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.
DawnS says
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?
Jeff with admin. says
This is correct.
Kind regards,
Jeff
Victor Vinluan says
Why should we dilute amiodarone in D5W only? Thanks.
Jeff with admin. says
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
Lisa says
Do you need to dilute aminodarone when given as ivp? Thanks
Jeff with admin. says
When giving amiodarone IV push during cardiac arrest, it can be given undiluted.
Kind regards,
Jeff
lovincent says
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?
Jeff with admin. says
Yes, it is recommended. It is part of the pulseless arrest algorithm. Any pulseless ventricular tachycardia would be treated the same way whether polymorphic or monomorphic.
Kind regards,
Jeff
carlos says
um no. polymorphic v-tach is treated with mag sulfate.
Jeff with admin. says
Correct Carlos. Thank you for the correction.
Kind regards,
Jeff
Jarred says
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
Jeff with admin. says
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
Heather says
For Cardiac arrest: After your initial 300mg, you follow with 150mg. How many additional doses can you administer?
Jeff with admin. says
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
Arvin Minocha says
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?
Jeff with admin. says
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
Alexander says
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
Jeff with admin. says
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
E. Staeheli says
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… : )…..
Jeff with admin. says
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
Holly says
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!
Jeff with admin. says
During cardiac arrest the medication should be given rapid IV push. It can be pushed as rapidly as you can depress the plunger on the syringe.
Kind regards,
Jeff
mudasir hassan says
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
Jeff with admin. says
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
Jeanne says
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.
Jeff with admin. says
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
mo says
And if no ectpoy? Would a maintenance of 150 into 100cc still apply?
Thank you
Jeff with admin. says
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
KJ says
How many times I can repeat amiodarone (150 mg over 10 minutes) in stable VT? What if we gave three doses and the rythm still VT. can we give another 4th and 5th dose or just use infusion?
Jeff with admin. says
The max dose of amiodarone in a 24 hour period is 2.2 grams.
I have never seen more than two 150mg boluses given in a code. The rhythm usually converts or changes to some other rhythm (PEA or Asystole)before this. By the time you would give a 3rd dose, you would be at least 20 minutes into a code. VT will not sustain this long. The rhythm with usually degrade into VF or asystole.
Kind regards,
Jeff
Will says
Just took the American Heart ACLS recert pre-test. Last Question asked: After cardiac arrest, one shock, and subsequent rhythm of persistent A-Flutter, an alert person with stable vitals preparing for transport should get? (two possible correct answers here) 1. Amioderone, or 2. Professional consultation. Thanks to your advise I chose the correct answer of professional consultation.
Jeff with admin. says
Yes, you are correct. If a patient is stable in the post arrest phase and a-flutter was persistent, the proper intervention would be to get professional consultation.
Kind regards,
Jeff
Jpsfirstresponse says
It says here on the blog question that a amiodarone infusion after the 300 and 150 bolus in pulseless vf/vt?
I see a infusion of 1mg/min for maintenance of a converted stable vt with a pulse but see nothing in the acls book of infusions post pulseless vf/vt conversion. does acls have post conversion?
I know in the back of the book it has rapid infusion , slow infusion maintenance infusion but are those for post conversion of stable vt with pulse or/and post conversion of pulseless vf/vt?
Jeff with admin. says
The main reason for the use of amiodarone post-arrest 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
Brenna says
In a case where you have pulseless vt/vf and both doses of amiodarone are given with no conversion do you then move on to lidocaine or is lidocaine only used if amiodarone is unavailable?
I found this confusing in the course and was unable to obtain an answer.
Thanks,
Brenna
Jeff with admin. says
You can move to lidocaine if amiodarone failed to convert the rhythm. I have seen this done several times in the past couple of years. Lidocaine is still considered an alternative if amio is not available and can be considered if amiodarone is not helpful with conversion.
Kind regards,
Jeff