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Mechanism of action[edit

See also: Adrenergic receptor
Physiologic responses to epinephrine by organ
Organ Effects
Heart Increases heart rate
Lungs Increases respiratory rate
Systemic Vasoconstriction and vasodilation
Liver Stimulates glycogenolysis
Systemic Triggers lipolysis
Systemic Muscle contraction

7x speed timelapse video of fish melanophores responding to 200uM adrenaline.
As a hormone and neurotransmitter, epinephrine acts on nearly all body tissues. Its actions vary by
tissue type and tissue expression of adrenergic receptors. For example, high levels of epinephrine
causes smooth muscle relaxation in the airways but causes contraction of the smooth muscle that
lines most arterioles.
Epinephrine acts by binding to a variety of adrenergic receptors. Epinephrine is a
nonselective agonist of all adrenergic receptors, including the major subtypes α
, α
, β
, β
and β
Epinephrine's binding to these receptors triggers a number of metabolic changes. Binding
to α-adrenergic receptors inhibits insulin secretion by the pancreas, stimulatesglycogenolysis in
the liver and muscle, and stimulates glycolysis in muscle.
β-Adrenergic receptor binding
triggers glucagon secretion in the pancreas, increased adrenocorticotropic hormone (ACTH)
secretion by the pituitary gland, and increased lipolysis by adipose tissue. Together, these effects
lead to increased blood glucose and fatty acids, providing substrates for energy production within
cells throughout the body.

Drug Name

Generic Name : epinephrine (adrenaline), epinephrine bitartrate, epinephrine borate, epinephrine

Brand Name:
 Aerosol: Primatene Mist
 Ophthalmic solution: Epinal
 Injection, OTC nasal solution: Adrenalin Chloride
 Insect-sting emergencies: EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. Auto-
Injector (delivers 0.15 mg IM for children)
 OTC solutions for nebulization: AsthmaNefrin, microNefrin, Nephron, S2
Classification: Sympathomimetic, Alpha-adrenergic agonist, Beta1- and beta2-adrenergic agonist, Cardiac
stimulant, Vasopressor, Bronchodilator, Antasthmatic, Nasal decongestant, Mydriatic

Pregnancy Category C

Dosage & Route


Epinephrine injection
 Cardiac arrest: 0.5–1 mg (5–10 mL of 1:10,000 solution) IV or by intracardiac injection into left
ventricular chamber; during resuscitation, 0.5 mg q 5 min.

0.2–0.4 mL of a 1:1,000 solution added to anesthetic spinal fluid mixture.
 Other use with local anesthetic: Concentrations of 1:100,000–1:20,000 are usually used.
1:1,000 solution
 Respiratory distress: 0.3–0.5 mL of 1:1,000 solution (0.3–0.5 mg), subcutaneously or IM, q 20 min
for 4 hr.
1:200 suspension (for subcutaneous administration only)
 Respiratory distress: 0.1–0.3 mL (0.5–1.5 mg) subcutaneously.
Inhalation (aerosol)
 Begin treatment at first symptoms of bronchospasm. Individualize dosage. Wait 1–5 min between
inhalations to avoid overdose.
Inhalation (nebulization)
 Place 8–15 drops into the nebulizer reservoir. Place nebulizer nozzle into partially opened mouth.
Patient inhales deeply while bulb is squeezed one to three times. If no relief in 5 min, give 2–3
additional inhalations. Use four to six times per day usually maintains comfort.
Topical nasal solution
 Apply locally as drops or spray or with a sterile swab, as required.
Ophthalmic solution
 Vasoconstriction, mydriasis: Instill 1–2 drops into the eye or eyes; repeat once if necessary.

Epinephrine injection
 1:1,000 solution, children and infants except premature infants and full-term newborns: 0.01
mg/kg or 0.3 mL/m2 (0.01 mg/kg or 0.3 mg/m2) subcutaneously q 20 min (or more often if
needed) for 4 hr. Do not exceed 0.5 mL (0.5 mg) in a single dose.
 1:200 suspension, infants and children (1 mo–1 yr): 0.005 mL/kg (0.025 mg/kg) subcutaneously.
 Children < 30 kg: Maximum single dose is 0.15 mL (0.75 mg). Administer subsequent doses only
when necessary and not more often than q 6 hr.
Topical nasal solution
 > 6 yr: Apply locally as drops or spray or with a sterile swab, as required.
Ophthalmic solutions
 Safety and efficacy for use in children not established.
 Use with caution; patients > 60 yr are more likely to develop adverse effects.

