Amiodarone is a class III antiarrhythmic agent and is used for the treatment of various types of tachyarrhythmias. Because of the toxicity and serious side-effects of amiodarone, use it cautiously and do not exceed the cumulative total of 2.2 grams in 24 hours.
Indications for ACLS
Within ACLS, amiodarone is used for its antiarrhythmic properties and is effective for the treatment of supraventricular arrhythmias and ventricular arrhythmias.
The mechanism of action for amiodarone’s antiarrhythmic properties remains unclear, but it continues to be the primary antiarrhythmic medication for the treatment of ventricular fibrillation and ventricular tachycardia within the cardiac arrest algorithm.
For cardiac arrest, amiodarone is used after the third shock for ventricular fibrillation and ventricular tachycardia that is unresponsive to shock delivery, CPR, and vasopressors. For tachycardia with a pulse, amiodarone may be considered, and expert consultation should be obtained prior to its use.
Do not use amiodarone for individuals with polymorphic VT associated with a prolonged QT interval because this may worsen the patient’s condition.
Amiodarone is only used after defibrillation (or cardioversion) and epinephrine (first line medication) fail 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 that are not life-threatening, consider expert consultation 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
To prepare Amiodarone for an IV infusion, mix with D5W and give through an in-line filter. Alternatively, it is NOT necessary to dilute amiodarone for IV push administration and a filter is not necessary.
When infusions exceed 2 hours, amiodarone can absorb into the plastic used for standard IV bags. This will change the medication concentration. Therefore, when an infusion exceeds 2 hours use a glass or polyolefin bottle for the administration container.
cahscania says
Can you tell me how often you can repeat the amiodaron dose. You give 300 initially, how long before you can give the 150?
Jeff with admin. says
The first dose needs time to fully circulate. You should be able to give the 2nd dose any time after the 4th shock. The key is to ensure that you have at least 2 minutes of high quality CPR before the 2nd dose is given.
Kind regards,
Jeff
jwpackerfan says
I understand the use of cardioversion for unstable a-fib/flutter. But what about stable a-fib/flutter, what drug would you give?
Jeff with admin. says
For someone with new onset a-fib or a-flutter who does not have a rapid heart rate, they will probably be started on an oral anticoagulant such as Coumadin. This will help prevent thrombus formation. They will also get a cardiology work-up to rule out any other underlying cardiovascular problems.
For someone with new onset a-fib or a-flutter who has a rapid heart rate but is stable, they will probably be started on some type of beta-blocker or calcium channel blocker for rate control and also an anticoagulant for thrombus prevention. They too will get a cardiology work-up to rule out any other underlying cardiovascular problems.
Kind regards,
Jeff
Matt says
Keep in mind beta-blockers are not preferred in patients with asthma or COPD, unless risk outweighs benefit.
Matt says
benefit outweighs risk* Haha
Jessica says
Is it ok to debribrillate a person who has a pulse of 218 and a rhythm A. fib with RVR and then pulse drops to 144 3 minutes later? or should they be cardioverted?
Jeff with admin. says
If the patient has not been on an anticoagulant, you would want to make sure that they did not have any thrombus in their heart. This can be done by performing a TEE (transesophageal echocardiogram).
If the patient is stable, cardioversion would probably not be the first choice. Giving a medication such as a Cardizem (calcium channel blocker) to slow the heart rate would be a good option for A.fib with RVR.
If the patient is unstable and thrombus has been ruled out then cardioversion would be the best choice.
Rate control with medications is a good place to start when dealing with a.fib/RVR. Expert cardiology consultation should also be obtained as soon as possible.
Kind regards,
Jeff
wen20 says
What does RVR stand for?
Jeff with admin. says
RVR stands for rapid ventricular rate.
Kind regards,
Jeff
Matt says
Do not defibrillate A-Fib.
steve says
Do not defibrillate A fib!! VT an VF are the only shockable rhythms, if the patient is significantly compromised then cardioversion may be a option.
chris says
Please all of you check out the serious side effects of this drug……blindness and pulmonary fibrosis being just two of them. It is a toxic drug that should be used as a last resort.
Steve says
What, for single doses?
Jeff with admin. says
One single dose of amiodarone would be 300mg IV. A second dose of 150mg may be given. Kind regards, Jeff
jane with pharmacy says
Long term use has its problems. The benefits definitely outweigh the risks in this situation.
