Drug Therapy Protocols: Adrenaline (Epinephrine) PDF

Drug Therapy Protocols: Adrenaline (epinephrine) Policy code DTP_ADR_0924 Date September, 2024 Purpose To ensure a consistent procedural approach to adrenaline (epinephrine) administration. Scope Applies to Queensland...

Drug Therapy Protocols: Adrenaline (epinephrine) Policy code DTP_ADR_0924 Date September, 2024 Purpose To ensure a consistent procedural approach to adrenaline (epinephrine) administration. Scope Applies to Queensland Ambulance Service (QAS) clinical staff. Health care setting Pre-hospital assessment and treatment. Population Applies to all ages unless stated otherwise. Source of funding Internal – 100% Author Clinical Quality & Patient Safety Unit, QAS Review date September, 2026 Information security UNCLASSIFIED – Queensland Government Information Security Classification Framework. URL https://ambulance.qld.gov.au/clinical.html While the QAS has attempted to contact all copyright owners, this has not always been possible. The QAS would welcome notification from any copyright holder who has been omitted or incorrectly acknowledged. All feedback and suggestions are welcome. Please forward to: [email protected] Disclaimer The Digital Clinical Practice Manual is expressly intended for use by appropriately qualified QAS clinicians when performing duties and delivering ambulance services for, and on behalf of, the QAS. The QAS disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this manual, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. © State of Queensland (Queensland Ambulance Service) 2024. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives V4.0 International License You are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the State of Queensland, Queensland Ambulance Service and comply with the licence terms. If you alter the work, you may not share or distribute the modified work. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/deed.en For copyright permissions beyond the scope of this license please contact: [email protected]  Adrenaline (epinephrine) September, 2024 Drug class [1,2] Sympathomimetic Contraindications Pharmacology [1-3] UNCONTROLLED WHEN PRINTED Adrenaline (epinephrine) is a naturally occurring catecholamine which primarily acts on Alpha (α) and Beta (β) adrenergic receptors. The actions of these Nil receptors cause an increase in heart rate (β1), increase in the force of myocardial contraction (β1), increase in the irritability of the ventricles (β1), Precautions bronchodilation (β2) and peripheral vasoconstriction (α1). Hypertension Hypovolaemic shock Metabolism [1-3] UNCONTROLLED WHEN PRINTED Concurrent MAOI therapy The majority of circulating adrenaline (epinephrine) is metabolised by Quetiapine toxicity sympathetic nerve endings. It is subject to the process of mitochondrial enzymatic breakdown by monoamine oxidase at the synaptic level. Side effects [1-3] Indications Anxiety Hypertension Cardiac arrest Palpitations/tachyarrhythmias UNCONTROLLED WHEN PRINTED Anaphylaxis Severe life-threatening bronchospasm Pupil dilation Tremor OR silent chest (patients must only be able to speak in single words AND/OR have haemodynamic Presentation compromise AND/OR an ALOC) Ampoule, 1 mg/1 mL (1:1,000) adrenaline (epinephrine) Shock unresponsive to adequate fluid resuscitation Ampoule, 1 mg/10 mL (1:10,000) adrenaline (epinephrine) UNCONTROLLED WHEN PRINTED Bradycardia with poor perfusion (unresponsive to atropine AND/OR transcutaneous pacing) Croup (moderate to severe) Pre-filled syringe EpiPen® Auto-injector, 300 microg adrenaline (epinephrine) Pre-filled syringe EpiPen® Jr Auto-injector, 150 microg adrenaline (epinephrine) Figure 4.2 QUEENSLAND AMBULANCE SERVICE 1061 Adrenaline (epinephrine) Onset Duration Half-life Special notes 30 seconds (IV) Ambulance officers must only administer medications for the listed indications 5–10 minutes 2 minutes 60 seconds (IM) and dosing range. Any consideration for treatment outside the listed scope of practice requires mandatory approval via the QAS Clinical Consultation and UNCONTROLLED WHEN PRINTED Schedule 1 mg/1 mL (1:1,000), S3 (therapeutic poison) Advice Line. 1:1,000 (1 mg/mL) adrenaline (epinephrine) presentation should be used for all nebuliser administration. 1 mg/10 mL (1:10,000), S3 (therapeutic poison) 1:10,000 (100 microg/1 mL ) or a 1 : 100,000 (10 microg/1 mL ) adrenaline 300 microg EpiPen® Auto-injector, S3 (therapeutic poison) (epinephrine) preparation should be used for all low dose IM/IV injections. 