Therapeutic actions
 Epinephrine, an active principle of the adrenal medulla, is a direct-acting sympathomimetic. It
stimulates α- and β-adrenergic receptors resulting in relaxation of smooth muscle of the
bronchial tree, cardiac stimulation and dilation of skeletal muscle vasculature. It is frequently
added to local anaesthetics to retard diffusion and limit absorption, to prolong the duration of
effect and to lessen the danger of toxicity.

 IV: In ventricular standstill after all other measures have failed to restore circulation, given by
trained personnel by intracardiac puncture and intramyocardial injection; treatment and
prophylaxis of cardiac arrest and attacks of transitory AV heart block with syncopal seizures
(Stokes-Adams syndrome); syncope due to carotid sinus syndrome; acute hypersensitivity
(anaphylactoid) reactions, serum sickness, urticaria, angioneurotic edema; in acute asthmatic
attacks to relieve bronchospasm not controlled by inhalation or subcutaneous injection;
relaxation of uterine musculature; additive to local anesthetic solutions for injection to prolong
their duration of action and limit systemic absorption
 Injection: Relief from respiratory distress of bronchial asthma, chronic bronchitis, emphysema,
other COPDs
 Aerosols and solutions for nebulization: Temporary relief from acute attacks of bronchial asthma,
 Topical nasal solution: Temporary relief from nasal and nasopharyngeal mucosal congestion due
to a cold, sinusitis, hay fever, or other upper respiratory allergies; adjunctive therapy in middle
ear infections by decreasing congestion around eustachian ostia
 0.1% ophthalmic solution: Conjunctivitis, during eye surgery to control bleeding, to produce

Adverse effects
 CNS effects; GI disturbances; epigastric pain; CV disorders; difficulty in micturition with urinary
retention; dyspnoea; hyperglycaemia; sweating; hypersalivation; weakness, tremors; coldness of
extremities; hypokalaemia. Gangrene, tissue necrosis and sloughing (extravasation) when used in
addition to local anaesthetics. Eye drops: Severe smarting, blurred vision, photophobia; naso-
lachrymal ducts obstruction. Oedema, hyperaemia and inflammation of the eyes with repeated

 Preexisting hypertension; occlusive vascular disease; angle-closure glaucoma (eye drops);
hypersensitivity; cardiac arrhythmias or tachycardia. When used in addition to local anaesthetics:
Procedures involving digits, ears, nose, penis or scrotum.

