Epinephrine for Asthmatic Arrest?

IM epinephrine is not indicated after cardiac arrest from asthma. Once cardiac arrest occurs, perfusion to peripheral tissues ceases, which prevents effective absorption and systemic delivery of IM medications (Wigginton et al., 2025). Current American Heart Association (AHA) guidelines recommend intravenous (IV) or intraosseous (IO) routes for epinephrine during cardiac arrest because these methods provide rapid and reliable access to the central circulation (Cao et al., 2025; Panchal et al., 2020).

Asthma-related cardiac arrest typically results from severe hypoxemia, hypercarbia, acidosis, and increased intrathoracic pressure, all of which compromise cardiac output before progressing to full arrest (Cao et al., 2025). Once perfusion is lost, IM epinephrine cannot reach target receptors to promote bronchodilation or improve circulation. Oxygen and adenosine triphosphate (ATP), both required for beta-adrenergic receptor function, are also absent during arrest, further limiting drug effectiveness.

IM epinephrine remains appropriate only for asthma exacerbations associated with anaphylaxis or angioedema (Reddel et al., 2024; Reddel et al., 2025). For isolated asthma, bronchodilators, corticosteroids, and airway optimization are preferred prior to arrest. After arrest, management should follow standard resuscitation protocols with attention to reversible causes such as hypoxia and tension pneumothorax (Cao et al., 2025).

In summary:

• IM epinephrine is ineffective during cardiac arrest due to absent perfusion.

• IV or IO administration is recommended for all cardiac arrests.

• IM epinephrine is reserved for anaphylaxis-related asthma, not isolated asthma.

References
Baggott, C., Hardy, J. K., & Sparks, J. (2022). Epinephrine compared to selective beta-2 agonists in adults or children with acute asthma: A systematic review and meta-analysis. Thorax, 77(6), 563–572.
Cao, D., Arens, A. M., & Chow, S. L. (2025). Part 10: Adult and pediatric special circumstances of resuscitation: 2025 American Heart Association guidelines for CPR and ECC. Circulation, 152(16_suppl_2), S578–S672.
Panchal, A. R., Bartos, J. A., & Cabañas, J. G. (2020). Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for CPR and ECC. Circulation, 142(16_suppl_2), S366–S468.
Reddel, H. K., Bacharier, L. B., & Bateman, E. D. (2024). Global strategy for asthma management and prevention. Global Initiative for Asthma.
Reddel, H., Bateman, E., & FitzGerald, G. (2025). Global strategy for asthma management and prevention. Global Initiative for Asthma.
Wigginton, J. G., Agarwal, S., & Bartos, J. A. (2025). Part 9: Adult advanced life support: 2025 American Heart Association guidelines for CPR and ECC. Circulation, 152(16_suppl_2), S538–S577.