page218
tion (for details see under Self-administration of
Adr-
enaline (Epinephrine), below).
Prompt injection
of adrenaline is of paramount impor-
tance. The following adrenaline doses are based on the
revised recommendations of the Working Group of the
Resuscitation Council (UK).
Dose of intramuscular injection of adrena-
line (epinephrine) for anaphylaxis
Age
Dose
Volume of
adrenaline
1 in 1000
(1 mg/mL)
Child under 6 years
150 micrograms
0.15 mL
1
Child 6–12 years
300 micrograms
0.3 mL
Adult and child 12–18
years
500 micrograms
0.5 mL
2
These doses may be repeated several times if necessary at
5-minute intervals according to blood pressure, pulse,
and respiratory function.
1.
Use suitable syringe for measuring small
volume
2.
300 micrograms (0.3 mL) if child is small
or prepubertal
Intravenous adrenaline (epinephrine)
Intravenous adrenaline should be given only by those
experienced in its use, in a setting where patients can be
carefully monitored. When the patient is severely ill and
there is real doubt about the adequacy of the circulation
and absorption after intramuscular injection, adrenaline
(epinephrine) can be given by slow
intravenous injec-
tion
in a dose of 50 micrograms (0.5 mL of the dilute 1 in
10 000
adrenaline
injection)
repeated
according
to
response;
if
multiple doses
are required,
adrenaline
should be given as a slow intravenous infusion
stopping
when a response
has
been obtained
;
children may
respond to as little as 1 microgram/kg (0.01 mL/kg of
the dilute 1 in 10 000 adrenaline injection)
by slow
intravenous injection
.
Great
vigilance is needed to ensure that
the
correct
strength
of
adrenaline injection is used;
anaphylactic
shock kits need to make a
very clear distinction
between
the 1 in 10 000 strength and the 1 in 1000 strength. It is
also
important
that,
where
intramuscular
injection
might still
succeed,
time should not be wasted seeking
intravenous access.
For
reference to the use of
the intravenous route for
cardiac resuscitation
,
see section 2.7.3.
Self-administration of adrenaline
(epinephrine)
Individuals at considerable risk of anaphylaxis need to
carry adrenaline (epinephrine) at all
times and need to
be
instructed in advance
when and how to inject
it;
injection technique is device specific.
In addition,
the
packs need to be labelled so that in the case of
rapid
collapse someone else is able to administer the adrena-
line. It is important to ensure that an adequate supply is
provided to treat symptoms until
medical
assistance is
available.
Adrenaline for administration by intramuscular injection
is
available
in
‘auto-injectors’
(e.g.
AnaPen
c
and
EpiPen
c
),
pre-assembled syringes fitted with a needle
suitable for very rapid administration (if necessary by a
bystander
or
a healthcare provider
if
it
is
the only
preparation available).
ADRENALINE/EPINEPHRINE
Indications
emergency treatment of acute anaphy-
laxis;
angioedema;
cardiopulmonary resuscitation
(section 2.7.3);
priapism [unlicensed] (section 7.4.5)
Cautions
for cautions in non-life-threatening situa-
tions,
see section 2.7.3
Interactions
Severe anaphylaxis in patients taking beta-
blockers may not respond to adrenaline, calling for bronch-
odilator therapy, see intravenous salbutamol (p.
177);
adr-
enaline can cause severe hypertension and bradycardia in
those taking non-cardioselective beta-blockers. Other
interactions, see Appendix 1 (sympathomimetics).
Renal impairment
section 2.7.3
Pregnancy
section 2.7.3
Breast-feeding
section 2.7.3
Side-effects
section 2.7.3
Dose
. Acute anaphylaxis,
by intramuscular injection (pre-
ferably midpoint in anterolateral thigh) of 1 in 1000
(1 mg/mL) solution, see notes and table above
. Acute anaphylaxis when there is doubt as to the
adequacy of the circulation,
by slow intravenous
injection of 1 in 10 000 (100 micrograms/mL) solution
(extreme caution—specialist use only), see notes
above
Important
Intravenous route should be used with extreme
care by specialists only,
see notes above
Intramuscular or subcutaneous
1
Adrenaline/Epinephrine 1 in 1000
(Non-proprietary)
A
Injection
,
adrenaline (as acid tartrate) 1 mg/mL,
net
price 0.5-mL amp = 52p;
1-mL amp = 57p
1
Minijet
c
Adrenaline 1 in 1000
(UCB Pharma) A
Injection
,
adrenaline (as hydrochloride) 1 in 1000
(1 mg/mL), net price 1 mL (with 25 gauge 0.25 inch
needle for subcutaneous injection) = £10.79,
1 mL
(with 21 gauge 1.5 inch needle for intramuscular
injection) = £6.36 (both disposable syringes)
Excipients
include sulphites
Intravenous
Extreme caution,
see notes above
Adrenaline/Epinephrine 1 in 10 000, Dilute
(Non-
proprietary) A
Injection
,
adrenaline (as acid tartrate) 100 micr-
ograms/mL,
10-mL amp,
1-mL and 10-mL prefilled
syringe
Minijet
c
Adrenaline 1 in 10 000
(UCB Pharma) A
Injection
,
adrenaline (as hydrochloride) 1 in 10 000
(100 micrograms/mL), net price 3-mL prefilled
syringe = £6.27;
10-mL prefilled syringe = £6.15
Excipients
include sulphites
Intramuscular injection for self-administration
Anapen
c
(Lincoln Medical) A
Anapen
c
500
(delivering a single dose of adrenaline
500 micrograms),
adrenaline 1.7 mg/mL,
net price
1.05-mL auto-injector device = £30.67
Excipients
include
sulphites
Note
0.75 mL of the solution remains in the auto-injector device
after use
Dose
by intramuscular injection,
ADULT and CHILD body-weight
over 60 kg or those at risk of severe anaphylaxis, 500 micrograms
repeated after 10–15 minutes as necessary
1.
A restriction does
not
apply to adrenaline injection
1 mg/mL where
administration
is
for
saving
life
in
emergency
198
3.4.3 Allergic emergencies
BNF 61
3
Respiratory system