150 microg EpiPen® Jr Auto-injector, S3 (therapeutic poison) Ensure all syringes are appropriately labelled. UNCONTROLLED WHEN PRINTED Routes of administration If possible, all time critical adrenaline (epinephrine) IM injections should be administered in the vastus lateralis (improved absorption). Adrenaline (epinephrine) can cause paradoxical hypotension following massive ACP2 CCP quetiapine overdose. Metaraminol is a suitable alternative. Nebuliser (NEB) Suitably qualified officers should, whenever possible, administer adrenaline C P ACP2 infusions through an appropriately placed central venous line. ACP1 CCP FR AT Intramuscular injection (IM) Suitably qualified officers should, whenever possible, use invasive pressure UNCONTROLLED WHEN PRINTED monitoring for patients being administered adrenaline (epinephrine) infusions. ACP2 CCP Intravenous injection (IV) Adrenaline (epinephrine) infusions must be administered through a dedicated line. Patients on adrenaline (epinephrine) infusions without continuous IBP CCP Intraosseous injection (IO) monitoring must have their NIBP measured regularly (every 5 mins at a minimum). All cannulae with adrenaline (epinephrine) infusions should be as proximal CCP Intravenous infusion (IV INF) as possible, be freely flowing, and be watched closely for extravasation. UNCONTROLLED WHEN PRINTED NIBP cuffs must not be placed on limbs with infusions to ensure flow is not obstructed. CCP Intaosseous infusion (IO INF) All cannulae and IV lines must be flushed thoroughly with sodium chloride 0.9% following each medication administration. QUEENSLAND AMBULANCE SERVICE 1062 Adrenaline (epinephrine) Adult dosages [1,2,4-7] Severe life-threatening bronchospasm OR silent chest (patients must only be able to speak in single words AND/OR Cardiac arrest have haemodynamic compromise AND/OR an ALOC) IV 1 mg 500 microg ACP2 IM CCP ACP2 ACP1 CCP Repeated at 3–5 minute intervals. No maximum dose. Repeated at 5 minute intervals. UNCONTROLLED WHEN PRINTED IO 1 mg No maximum dose. CCP Repeated at 3–5 minute intervals. No maximum dose. IV/IO May be administered for refractory severe life-threatening CCP INF bronchospasm or silent chest unresponsive to 2 x IM adrenaline (epinephrine) injections and adequate fluid Anaphylaxis administration. IM EpiPen® Auto-injector (300 microg) 20–50 microg bolus (IV/IO) C P FR AT Single dose only. Immediately followed by an infusion commencing at 10 microg/minute (10 mL/hr) − titrate accordingly to UNCONTROLLED WHEN PRINTED IM 500 microg indication and patient’s physiological response to treatment. ACP2 Maximum infusion rate 50 microg/min (50 mL/hr). ACP1 CCP Repeated at 5 minute intervals. No maximum dose. Infusion preparation: Mix 3 mg (3 mL) of 1:1000 adrenaline (epinephrine) with 47 mL of sodium chloride NEB 5 mg 0.9% to achieve a final concentration of 60 microg/mL. ACP2 CCP Single dose only. Ensure the syringe is appropriately labelled. Administer May be administered for upper airway obstruction the infusion via the Perfusor® Space Medication Library that is refractory to 3 X IM adrenaline (epinephrine) (Adrenaline-Adult (shock)). injections. UNCONTROLLED WHEN PRINTED IV/IO May be administered for refractory anaphylaxis or severe Shock unresponsive to adequate fluid resuscitation CCP INF allergic reaction unresponsive to 2 x IM adrenaline (epinephrine) injections and adequate fluid administration. IV/IO 20–50 microg bolus (IV/IO) CCP INF Immediately followed by an infusion commencing at 20–50 microg bolus (IV/IO) 10 microg/minute (10 mL/hr) − titrate accordingly to Immediately followed by an infusion commencing indication and patient’s physiological response to treatment. at 10 microg/minute (10 mL/hr) − titrate accordingly Maximum infusion rate 50 microg/min (50 mL/hr). to indication and patient’s physiological response to treatment. Infusion preparation: Mix 3 mg (3 mL) of 1:1000 Maximum infusion rate 50 microg/min (50 mL/hr). adrenaline (epinephrine) with 47 mL of sodium chloride UNCONTROLLED WHEN PRINTED Infusion preparation: Mix 3 mg (3 mL) of 1:1000 adrenaline (epinephrine) with 47 mL of sodium chloride 0.9% to achieve a final concentration of 60 microg/mL. Ensure the syringe is appropriately labelled. Administer the infusion 0.9% to achieve a final concentration of 60 microg/mL. Ensure the syringe is appropriately labelled. Administer the infusion via the Perfusor® Space Medication Library (Adrenaline-Adult (shock)). via the Perfusor® Space Medication Library (Adrenaline -Adult (shock)) QUEENSLAND AMBULANCE SERVICE 1063 Adrenaline (epinephrine) Paediatric dosages (cont.) Adult dosages (cont.) Anaphylaxis Bradycardia with poor perfusion IM 6 years or older – EpiPen® Auto-injector (300 microg). (unresponsive to atropine AND/OR transcutaneous pacing) C P FR AT Single dose only. IV/IO 20 – 50 microg 1 year – less than 6 years – EpiPen® Jr Auto-injector CCP Repeated at 1 minute intervals. No maximum dose. UNCONTROLLED WHEN PRINTED (150 microg) IM 6 years or older – 300 microg ACP2 ACP1 CCP Repeated at 5 minute intervals. No maximum dose. Paediatric dosages [1-6, 5-7] 1 year – less than 6 years – 150 microg Repeated at 5 minute intervals. No maximum dose. 6 months – less than 1 year – 100 microg Cardiac arrest Repeated at 5 minute intervals. No maximum dose. IV Less than 6 months – 50 microg ACP2 CCP Age/Weight Dose Repeat/max dose Repeated at 5 minute intervals. No maximum dose. UNCONTROLLED WHEN PRINTED ≥ 1 yr (≥ 10 kg) 10 microg/kg 3−5 minutes. No max dose. NEB 5 mg ACP2 CCP 6−12 months 100 microg 3−5 minutes. No max dose. Single dose only. 3−5 months 70 microg 3−5 minutes. No max dose. May be administered for upper airway obstruction that is refractory to 3 x IM adrenaline (epinephrine) 38 weeks gestation injections. 50 microg 3−5 minutes. No max dose. − 2 months 27−37 weeks IV/IO May be administered for refractory anaphylaxis or severe CCP 25 microg 3−5 minutes. No max dose. gestation INF allergic reaction unresponsive to 2 x IM adrenaline UNCONTROLLED WHEN PRINTED < 27 weeks gestation 10 microg 3−5 minutes. No max dose. (epinephrine) injections and adequate fluid administration. 6 years or older − 1 microg/kg bolus (IV/IO) IO Immediately followed by an infusion commencing at CCP Age/Weight Dose Repeat/max dose 0.2 microg/kg/min (0.2 mL/kg/hr) − titrate accordingly ≥ 1 yr (≥ 10 kg) 10 microg/kg 3−5 minutes. No max dose. to indication and patient’s physiological response to treatment. Maximum infusion rate 0.5 microg/kg/min 6−12 months 100 microg 3−5 minutes. No max dose. Less than 6 years − QAS Clinical Consultation and Advice 3−5 months 70 microg 3−5 minutes. No max dose. Line consultation and approval required in all situations. UNCONTROLLED WHEN PRINTED 38 weeks gestation − 2 months 27−37 weeks 50 microg 25 microg 3−5 minutes. No max dose. 3−5 minutes. No max dose. Infusion preparation: Mix 3 mg (3 mL) of 1:1000 adrenaline (epinephrine) with 47 mL of sodium chloride 0.9% to achieve a final concentration of 60 microg/mL. Ensure the syringe is appropriately labelled. Administer gestation the infusion via the Perfusor® Space Medication Library < 27 weeks (Adrenaline-Paed (shock)). 10 microg 3−5 minutes. No max dose. gestation QUEENSLAND AMBULANCE SERVICE 1064 Adrenaline (epinephrine) Paediatric dosages (cont.) Severe life-threatening bronchospasm OR silent chest Croup (moderate to severe) (patients must only be able to speak in single words AND/OR 5 mg NEB ACP2 CCP have haemodynamic compromise AND/OR an ALOC) Single dose only. UNCONTROLLED WHEN PRINTED IM 6 years or older – 300 microg ACP2 ACP1 CCP Repeated at 5 minute intervals. No maximum dose. Shock unresponsive to adequate fluid resuscitation 1 year – less than 6 years – 150 microg IV/IO 1 microg/kg CCP Repeated at 5 minute intervals. Single dose not to exceed 50 microg. No maximum dose. Repeated at 2 minutes intervals. 6 months – less than 1 year – 100 microg No maximum dose. Repeated at 5 minute intervals. No maximum dose. UNCONTROLLED WHEN PRINTED IV/IO QAS Clinical Consultation and Advice Line CCP Less than 6 months – 50 microg consultation and approval required in all Repeated at 5 minute intervals. INF situations. No maximum dose. IV/IO May be administered for refractory severe life-threatening Bradycardia CCP INF bronchospasm or silent chest unresponsive to 2 x IM (unresponsive to atropine AND/OR transcutaneous pacing) adrenaline (epinephrine) injections and adequate fluid administration. IV/IO QAS Clinical Consultation and Advice Line CCP UNCONTROLLED WHEN PRINTED 6 years or older − 1 microg/kg bolus (IV/IO) consultation and approval required in all situations. Immediately followed by an infusion commencing at 0.2 microg/kg/min (0.2 mL/kg/hr) − titrate accordingly to indication and patient’s physiological response to treatment. Maximum infusion rate 0.5 microg/kg/min Less than 6 years − QAS Clinical Consultation and Advice Line consultation and approval required in all situations. Infusion preparation: Mix 3 mg (3 mL) of 1:1000 UNCONTROLLED WHEN PRINTED adrenaline (epinephrine) with 47 mL of sodium chloride 0.9% to achieve a final concentration of 60 microg/mL. Ensure the syringe is appropriately labelled. Administer the infusion via the Perfusor® Space Medication Library (Adrenaline-Paed (shock)). QUEENSLAND AMBULANCE SERVICE 1065