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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.

  150 Responses to “Amiodarone and ACLS”

  1. you do not go into the dosing of procainamide and sotalol. Is that because they are not considered for use by basic ACLS providers and are not on the test? I guess they could be part of the megacode and not the written exam? What is your experience? Thanks so much for this site. It has given me lots of info and much more confidence.

    • You are correct. In the last 5 years, I have not seen these covered in any manner on the test or in a megacode situation. In my experience, these two medications are rarely used, and in an attempt to deemphasize the use of medications the AHA has not included much information about them.

      Kind regards,
      Jeff

  2. Can you please cite evidence showing amio actually helps save lives in this setting? If there is none why is ACLS recommending it? Same goes for epinephrine.
    Dorian et al. and Kudenchuk showed that amio just led to more patients being admitted to the hospital to die or to be vegetables. Kudenchuk et al. in NEJM reported that the rate of survival with good neurologic recovery with amiodarone was similar to that without amiodarone. The benefit if any is so small that it is simply not practical from a cost-benefit comparison.
    There is now good evidence for esmolol in arrhythmogenic storm. ECMO looks promising in select patients.

    Also FYI- procainamide has been shown to be far better than amio at converting VT to sinus rhythm.

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