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.
Mohammed Abbasi says
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.
Pangeran says
i would like to ask why amiodarone cannot be diluted with NS?is it will be precipitated.
ANd i’d like to ask i got some patient VT pulseless then i did some DC shock then the patient become VF,i did some DC shock again,according to ACLS the 2nd DC shock i should give him epinephrine right?but how if the ecg changes like this?should i start DC without epi or should i continue the algorithm DC with epi?
Then short story,the patient become accelerated idioventricular rhythm with pulse,what should i do?thanks
Jeff with admin. says
Kind regards,
Jeff
AM says
Hi – if a patient is in VTACH, and no shock is administered, should they be given amiodarone. A fellow cardiologist said that if amiodarone when a person is in VTACH and without a shock, it can put someone in a cardio depressive state?
Jeff with admin. says
If a patient has stable VT and no shock is administered, amiodarone would be considered a medication of choice for the treatment of this arrhythmia. The statement about a “cardio depressive state” would be anecdotal information according to an individual experience. This is not my experience with amiodarone. I have seen amiodarone used successfully a number of times for stable VT and I have not seen any “cardio depressive state.”
Kind regards,
Jeff
hamid says
2 question in unstable very tach is amiodarone indicated after succesful single dc shock
Jeff with admin. says
Post stabilization management may include antiarrhythmics like amiodarone. There are not specific guidelines for antiarrhythmic use provided by the American Heart Association for post-conversion of VT. Amiodarone would definitely be indicated if arrhythmias persist in the post conversion period. In my experience it is quite common for physicians to begin an amiodarone infusion after the initial bolus.
Kind regards,
Jeff
James says
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?
James says
Also for the 300mg and 150mg IV push how should it be diluted?
Jeff with admin. says
Each dose of amiodarone would be diluted with 20 mL of D5W and given rapid IV push.
Kind regards,
Jeff
Jeff with admin. says
That is correct. Kind regards, Jeff
Liz says
Thank you Jeff for the comments and asnwers you have given above, I have learnt a lot.
I had a question if you are kind to help.
#1 if during cpr there is rosc/ pulse return, but on the monitor you notice a rhythm of rapid afib, can you give amiodarone push at that time or there is no indication for amiodarone push during cpr in a patient with a pulse?
Thanks a lot
Liz
Jeff with admin. says
You would not use the IV push that is used during the arrest. You would use the post-arrest amiodarone infusion protocol. 150 mg IV bolus over 10 minutes. Then 360 mg over 6 hours. Then 540 mg over 18 hours.
Kind regards,
Jeff
JANINE D says
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
Jeff with admin. says
You would dilute with 20ml of D5W and give it as an IV push. Push the medication as quickly as you can press the plunder down. Make sure to follow with 20ml of NS.
Kind regards,
Jeff
Tena Flanary says
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
Joseph says
How long do you have to wait until giving the second dose of Amiodarone? Thanks!
Jeff with admin. says
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
Paula says
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?
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
Lori says
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?
Jeff with admin. says
Yes it is important. For persistent pulseless VF, the amiodarone infusion should be started immediately after the bolus is given.
Kind regards,
Jeff
Lori says
Thank you Jeff. I appreciate your help!
Ramon says
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?
Jeff with admin. says
Kind regards,
Jeff
hamid says
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
Jeff with admin. says
You are very welcome. Kind regards, Jeff
Michael says
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.
Jeff with admin. says
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
Holly says
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
Jeff with admin. says
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
Kevin says
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???
Jeff with admin. says
Reply:
Antiarrhythmics are only used in the post arrest phase if there is a reoccurrence of an arrhythmia that would require their use.
Kind regards,
Jeff