Push-Dose Epinephrine
Epinephrine (diluted)
Brand names:Generic (technique, not a product)
A technique for administering small intravenous boluses of dilute epinephrine (10 mcg/mL) to treat peri-arrest hypotension, post-intubation hypotension, and bridge to vasopressor infusion. Push-dose epinephrine delivers vasopressor support in 5 to 20 mcg increments, allowing titration to effect without committing to a continuous infusion setup.
Pharmacology and Actions
Alpha-1 adrenergic agonism produces peripheral vasoconstriction, raising mean arterial pressure. Beta-1 agonism increases heart rate and contractility, augmenting cardiac output. The combination produces rapid hemodynamic support, ideal for the peri-arrest or post-intubation patient who needs immediate vasopressor effect while infusion is being prepared.
Indications
- Peri-arrest hypotension responsive to volume resuscitation but requiring vasopressor support
- Post-intubation hypotension from sedation-induced sympathetic withdrawal or positive pressure ventilation effects
- Bridge to vasopressor infusion in critically ill patients
- Anaphylactic shock not responsive to IM epinephrine when IV access established
Absolute Contraindications
- None in life-threatening hypotension or peri-arrest setting
- Relative: hypovolemic shock without volume replacement (treats the number, not the underlying problem)
Precautions and Side Effects
Hypertension if over-titrated. Tachyarrhythmias. Myocardial ischemia in patients with coronary artery disease. Dosing errors are the dominant safety concern - the dilution preparation must be done carefully and clearly labeled to avoid confusion with the 1 mg/10 mL cardiac arrest dose. Multiple high-profile patient deaths have been associated with cardiac-arrest-dose epinephrine being administered as push-dose. Anxiety, tremor, headache common at therapeutic doses.
Adult Dosing
Pediatric Dosing
1 mcg/kg IV/IO push-dose, max 10 mcg per dose, repeat every 2 to 5 minutes as needed. Requires careful weight-based calculation and dilution preparation.
Pharmacokinetics
Peak Effect: 1 to 2 minutes
Duration: 5 to 10 minutes per bolus
Storage and Handling
Cardiac arrest epinephrine (1 mg in 10 mL prefilled syringe) is the typical source for dilution. Push-dose dilution should be prepared immediately before use, clearly labeled, and used within 1 to 4 hours of preparation per institutional protocol. Do not pre-prepare push-dose dilution in advance for storage.
Reconstitution:
Standard preparation: draw 1 mL of cardiac arrest epinephrine (0.1 mg/mL) into a 10 mL syringe, then draw up 9 mL of normal saline to total 10 mL. Final concentration: 10 mcg/mL. Label clearly as PUSH-DOSE EPINEPHRINE 10 MCG/ML to distinguish from undiluted cardiac arrest preparation.
TCCC and TECC Role
Not a TCCC core formulary technique. Used in critical care transport, emergency department resuscitation, and advanced prehospital ALS. CPP tier providers may use push-dose epinephrine in extended care scenarios. The technique is increasingly documented in emergency medicine and critical care literature as a bridge intervention before continuous infusion setup.
Push-dose epinephrine is the bridge technique between recognizing peri-arrest hypotension and getting a vasopressor infusion running. The patient who just had RSI for airway protection and dropped their MAP to 55 needs vasopressor support now, not in 10 minutes when the pharmacy delivers the pre-mix. Push-dose lets you support the patient with 10 to 20 mcg boluses every 2 to 5 minutes while the infusion is being prepared. The dilution preparation is the safety-critical step: 1 mL of cardiac-arrest epinephrine (1 mg/10 mL = 0.1 mg/mL) mixed with 9 mL of normal saline produces 10 mL of 10 mcg/mL push-dose epinephrine. Clear labeling is mandatory to prevent the catastrophic error of pushing the undiluted cardiac arrest dose as a bolus.
Confusing the 1 mg/10 mL cardiac arrest preparation with the 10 mcg/mL push-dose preparation. Multiple patient deaths have been documented from this error - the cardiac arrest dose given as push-dose produces severe hypertension, tachyarrhythmia, and stroke or myocardial infarction. Always prepare push-dose dilution at the bedside with both verbal and written confirmation, clearly label the syringe, and verify dose before administration. The other common mistake is using push-dose in a clearly hypovolemic patient who needs volume; vasoconstriction in the absence of circulating volume worsens tissue perfusion.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
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Drug information evolves. Last reviewed dates and source citations are provided for each entry. Confirm currency against the cited source before clinical use.
Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Push-Dose Epinephrine
| IV/IO | 10 mcg per push-dose bolus initial (1 mL of the 10 mcg/mL dilution), repeat every 2 to 5 minutes as needed. Range 5 to 20 mcg per dose, titrate to MAP target. Cumulative dosing typically 50 to 200 mcg total before transitioning to infusion. (Less than 1 minute) |
| IM | Not used as push-dose technique (IM epinephrine is separate doctrine - 0.3 mg for anaphylaxis). (None) |
| IN | None (None) |
| PO | None (None) |