Date Published

January 19, 2022

Updated For

ALS PCS Version ALS PCS Version 5.2


When dealing with an anaphylactic patient, the PCP medical directive says to administer up to 2 doses of epi at a maximum single dose of 0.5mg, whereas the bronchoconstriction AND cardiac arrest medical directives are only one dose at a maximum single dose of 0.5mg. Can some explain why?


Epinephrine is the most important and life-saving treatment of anaphylaxis.  However, in 12-36% of cases a second dose is needed.  Therefore, 2 doses are written into the Medical Directive.

Epinephrine for asthma is less evidence-based.  Please check out our podcast on this topic (here).  Within the Considerations for Paramedics Managing Patients During the COVID-19 Pandemic, IM epinephrine administration was expanded to use for those in severe respiratory distress with known asthma and a cough < 50 years of age.  The requirement for BVM ventilation was removed and the dosages were expanded to two (2) doses, at a 5-minute interval, if needed.

Epinephrine in the patient in cardiac arrest is limited to one dose, as if the single dose does not generate a ROSC, then focus should remain on evidence-based resuscitation: Good quality CPR, minimizing time off-the-chest and early recognition and management of shockable rhythms.  If this single dose of epinephrine does generate a ROSC, then you may utilize further epinephrine per the Moderate to Severe Allergic Reaction Medical Directive.



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