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.
Becky Rhine says
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.
Jeff with admin. says
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
margaret says
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?
Jeff with admin. says
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
mona says
How we are calculating the amidorone for example let’s say 0.5mg/min how many ml/hr will be
Jeff with admin. says
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
Alex says
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?
Jeff with admin. says
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
Josh says
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?
Jeff with admin. says
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
clavid says
Why doe we need an in line filter with AMIODORONE
Jeff with admin. says
The inline filter is needed for amiodarone since the amiodarone can precipitate out into a solid form. The filter catches any precipitate.
Kind regards,
Jeff
Yvette Cronje says
Quick question:
DO we push AMIODARIONE undiluted iv and flush with Saline or D5W?
Jeff with admin. says
Amiodarone when given during cardiac arrest can be given undiluted and then followed with 20 ML NS flush.
Kind regards,
Jeff
Sal says
After my first 300mg push in VF or pulseless VT when do I push the second dose of 150mg?
Jeff with admin. says
You would push the 2nd dose of amiodarone after the 4th shock during CPR.
Kind regards, Jeff
John says
would you give amiodaone post arrest following DCCS x3 with patient in Idioventricular.
Jeff with admin. says
I am assuming that DCCS means “direct current counter shock.” I could not find any other meaning of this acronym.
Amiodarone is used in the post-arrest phase only if there are continued tachyarrhythmias. AHA 2010 ACLS revisions removed the prophylactic use of amiodarone since the research showed no changes in outcomes unless there were continued tachyarrhythmias in the post arrest phase.
Kind regards,
Jeff
tony g says
Hey Jeff,
Just to clarify, it’s alright to push epi AND amiodarone in the same round of CPR? I’ve been on codes where epi is due right after a shock has been delivered, and it’s confused crews. Amio gets put off until the next rhythm check, which is inevitably PEA or asystole, and then the amiodarone doesn’t get used at all. Also, if we get IV access early, why do we need to wait until after the “third shock” to start using amiodarone? Thank you very much
Jeff with admin. says
It is ok to push epinephrine and amiodarone in the same round of CPR.
The main reason why the amiodarone is not given until after the 3rd shock, is because AHA wants to emphasize high quality CPR over medications. There is no medication that has been shown to improve survival to hospital discharge. Because of this, medications are considered secondary.
Remember, however, that the AHA guidelines are just guidelines. If you have IV access and your team determines that amiodarone administration may be helpful for the situation, you can and should give it.
Kind regards,
Jeff
Bernd Ennig says
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?
Jeff with admin. says
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
nick says
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
Jeff with admin. says
The Maximum 24 hour cumulative dose for amiodarone in any situation is 2.2 grams.
Yes, amiodarone should be administered using a glass IV container.
Kind regards,
Jeff
jks says
since MgSO4 is for polymorphic vtach, i’d like to ask how it is given?
Jeff with admin. says
MgSO4 is given direct IV push. In cardiac arrest is given rapid IV push.
Kind regards,
Jeff
Thomas J Egan Jr says
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…
Jeff with admin. says
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
Chuck says
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.
Jeff with admin. says
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
fortuna says
What is a pulseless polymorphic VT?
Thanks
Jeff with admin. says
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