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Amiodarone and ACLS

 

Amiodarone and ACLS


Amiodarone is considered a class III antiarrhythmic agent and is used for various types tachyarrhythmias. Because of its associated toxicity and serious side-effects it should be used cautiously and care should be taken to ensure that cumulative doses are not exceeded.

Indications for ACLS

Amiodarone is an antiarrhythmic that is used to treat both supraventricular arrhythmias and ventricular arrhythmias.

The mechanism of action of amiodarone remains unknown, but within the framework of ACLS, amiodarone is used primarily to treat ventricular fibrillation and ventricular tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors.

Amiodarone should not be used in individuals with polymorphic VT as it associated with a prolonged QT interval which is made worse with antiarrhythmic drugs.

Amiodarone should only be used after defibrillation/cardioversion and first line drugs such as epinephrine and vasopressin have failed to convert VT/VF.

Route

Amiodarone can be administered by intravenous or intraosseous route.

Dosing

The maximum cumulative dose in a 24 hour period should not exceed 2.2 grams.

Within the VT/VF pulseless arrest algorithm, the dosing is as follows:
300mg IV/IO push → (if no conversion) 150 mg IV/IO push → (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)

For tachyarrhythmias other than life threatening, expert consultation should be considered before use.

For Tachycardia other than pulseless VT/VF, Amiodarone dosing is as follows: (see above note)
150 mg over 10 minutes → repeat as needed if VT recurs → maintenance infusion of 1mg/min for 6 hours

Amiodarone should only be diluted with D5W and given with an in-line filter.

Infusions exceeding 2 hours must be administered in glass or polyolefin bottles containing D5W.

Return to main ACLS Pharmacology page.

  95 Responses to “Amiodarone and ACLS”

  1. Amiodarone is infused over 10 minutes. Any recommendations on what type of administration set that should be used when no pump is available? Baxter Continu-flo (10 gtt) or Secondary medication set and infusing like a piggyback method?

    • When giving bolus doses with the tachycardia algorithm or during the post arrest phase, amiodarone may be administered with any type of drip set. Amiodarone should not be given as a secondary drip with other medications or IV fluids, but should be administered with a designated port or line. It is also diluted only with D5W and should be filtered.

      Kind regards,
      Jeff

  2. if for atrial fibrillation, what is the maximum dosage of amiodarone? Is it advisable to give 900mg of amiodarone over 24 hours? Should we administer using glass container? TQ

  3. since MgSO4 is for polymorphic vtach, i’d like to ask how it is given?

  4. Hi Jeff,
    I just want to clarify med administration timing.
    - VT/VF –> 1st shock
    - 2 min CPR
    - VT/VF –> 2nd shock & Epi
    - 2 min CPR
    - VT/VF –> 3rd shock & 300 mg Amiodarone IVP
    - 2 min CPR
    - VT/VF –> 4th shock and ???
    In post #1 to Chuck your response to him says:
    “…300mg Amiodarone should be given after the 3rd shock and then a second dose of 150mg may be given after the 4th shock during CPR”
    At the 4th shock its time for Epi again. Would we give both Epi 1 mg — AND — Amio 150 mg? In all of my codes its always been one drug per shock…

    • Epinephrine is basically on its own time table and is to be given every 3-5 minutes. You can give the epinephrine after the 2nd dose of amiodarone or whenever the 3-5 minutes has passed. Just remember to give it when you are performing CPR. This will ensure adequate distribution of the medication in the circulatory system.
      There is no hard and fast rule in AHA ACLS Guidelines that says “one drug per shock” This will be true for the first 3 shocks, but after the 3rd shock you may be giving epi and amio or lidocaine back to back.

      Kind regards,
      Jeff

  5. A recent conversation took place during an education session. Is Amiodarone during continuous, non-converted, ventricular fibrillation be repeated every 3 to five minutes or after 10 minutes ? If it is repeated then is there a cut off as to the amount to be administered since it is not to exceed 2.2 grams per day.

    Thank you.

