February 27, 2026

Welcome again to UH EMSI’s Pharmacy Phriday CE offering. As mentioned in our last installment, the February CE topic focused on the different types of shock and their treatments, and we reviewed the use of normal saline 0.9% (NS). In this installment, we’ll discuss epinephrine and its administration as small boluses in stabilizing blood pressure, often known as push dose epinephrine (PDE). 

Epinephrine is a catecholamine that is found naturally in the body and affects the sympathetic nervous system. It is an adrenergic (sympathomimetic) agent and cardiac stimulant that acts on both alpha and beta receptor sites. 

Epinephrine’s alpha effects cause vasoconstriction that improves perfusion pressure to the brain and heart. Its effect on beta receptors includes those of the heart, vascular, and other smooth muscle. Stimulation of the beta1-adrenergic receptors in the heart results in a positive inotropic effect (increasing contractility), a positive chronotropic effect (increasing the heart rate), and a positive dromotropic effect (increasing the rate of conduction through the AV node). 

In cases of septic, cardiogenic, and neurogenic shock, PDE is indicated when the patient does not respond to fluids, or the patient is already overloaded with fluids. PDE is also referenced in our “Bradycardia” and “Post–Resuscitation Cardiac Care” algorithms to treat hypotension.  

PDE, sometimes referred to as an “epi spritzer”, is a dosing of epinephrine that provides the patient with small doses, between 10-50 mcg, with each administration. The goal of this dosing is to maintain a MAP > 65, a systolic BP of 90 mm/hg if MAP is unavailable, or a radial pulse. 

Take note: In cases of severe anaphylactic shock with no radial pulses, the epinephrine dosing changes. Our protocols describe this as “impending arrest,” indicating a very dire circumstance requiring higher doses of epinephrine. In these cases, an IV dosing of 1 ml of the 1 mg/10 ml concentration, or 100 mcg/ml concentration, is indicated. One (1) ml, or 100 mcg, is administered every minute until the desired effect mentioned above is reached. The maximum dose given in this circumstance would be 500 mcg or 5 ml. 

This different dosing raises a crucial point: When administering epinephrine, be sure you have the correct concentration and dose for the proper treatment! Epinephrine is provided in our UH drug boxes in various concentrations that include:  

• The 1 mg/ml concentration (old ratio 1:1000), sometimes referred to as IM epinephrine 

• The 0.1 mg/ml concentration (old ratio 1:10,000), sometimes called cardiac epinephrine 

• Racemic epinephrine, 0.5 ml 2.25% solution used for aerosol treatments 

Returning to the administration of PDE, remember that the provider must prepare the proper concentration. There are many suggested ways to mix this medication, but the preferred method of the UH system and its medical directors is described in the protocols (see the illustration below).  

To prepare this concentration, the provider can use the “pull one, push one, pull one, push one” mnemonic. This will assist the provider in remembering the following steps: 

1. Pull One - Draw up 1 mg of epinephrine 1 mg/ml (1000 mcg/ml). Use a filter needle if drawing from an ampule and discard the needle before injecting into the 100 ml bag.  

2. Push One - Add the 1 mg of epinephrine to a 100 ml bag of D5W or NS and mix. This results in a 10 mcg/ml concentration. Label the bag appropriately! 

3. Pull One - Draw up from the bag to administer the new concentration.  

4. Push One – Administer 1 ml or 10 mcg as a slow push, titrated to the desired effect of maintaining a MAP > 65, a systolic pressure >90, or the presence of peripheral pulses. The provider may give up to 50 mcg or 5 ml for a single dose if needed to meet the desired effect.

As always, monitor the patient and their blood pressure. The need to repeat the PDE dosing is likely. As soon as the provider notes a drop in blood pressure, another dose should be administered. If continued administration is needed, the provider can choose to convert the PDE to a drip. This can be accomplished by spiking the mixed bag with a 10 gtt set (1 gtt equals 1 mcg) and titrating the drip rate to the desired effect.

Use of PDE in the pediatric patient is within the protocol but requires approval from online medical direction. The listed dosing is 1 mcg/kg every 2-5 minutes with a max dose of 10 mcg. 

Until next time, stay safe!

The UH EMS-I Team

University Hospitals

August 15, 2025

Welcome again to UH EMSI’s Pharmacy Phriday CE offering. Over the past few weeks, we have focused on some of the medications administered in cardiac care algorithms. In this installment, we’ll review the 0.1 mg/ml concentration of epinephrine, the first-line medication administered IV or IO in cardiac arrest.  

Epinephrine is a catecholamine found naturally in the body that affects the sympathetic nervous system. It is an adrenergic (sympathomimetic) agent and cardiac stimulant that acts on both alpha and beta receptor sites. It is a mainstay in the management of cardiac arrest and impending arrest during anaphylactic shock. Cited in current American Heart Association (AHA) texts, early administration of epinephrine in cardiac arrest is associated with greater return of spontaneous circulation (ROSC).  

Epinephrine’s alpha effects cause vasoconstriction that improves perfusion pressure to the brain and heart. Its most prominent actions are on the beta receptors of the heart, vascular, and other smooth muscle. When given as an IV bolus, stimulation of the beta-1 adrenergic receptors in the heart results in a positive inotropic effect (increasing contractility), a positive chronotropic effect (increasing the heart rate), and a positive dromotropic effect (increasing the rate of conduction through the AV node).  

Epinephrine is provided in our UH drug boxes in various concentrations. Ensure you have the correct concentration and dose for proper treatment before administration. Remember, in this article, we are discussing the “cardiac” epinephrine, the concentration of 0.1 mg/ml (100 mcg/ml).  

Epinephrine in the concentration of 0.1 mg/ml is indicated for use by UH protocols in cases of cardiac arrest and impending arrest during anaphylaxis. Impending arrest in anaphylaxis is defined in our protocols as the lack of or weak, thready radial pulses, severe hypotension, decreased level of consciousness, and airway compromise. Dosages are indicated in the following table: 

Until the next installment, stay safe! 

Sincerely, 

The UH EMS-I Team 

University Hospitals