Nalapheonix12 says
I’ll take the risk. End result could be death.
Kelly says
I’m thinking I’ll just have specialists for toxicity of my organs.
helcook@att.net says
very good and useful for preparation of ACLS test
debra tanis says
Weighing in on some of the Amiodarone questions: according to Davis’s Drug Guide for Nurses (12th edition, 2011):
Direct IV: Adminstered undiluted. May also be diluted in 20-30 ml of D5W or 0.9% NaCl. Rate: IV push
Intermittent Infusion: Dillute 150 mg of amiodarone in 100 ml of D5W. Infusion stable for 2 hr in PVC bag. Rate: Infuse over 10 min. Do not administer IV push
Jeff with admin. says
Thanks for the input Debra. The only thing that I would disagree with is the part at the end about “do not administer IV push.” In a code situation when the pt. is in VT/VF (dying), you can push amiodarone.
Kind regards, Jeff
Ryan says
I believe the push is referring to intermittent infusion and not direct IV. The 2012 (13th edition) states….
Direct IV: Diluent: Administer undiluted. May also be diluted in 20-30 mL of D5W or 0.9% NaCl. Concentration: 50 mg/mL. Rate: Administer IV push.
Intermittent Infusion: Diluent: Dilute 150 mg of amiodarone in 100 mL of D5W. Infusion stable for 2 hr in PVC bag., or use pre-mixed bags. Concentration: 1.5 mg/mL. Rate: Infuse over 10 min. Do not administer IV push.
I hope this clarifies, Ryan
Jeff with admin. says
The first 300mg and the 2nd 150mg are IV push.
In other words, within the pulseless arrest algorithm, after the 3rd shock, push amiodarone in as fast as you can squeeze the plunger on the syringe. Same for the 2nd dose when it is due to be given. If we are talking about post-arrest or a state where a patient has a pulse then you will administer by infusion. Also see pg. 165 of the AHA provider manual under the amiodarone section. Kind regards, Jeff
Maria Gilmour says
Is an Amiodarone Infusion prepared in a “special” bag or glass? Thanks.
Jeff with admin. says
I have only seen amiodarone infusions prepared in glass bottles.
R Ndungi says
Glass or DEHP free bags is standard practice
DAVIDY says
HOW FAST CAN YOU PUSH AMIODARONE IN PULSELESS V FIB, DOES IT NEED DILUTED AND A FILTER
Jeff with admin. says
The 300mg and 150mg amiodarone used during ACLS treatment of VF/VT can be pushed in 1 minute or less. It needs to be diluted per manufacturer instructions and given with a filter.
Donny says
If you convert with the first 300, do you then hang the 1mg/min dose?
Jeff with admin. says
As soon as possible during the post arrest phase.
matt says
Does Amiodarone still need to be diluted in 25-30 cc’s of D5W or Normal saline ? Thanks!
Jeff with admin. says
Amiodarone should be diluted with D5W not normal saline. —Jeff
silliv says
hey Jeff,
after reading the comments I became confused. In code vt/vf give the amio straight from the package you opened from crash cart and push it as fast as you can.. you are not suppose to dilute THAT with d5w are you? it’s once you start a drip that you dilute..correct.
one more question— pt. has vt/vf so you give the 1st 300 amio iv push. now he has pulse and rhythm…do you still have to give the 150 amio (slowly). what would happen if you did not give the 150 amio. would their pulse/rhythm remain???
Jeff with admin. says
Yes you are correct in a code with PULSELESS vt/vf give the amio straight from the package you opened from crash cart and push it as fast as you can.. you are not suppose to dilute THAT with D5W ( you can dilute with 10-20ml NS to help disperse the med in the circulation quicker). it’s once you start a drip that you dilute in 250ml.
You probably are ok not giving the 2nd dose of amiodarone if the pt. regained a pulse after the first dose. A lot of physicians like to start an amiodarone drip if they achieved conversion with the amiodarone push. There is, however, no clinical research that has shown that this type of post arrest infusion of amiodarone improves or changes outcomes. If it were me, I would no longer use the amio drip, but it is ok if a physician thinks it will help prevent any further arrhythmias in the post arrest phase.