    • According to AHA ACLS guidelines, 300mg Amiodarone should be given after the 3rd shock and then a second dose of 150mg may be given after the 4th shock during CPR. This would put the 2nd dose at about 3 minutes after the first dose. Both doses would have been administered by the 8 minute mark. During a code, I have not seen more than this given during the arrest. It seems that is amiodarone is going to have any effectiveness as an arrhythmia, it will occur with the first two doses.

      I cannot find anything about giving more than this AHA recommendation.

      Kind regards,
      Jeff

  6. What is a pulseless polymorphic VT?
    Thanks

    • You can learn about both monomorphic and polymorphic VT here.

      This information applies also if the patient is pulseless. The only difference is if the rhythm is with a pulse you will use the tachycardia algorithm and if the rhythm is without a pulse, you will use the pulseless arrest algorithm.

      Kind regards,
      Jeff

  7. So can I clarify… If I am giving 150mg Amiodarone over 10 minutes diluted with 100ml D5W for tachycardia it should be in a glass bottle and using a filter?

  8. Why should we dilute amiodarone in D5W only? Thanks.

    • For infusions, manufacturer recommendation is to dilute amiodarone with D5W. Most likely this is due to reduced therapeutic affect with other solutions or the potential for amiodarone to precipitate (form solids) when mixed with other solutions.
      For infusions, it is recommended that the medication be diluted with D5W. For code situations, the amiodarone can be drawn up and given undiluted.
      Always follow rapid IV push doses with 20ml of NS.

      I did find this in a PubMed article concerning the stability of amiodarone:
      “Amiodarone hydrochloride is stable when mixed with either 5% dextrose injection or 0.9% sodium chloride injection in polyvinyl chloride or polyolefin containers alone or with potassium chloride, lidocaine, procainamide, verapamil, or furosemide and stored for 24 hours at 24 degrees C. Amiodarone should not be mixed with quinidine gluconate in polyvinyl chloride containers.”
      So honestly, I’m not sure why the manufacturer recommends only D5W.

      Davis Drug guide says “dilute only with D5W.”

      Kind regards,
      Jeff

  9. Do you need to dilute aminodarone when given as ivp? Thanks

  10. If it is a pulseless polymorphic VT arrest, and you have followed the algorithm, you have given 3rd shock and amiodarone now called for…. is it still recommended?

  11. When giving Amiodarone IV push during V-fib/Vtach, should we be using an inline filter? Can we give it as fast as we can?

    When mixing Amiodarone does it take some time to mix up? Is it smart to start mixing this drug right away in anticipation of using this drug, or is that vasopressing that takes time to mix up?

    Jarred

    • You should use an inline filter for amiodarone. When coding a patient, the amiodarone is pushed as fast as possible just like epinephrine.
      It would be wise, if extra hands are available, to mix the amiodarone well in advance. During a code, I usually have the person administering medications prepare and mix medications while CPR is being performed.
      Kind regards,
      Jeff

  12. For Cardiac arrest: After your initial 300mg, you follow with 150mg. How many additional doses can you administer?

    • Amiodarone is usually given x 2 with one dose of 300mg and then a dose of 150mg. Usually pulseless VT/VF will not last long enough to give a third or 4th dose of 150mg, but it could be given if it was deemed necessary.

      Kind regards,
      Jeff

  13. I know this is not following the ACLS protocol but…
    If a paitient is recieving manual compressions and is not in VT or been shocked but Amiodarone is given – what happens? Does this put a person in a cardio depressive state?

    • At best it would do nothing. At worst it would take attention away from high quality CPR. As amiodarone suppresses electrical activity on many levels it may be harmful. The only time amiodarone should be considered in the setting of cardiac arrest is VFIB-Pulseless VT after 3 shocks and a dose of epinephrine.
      Kind regards,
      Jeff

  14. Just want to make sure I got this right. You only give a dose of 300mg of Amiodarone if you have not converted the rhythm and you only give it once? You would only give a dose of 150mg Amiodarone only if the rhythm is successfully converted?

