ER Basics for Rookies

Every rookie knows epinephrine is part of ACLS, but the timing often gets confusing in the chaos of a code. Give it right away? After shocks? Every round? This guide breaks down exactly when to give epinephrine in cardiac arrest, based on current ACLS guidelines and best evidence.

Why Epinephrine?

• α-adrenergic effect: vasoconstriction → increases coronary and cerebral perfusion pressure during CPR.
• β-adrenergic effect: increases heart rate and contractility (but also increases myocardial O₂ demand).
• Goal: improve chance of ROSC (return of spontaneous circulation).

Step 1: Identify Rhythm (Shockable vs Non-Shockable)

Non-Shockable (PEA, Asystole)

• Epinephrine is given immediately after IV/IO access obtained.
• Then continue every 3–5 minutes during resuscitation.
• It’s the first drug in non-shockable rhythms.

Shockable (VF, pulseless VT)

• Priority = defibrillation.
• Epinephrine is given after the 2nd shock, then every 3–5 minutes.
• Why? Shocking early is the best chance of ROSC; epi too early delays shocks.

Step 2: Dosing

• 1 mg IV/IO every 3–5 minutes.
• No maximum total dose in ACLS guidelines.
• Always flush with 20 mL saline and elevate extremity if peripheral line used.

Step 3: Practical ED Workflow

1. Start CPR immediately.
2. Identify rhythm:
   • If PEA/asystole → give epi immediately.
   • If VF/pVT → shock first.
3. Administer epi every 3–5 minutes thereafter.
4. Keep track of times — designate one team member to call out “epi due.”
5. Resume compressions after every dose — never stop for drug push.

Evidence Snapshot

• Epinephrine improves ROSC but has not clearly improved long-term neurologic survival in RCTs.
• Early administration in non-shockable rhythms improves survival to discharge.
• In shockable rhythms, survival is highest when shocks are prioritized, then epi given after 2nd shock.

Common Rookie Mistakes

• Giving epi too early in VF/pVT before first shock.
• Forgetting to repeat every 3–5 minutes — giving “one and done.”
• Stopping compressions too long to push epi.
• Not flushing line → drug doesn’t reach circulation quickly.
• Confusing “epi for arrest” (1 mg every 3–5 min) with “epi drip” for anaphylaxis/shock.

Rookie Pearls

• In codes, assign a med nurse/doctor whose only job is to give epi on time.
• Always follow epi with flush + arm elevation for faster central delivery.
• If IO line used, epi works just as well as IV.
• Document exact times of administration — critical for handoff and post-ROSC care.

Take-Home Message

For rookies:

• PEA/Asystole: epi immediately, then q3–5 min.
• VF/pVT: shock first, epi after 2nd shock, then q3–5 min.
• Dose = 1 mg IV/IO, no max.

Remember: “Non-shockable = epi now. Shockable = shock first, epi after second.”