sites frequently.
• Keep a rapidly acting alpha-adrenergic blocker (phentolamine) or a vasodilator (a
nitrate) readily available in case of excessive hypertensive reaction.
• Have an alpha-adrenergic blocker or facilities for intermittent positive pressure
breathing readily available in case pulmonary edema occurs.
• Keep a beta-adrenergic blocker (propranolol; a cardioselective beta-blocker, such
as atenolol, should be used in patients with respiratory distress) readily available
in case cardiac arrhythmias occur.
• Do not exceed recommended dosage of inhalation products; administer
pressurized inhalation drug forms during second half of inspiration, because the
airways are open wider and the aerosol distribution is more extensive. If a second
inhalation is needed, administer at peak effect of previous dose, 3–5 min.
• Use topical nasal solutions only for acute states; do not use for longer than 3–5
days, and do not exceed recommended dosage. Rebound nasal congestion can
occur after vasoconstriction subsides.

Teaching points
 • Do not exceed recommended dosage; adverse effects or loss of effectiveness may
result. Read the instructions that come with respiratory inhalant products, and
consult your health care provider or pharmacist if you have any questions.
• To give eye drops: Lie down or tilt head backward, and look up. Hold dropper
above eye; drop medicine inside lower lid while looking up. Do not touch dropper
to eye, fingers, or any surface. Release lower lid; keep eye open, and do not blink
for at least 30 sec. Apply gentle pressure with fingers to inside corner of the eye
for about 1 min; wait at least 5 min before using other eye drops.
• These side effects may occur: Dizziness, drowsiness, fatigue, apprehension (use
caution if driving or performing tasks that require alertness); anxiety, emotional
changes; nausea, vomiting, change in taste (eat frequent small meals); fast heart
rate. Nasal solution may cause burning or stinging when first used (transient).
Ophthalmic solution may cause slight stinging when first used (transient);
headache or brow ache (only during the first few days).
• Report chest pain, dizziness, insomnia, weakness, tremor or irregular heart beat
(respiratory inhalant, nasal solution), difficulty breathing, productive cough,
failure to respond to usual dosage (respiratory inhalant), decrease in visual acuity
(ophthalmic).

Adverse effects in Italic are most common; those in Bold are life-threatening.