    So let’s say the the second shock is successful, you would skip the 300mg dose and only use the 150mg dose?

    You wouldn’t follow the dose of 300mg Amiodarone with 150mg Amiodarone if there has not been a conversion?

    Kind regards,

    Alexander

    • If the second shock is successful, there would be no need to give amiodarone at all. If any arrhythmias persist, an amiodarone infusion may be started in the post arrest phase.
      If the second shock fails, you would give 300mg amiodarone. If after the 3rd shock the rhythm remains pulseless VT or VF, you would give the 2nd dose of amiodarone. Make sure to wait at least 3 minutes to ensure adequate circulation of the first dose of amiodarone.
      Kind regards,
      Jeff

      • Okay. Now I’m confused. Isn’t the first shock given without any drug, epinephrine after the 2nd shock, and amiodarone after the 3rd shock? And I guess the person leading just has to make sure that the person doing the epinephrine is paying attention to time, because this must get pretty busy, this business of trying to cardio-convert!
        And, by the way, I hope you are making a comfortable living from this…love your “kind regards.” Obviously some of us are tired and not thinking clearly…just need someone like you to patiently see us through… : )…..

      • First, thanks for the encouragement I truly enjoy helping people with ACLS preparation and it is my hope that I can help take away some of the anxiety involved and really prepare them for emergency situations. Also, it is my hope that I can reflect the some of the wonderful grace of God to others through the help I give on the website.

        For the question about the medication sequence. Your statement was basically correct: “Isn’t the first shock given without any drug, epinephrine after the 2nd shock, and amiodarone after the 3rd shock? And I guess the person leading just has to make sure that the person doing the epinephrine is paying attention to time.”

        Once the first dose of epinephrine is give after the first shock, it is on its own time table and is to be given every 3-5 minutes. During a code, the recorder will usually call out when the next medication can be given and another person will deliver the medications per the team leaders instructions.
        It can get a bit hectic in a code, but if each person involved is familiar with the algorithms, this all can be a very smooth process. I have seen bad codes and good codes. The main difference regarding the knowledge/experience level of those participating.
        I hope this site gets people ready for the real thing.
        Kind regards,
        Jeff

  15. Question…how long should it take to give IV Amidarone? For 300 mg is it 10 minutes and for 150 mg also 10 minutes? I cannot find a clear answer for this question.

    Thanks!

  16. can inj.amoidarone be administer prior to a shock in a persistent asystole and no change in rythem and has systolic 60/?no resp. fixed and dilated pupils in ed after administratiln of epinehrine inj.and continuos cpr for almost 15 minutes in ed followd by shock

    • If the patient is in asystole, you would NOT administer amiodarone or shock. Asystole calls for use of the right branch of the pulseless arrest algorithm and therefore, CPR with epinephrine given every 3-5 minutes would be in order.
      Also, if you have been coding for 15 minutes, the patient is in asystole, and their pupils are fixed and dilated, you would want to consider discontinuing resuscitative efforts.

      Amiodarone and unsynchronized shocks are reserved for patient’s with pulseless VT and VF. Amiodarone is an antiarrhythmic and should be used to treat arrhythmias.

      Kind regards,
      Jeff

  17. post conversion, no antiarrhymics given, what would the dose of amiodarone be in a patient with venticular ectopy but ROSC. The consensus here is that it would be the 150mg in 100cc.

    • Yes, you would give 150mg IV over the first 10 minutes. Dilute in 100ml of D5W. This dose can be repeated every 10 minutes as needed.

      Kind regards,
      Jeff

      • And if no ectpoy? Would a maintenance of 150 into 100cc still apply?
        Thank you

      • According to AHA, the maintenance dose in the post arrest phase would only apply if arrhythmias persist. There is still some debate about this and some physicians that I know are still starting amiodarone post-arrest even if there is no continued arrhythmia.
        There is no research that shows continuing amiodarone in the post arrest phase is necessary unless arrhythmias persist.

        Kind regards,
        Jeff

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