Kind regards,
Jeff
C. ONEIL says
If amiodarone is given in the feild for cardiac arrest at a dose of 300mg and pt arrived to the ER and 30-40 min pass from time of transfer to further treatment in the ER is that dose count if pt continues to have vt or v-fib or can we give another 300mg dose and start from that time line? or count the 300mg dose and give 150mg ?
Jeff with admin. says
I believe that you would stick with the algorithm, give the 150mg and then start an infusion if needed. —Jeff
eileen says
For ventricular irritability… multifocal PVCs, runs of VT, is lidocaine vs amiodarone a perscribers preference or is one better than the other? I am seeing both used… Seems to change back and forth, both have concerning side effects. Thanks!
Jeff with admin. says
In my experience, I have seen a much wider use of amiodarone for ventricular irritability. (over the past 5 years). As you state, it is not without its side effects. I think if I were a physician, I would pick amiodarone because it works amazingly well for decreasing ventricular arrhythmias and stabilizing an irritable heart.
I would not want to use it for more time than the ACLS guidelines call for due to its side effects.
Donabel Thurman says
Is Amiodarone only given for two doses for pulseless VT/VF? Initially 300 mg IV push and if no conversion, then 150 mg IV push? What happens if after the 150 mg IV push there is still no change in rhythm? Can you give one more dose of Amiodarone? Sorry for all these questions. Thanks!
Jeff with admin. says
If the two doses of amiodarone do not work the drug is finished and there are no repeat doses. It it works and converts, you will started an amiodarone infusion per protocol. In my experience, if it is going to work, it will usually convert with the first dose. However, studies have shown that the 2nd dose has a high enough conversion rate to justify it in the algorithm.—Jeff
Jeremy says
According to page 77 of the ACLS provider manual, there is no role for prophylactic antiarrythmic medications (amiodarone) once patient achieves ROSC. I do not understand then why you advocate an amiodarone infusion. Amiodarone infusion seems to only come in to play during stable wide-complex tachycardias.
Jeff with admin. says
The main reason would be that the patient converted after the use of amiodarone. It has been common practice to begin an infusion of the medication that help in the conversion of the rhythm out of VT/VF to a perfusing rhythm.
Recently I have been discussing the use of amiodarone infusions in the post arrest phase with several colleagues. Due to the vague nature of a statement in the AHA ACLS provider manual, we have not been able to fully understand the AHA position. The statement from the AHA ACLS provider manual can be found on page 77 at the bottom of the page. It states: “There is no evidence to support continued prophylactic administration of antiarrhythmic medications once the patient achieves ROSC.” There is no other information in the book about the subject so we are left to deduce what this means.
Some interpret this to mean: “if amiodarone was not used prior to ROSC then its prophylactic use as an infusion is not necessary, but it was used to achieve ROSC then it may be used as an infusion.”
Others interpret this to mean: “amiodarone infusion in the post arrest phase is not necessary at all in the post arrest phase.”
In am becoming more inclined to believe that the latter is correct.
At this time on the site, I have included it’s post-arrest use if it was used to bring about ROSC. I do not think that you will see such a detailed question during certification, but it would be nice if AHA clarified on this statement.
I will adjust the site accordingly as I gain more information.
Kind regards,
Jeff
Denise Earles says
All dead full dose 300mg. Half dead (still have a pulse), half the dose 150mg.
First drug for dead people Epi.
JenJenRN says
Great way to put it. I’ll have to pass that on to my students.
Joni Eady says
In cardiac arrest algorithm, how fast is Amiodarone given? I just took a pre-test for my ACLS class that said to give 300mg IV over 2 minutes – I specifically asked the instructor ans she said the guidelines say to giver over 2 minutes but the info above says to give IV push?? Please give me the correct answer Thanks
Jeff with admin. says
The 300 mg that is given in pulseless rhythms is given IV Push over a couple of seconds (as fast as you can push it in. The patient is dead, so it won’t hurt their ventricular activity! The 150mg dose is given for rhythms with a pulse, and therefore is given slower, over 10 minutes, which would be 15mg/min. When a patient has a pulse (ventricular activity), if you give amiodarone to fast, there is a risk of reducing cardiac output by suppressing ventricular muscular contraction.
You can look at page 165 in the AHA provider manual and it says under Amiodarone. For Cardiac Arrest the first dose is give IV push and if needed a second dose can be given IV push.
Hope this helps. Jeff