Nursing considerations

 History: Allergy or hypersensitivity to epinephrine or components of drug preparation; narrow-
angle glaucoma; shock other than anaphylactic shock; hypovolemia; general anesthesia with
halogenated hydrocarbons or cyclopropane; organic brain damage, cerebral arteriosclerosis;
cardiac dilation and coronary insufficiency; tachyarrhythmias; ischemic heart disease;
hypertension; renal impairment; COPD; diabetes mellitus; hyperthyroidism; prostatic
hypertrophy; history of seizure disorders; psychoneuroses; labor and delivery; lactation; contact
lens use, aphakic patients (ophthalmic preparations)
 Physical: Weight; skin color, T, turgor; orientation, reflexes, IOP; P, BP; R, adventitious sounds;
prostate palpation, normal urine output; urinalysis, renal function tests, blood and urine glucose,
serum electrolytes, thyroid function tests, ECG
 WARNING: Use extreme caution when calculating and preparing doses; epinephrine is a very
potent drug; small errors in dosage can cause serious adverse effects. Double-check pediatric
 Use minimal doses for minimal periods of time; "epinephrine-fastness" (a form of drug tolerance)
can occur with prolonged use.
 Protect drug solutions from light, extreme heat, and freezing; do not use pink or brown solutions.
Drug solutions should be clear and colorless (does not apply to suspension for injection).
 Shake the suspension for injection well before withdrawing the dose.
 Rotate subcutaneous injection sites to prevent necrosis; monitor injection sites frequently.
 WARNING: Keep a rapidly acting alpha-adrenergic blocker (phentolamine) or a vasodilator (a
nitrate) readily available in case of excessive hypertensive reaction.
 WARNING: Have an alpha-adrenergic blocker or facilities for intermittent positive pressure
breathing readily available in case pulmonary edema occurs.
 WARNING: Keep a beta-adrenergic blocker (propranolol; a cardioselective beta-adrenergic
blocker, such as atenolol, should be used in patients with respiratory distress) readily available in
case cardiac arrhythmias occur.
 Do not exceed recommended dosage of inhalation products; administer pressurized inhalation
drug forms during second half of inspiration, because the airways are open wider and the aerosol
distribution is more extensive. If a second inhalation is needed, administer at peak effect of
previous dose, 3–5 min.
 Use topical nasal solutions only for acute states; do not use for longer than 3–5 days, and do not
exceed recommended dosage. Rebound nasal congestion can occur after vasoconstriction
Teaching points
 Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read
the instructions that come with respiratory inhalant products, and consult your health care
provider or pharmacist if you have any questions.
 To give eye drops: Lie down or tilt head backward, and look up. Hold dropper above eye; drop
medicine inside lower lid while looking up. Do not touch dropper to eye, fingers, or any surface.
Release lower lid; keep eye open, and do not blink for at least 30 seconds. Apply gentle pressure
with fingers to inside corner of the eye for about 1 minute; wait at least 5 minutes before using
other eye drops.
 You may experience these side effects: Dizziness, drowsiness, fatigue, apprehension (use caution
if driving or performing tasks that require alertness); anxiety, emotional changes; nausea,
vomiting, change in taste (eat frequent small meals); fast heart rate. Nasal solution may cause
burning or stinging when first used (transient). Ophthalmic solution may cause slight stinging
when first used (transient); headache or brow ache (only during the first few days).
 Report chest pain, dizziness, insomnia, weakness, tremor or irregular heart beat (respiratory
inhalant, nasal solution), difficulty breathing, productive cough, failure to respond to usual dosage
(respiratory inhalant), decrease in visual acuity (ophthalmic).
Assessment & Drug Effects
 Monitor BP, pulse, respirations, and urinary output and observe patient closely following IV
administration. Epinephrine may widen pulse pressure. If disturbances in cardiac rhythm occur,
withhold epinephrine and notify physician immediately.
 Keep physician informed of any changes in intake-output ratio.
 Use cardiac monitor with patients receiving epinephrine IV. Have full crash cart immediately
 Check BP repeatedly when epinephrine is administered IV during first 5 min, then q3–5min until
 Advise patient to report to physician if symptoms are not relieved in 20 min or if they become
worse following inhalation.
 Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be
 Monitor blood glucose & HbA1c for loss of glycemic control if diabetic.
Patient & Family Education
 Be aware intranasal application may sting slightly.
 Administer ophthalmic drug at bedtime or following prescribed miotic to minimize mydriasis,
with blurred vision and sensitivity to light (possible in some patients being treated for glaucoma).
 Transitory stinging may follow initial ophthalmic administration and that headache and
browache occur frequently at first but usually subside with continued use. Notify physician if
symptoms persist.
 Discontinue epinephrine eye drops and consult a physician if signs of hypersensitivity develop
(edema of lids, itching, discharge, crusting eyelids).
 Learn how to administer epinephrine subcutaneously. Keep medication and equipment available
for home emergency. Confer with physician.
 Note: Inhalation epinephrine reduces bronchial secretions and thus may make mucous plugs
more difficult to dislodge.
 Report tolerance to physician; may occur with repeated or prolonged use. Continued use of
epinephrine in the presence of tolerance can be dangerous.
 Take medication only as prescribed and immediately notify physician of onset of systemic
effects of epinephrine.
 Discard discolored or precipitated solutions.
 Do not breast feed while taking this drug without consulting physician.