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Is there a place in pre-hospital care for push dose epi?

Question# 785

In severe anaphylaxis, or after 2 dose of epinephrine and a patient that is still deteriorating. Should paramedic consider initiating base hospital patch to consider IV push dose epi (1mcg/kg q 0.5-2min PRN). Obviously there is different factors to consider (signs of respiratory failure, angioedema, dilatation) and the fact that IM epinephrine can have an onset up to 5-8min which can be a long time for a patient that we cannot ventilate or can't perfuse adequately. Is there a place in pre-hospital care for push dose epi?


Most patients in anaphylaxis will respond to one or two doses of IM epinephrine when it is given promptly. In anaphylaxis refractory to two doses and hypotension despite fluid resuscitation, IV epinephrine is recommended.

However, IV epinephrine has been associated with significant cardiovascular complications. Dosing errors have been shown to be common in IV epinephrine in anaphylaxis (possibly due to unfamiliarity as it is rarely required); with higher error rates in push dose versus continuous infusion.

The consensus by experts in emergency medicine, intensive care, and immunology are unanimous in recommending that IV epinephrine in anaphylaxis should be delivered via infusion pump, and managed by clinicians trained and experienced in vasopressor administration.

For immediate prehospital and general ED treatment, patients should receive additional doses of IM epinephrine and aggressive fluid resuscitation.

If your patient is refractory to two doses of IM epinephrine and 20 ml/kg of IV normal saline, it is best to patch for additional doses of IM epinephrine and higher fluid volumes.


Farkas. 2019. PulmCrit- How to use IV epinephrine for anaphylaxis.
Fujizuka, et al. 2022. Comparison of the efficacy of continuous intravenous infusion versus intramuscular injection of epinephrine for initial anaphylaxis treatment.
White, et al, 2022. Emergency treatment of anaphylaxis: concise clinical guidance.
UpToDate, 2024. Anaphylaxis: Emergency treatment.


22 February 2024

ALSPCS Version




Please reference the MOST RECENT ALS PCS for updates and changes to these directives.