adrenaline 1:1,000

presentation - what the drug is sealed in, its concentration and how it might look

Adrenaline 1:1,000 normally comes in one of these three presentations:

  • Pre-filled syringe.

  • Auto-injector (generally for use by the public/bystanders).

  • Ampoule containing 1 milligram of adrenaline (epinephrine) in 1 ml (1:1,000) ADM.

UK NHS and private ambulance services tend to favour the ampoules to their the significant difference in price (i.e. ~£1 per ampoule).

INDICATIONS - reasons you should administer this drug

Adrenaline 1:1,000 can be used by trained ambulance staff (SALM, EMT, Paramedic) to treat:

  • Anaphylaxis (IM only).

    • i.e. a life-threatening allergic reaction characterised by rapid onset (<2 minutes).

  • Life-threatening asthma with failing ventilation and continued deterioration despite nebuliser therapy (IM only).

    • i.e. silent asthma: no audible chest sounds and low or zero respiratory rate.

CONTRAINDICATIONS - reasons you should not administer this drug

There are no contraindications for the use of adrenaline 1:1,000 in an emergency situation. The IM only route reduces any systemic issues if given inappropriately by slowing down and ‘smoothing out’ absorption.

cautions - reasons that if you administer this drug you must monitor for side effects more than usual

  • Severe hypertension may occur in patients on non-cardioselective beta-blockers (e.g. Propranolol).

  • Only administer IM.

pharmacological action - what does it to the body and what does the body do to it?

FREC 3 and FREC 4:

Reverses allergic manifestations of acute anaphylaxis.

Relieves bronchospasm in acute severe asthma.

FREUC 5 and L4 AAP

  • Pharmacokinetics:

    • Absorption: Well-absorbed via muscular vasculature; Full therapeutic effect at around 5–10 minutes IM.

    • Distribution: Widely distributed; crosses placenta and GI tract.

    • Metabolism: Extensively metabolised in the liver.

    • Elimination: Excreted in urine and faeces; half-life of 3–5 hours.

  • Pharmacodynamics

    • Cardiac effects:

      • Positive inotrope: increases contractility (heart squeezes harder).

      • Positive chromotrope: increases heart rate.

      • Positive dromotrope: increases conduction speed through the AV node.

    • Vascular effects:

      • Vasoconstriction: tightens ‘leaky’ blood vessels which raises BP and reduces airway swelling by reducing fluid shift.

    • Respiratory/allergy effects:

      • Bronchodilation: relaxes airway smooth muscle which opens the bronchi

      • Mast cell stabilisation: reduces further histamine release which slows swelling. Although an anti-histamine will be needed for full mast cell stabilisation but this is now de-emphasized by many guidelines and ADR 1:1,000 is the priority in anaphylaxis.

side effects - unwanted secondary effects of this drug

None when used appropriately.

dosage and administration - how much do we give and how do we give it?

NB: Below apply to both anaphylaxis and life-threatening asthma.

NBB: Use intramuscular route only.

Adults:

  • Route: Intramuscular – antero-lateral aspect of thigh. NB Patients with a higher BMI will need a longer IM needle.

  • Initial dose: 500mcg

  • Repeat dose: 500mcg

  • Dose Interval: 5 minutes

  • Concentration: 1mg/1ml

  • Volume: 0.5ml

  • Max dose: Unlimited

Children:

Please see JRCALC Page for Age guidelines.

Tip: Due to it’s low cost and high reward profile, K2 International recommends drawing up several doses at the same time into 2ml syringes (4 doses per syringe). This will allow you to give 0.5 ml accurately per does, but give you mulptile pre-draw doses so you are not drawing up drugs enroute to ED.

legislation and regulations - what legal class of drug is it, who can possess it and who can give it?

Adrenaline 1:1,000 falls into these categories:

  • Prescription-Only Medicine (POM)

    • Adrenaline 1:1000 is a Prescription-Only Medicine (POM).

    • Normally this would require a prescription from an authorised prescriber such as a doctor or Advanced Paramedic.

  • Not a Controlled Drug

    • It is not classified as a Controlled Drug.

    • No CD register or CD cabinet requirements apply.

    • However, it must still be locked in a cabinet with restricted access.

  • Schedule 19 (Life-Saving Medicines)

    • Adrenaline 1:1000 is listed in Schedule 19 of the Human Medicines Regulations 2012.

    • Schedule 19 allows any person to administer it for immediate life-saving treatment,

    • It can therefore be given without a prescription or PGD in these emergencies.

    • This is not to be confused with a prescription having never been done, it will have been prescribed for a particular person and anyone can use it on them (think epi-pen and anaphylaxis), or an HCP will have ordered them via a prescription or order request (exemptions) for trained personnel other than themselves to use in the course of their duties (this will be a medical and/or a clinical director, ideally a pharmacy director will be involved too).

  • Awarding Body & Training Frameworks (SALM)

    • Under training standards such as Qualsafe’s SALM, adrenaline 1:1000 is included in the list of drugs that MUST be covered on SALM.

    • Despite Schedule 19 giving anyone the legal exemption to administer it, it does not mean they can give it safely. Hence SALM- Safe Administration of Lifesaving Medications.

bibliography

  1. National Institute for Health and Care Excellence. 2018. Adrenaline/Epinephrine. Available from:

https://bnf.nice.org.uk/drug/adrenalineepinephrine.html

Next

Adrenaline 1:10,000 [POM/Sch.17]