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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.

  139 Responses to “Amiodarone and ACLS”

  1. So if you reach the point where amiodarone is necessary for the VF/pulseless VT algorhythm, the amiodarone should be given 300mg rapid IV push?

  2. i have been in ccl for years &recently transferred to competition facility. they have “their own protocols” for acls drugs it sems.
    i have always pushed amio 300 iv for pulseless vf/vt. they had issue with that.
    they also have a partial fill d5w of 25 cc in emerg box for diluting
    please spell out exactly how to push and dilute and rates
    thanx

  3. Thank you, Jeff!! Wow, this was so helpful to read. I have to take ACLS for the first time in a month. I would love to learn so much more from you. Thank you for sharing.

    Tena

  4. How long do you have to wait until giving the second dose of Amiodarone? Thanks!

    • At least until the next cycle of CPR begins. At least approx. 3 minutes. The main point would be to ensure that the first dose gets to the central circulation and is able to deliver some affect before giving another dose. Effective CPR is the key.

      Kind regards,
      Jeff

  5. What time frame do we use for the IV push of amiodarone? Is it a rapid bolus push or do we push it over a matter of minutes?

  6. Hi there,

    If an amiodarone boluses are given for persistent pulseless VF, how important is it to begin an IV infusion soon after the bolus? Serum concentrations decrease rapidly (30-45 minutes) after an IV bolus, I think because of the drug’s distribution into the tissues. Does this mean that it is important to begin the 1mg/min infusion soon after the bolus? And if so, how soon?

  7. I would like to ask regarding my patient in the ED… He came in with an unstable VT and was converted to sinus after a single 100J sync cardioversion. While working up (ECG, Extracting blood, starting line, etc.), the patient had another unstable VT which was again converted to sinus after a single 100J sync cardioversion. After about 5 minutes, patient had another unstable VT and was converted to sinus by 100J sync cardioversion. My question is:

    1. Is it reasonable to start an antiarrhythmic drug to my patient (I started Amiodarone)?
    2. Do you have to give a loading dose (Amiodarone 150mg slow IV in 10 minutes) prior to starting a drip even if current cardiac monitor reading is already sinus?
    3. What does AHA stands regarding prophylactic antiarhythmics?

      1. Yes it is reasonable.
      2. You should give a loading dose if you are dealing with refractory VT.
      3. The stand regarding no prophylactic use of antiarrhythmics is strictly speaking of use after conversion from one episode of pulseless VT or VF. It would not apply in this case. Amiodarone would be indicated since the pt. had refractory VT with a pulse.

      Kind regards,
      Jeff

  8. thanks alot mr jeff for your exellent answers to others questions; i read all of the questions and your verry educational answers and learn very things ;thanks alot again mr jeff

  9. What is AHA recommendation for recurrent VF/VT after amio was given at 300mg, and then at 150 mg? CPR, defib and epi are being done as recommended. I wanted to know if AHA recommends continuing amio at 150 mg IVP, and continuing if need be up to 2.2 gms, or would you switch to a different antiarrhythmic such as lido since VF/VT did not convert after 450 mg total of amio was given.

    • Alternative antiarrhythmics may be attempted after amiodarone, but AHA does not hold a strong position on their use as there is no evidence that the use of any antiarrhythmics improve survival to hospital discharge. If amiodarone has not been effective after the first 2 doses then then an alternative like lidocaine could be attempted rather than continuing with amiodarone which has not been effective.

      Kind regards,
      Jeff

  10. I have a case that I can’t decide which treatment to choose: A pt with ventricular fibrillation has received multiple defibrillations, epinephrine at the appropriate dose, and an initial dose of amiodarone 300 mg IV. The physician would like to give a second dose of amiodarone but is not sure how it should be administered. He consults you to assist with preparation of the next dose of amiodarone. What do you suggest?

    Would I choose:
    1. Repeat amiodarone 300 mg IV push
    2. Amiodarone 150mg diluted in 100 ml D5W
    3. Amiodarone 150 mg IV push
    4. Start an amiodarone infusion at 1mg/min

    • I would choose #3 which would be appropriate for the cardiac arrest algorithm. This would be done during chest compressions. This would be the proper intervention according to the American Heart Association guidelines.

      Kind regards,
      Jeff

  11. I remember after successfull conversion of VF a lidocaine bolus was given along with a maintence infusion of 2 – 4 mg/min. After successfull conversion of VF – to ROSC (say sinus) today in ACLS there is no bolus of amnioderone???

  12. I am taking the acls protest and it says after one dose of epi and two shocks five amiodarone 300. Am I wrong in thinking it was after the third shock?? They only gave epi once.

    • Epinephrine is given after the second shock. Any subsequent doses of epinephrine are given every 3 to 5 minutes. Epinephrine is basically on it’s own timetable after the initial dose.
      The first dose of Amiodarone is always given after the third shock. Any subsequent dose of amiodarone is given after the first dose has had adequate time to circulate. This usually occurs any time after the fourth shock, but always during CPR.

      Kind regards,
      Jeff

  13. Post arrest with ROSC within several minutes, should the initial bolus dosing of amiodarone be given IVP or should it be hung as a piggyback over 10 minutes?

    • This would be used only if arrhythmias persisted in the post arrest period. You do not use it as prophylactically.
      The initial bolus dosing should be given as follows:
      (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)

      Kind regards,
      Jeff

      • How we are calculating the amidorone for example let’s say 0.5mg/min how many ml/hr will be

      • It depends upon the concentration of your amiodarone mix. Let’s say you have 150mg amiodarone in a 250ml of D5W. Then you would calculate ml/hr like this:
        0.5mg/min x 60min/1hr= 30mg/hr. Then you would use desired dose (30mg/hr) divided by the dose on hand (150mg) x volume 250 = 50ml/hr. This would equal 30 mg/hr.

        Kind regards,
        Jeff
        http://www.acls-algorithms.com

  14. My question is if you bulus with lidocaine can you use amiodarone for a maintenance drip or do you just stay with lidocaine or vise versa?

    • If the antiarrhythmic you use is effective for treatment then it would be appropriate to use this in the post arrest phase if there is any re-occurrence of the arrhythmia. Stick with what has worked. If the first does not work, try an alternative.

      Kind regards,
      Jeff

  15. After giving epinephrine, then going through a 2 minute cycle of compressions during cardic arrest, can you then give amiodarone. I know you are supposed to wait 3-5 min in between epinephrine doses, but can you slip in an amiodarone after only 2 minutes after giving epi?

    • Epinephrine is given after the 2nd shock during CPR. The first dose of amiodarone is given after the 3rd shock during CPR. This would be approximately 2 minutes.

      Kind regards,
      Jeff

  16. Why doe we need an in line filter with AMIODORONE

  17. Quick question:

    DO we push AMIODARIONE undiluted iv and flush with Saline or D5W?

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