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.
Jenny says
Hi.
How do we mix up amiodarone if we were to give it 300mg IVP?
Jeff with admin. says
Is you are using amiodarone in the treatment of cardiac arrest and providing the 300 mg IV push, you will mix the amiodarone with 10 ml NS or D5W and push The medication as rapidly as possible. Follow this with 20 mL of NS.
Kind regards,
Jeff
Elisa verdida says
Good day jeff! Just a clarification, what if on the 1st scenario of pvt and vf epinephrine is not available in the first place, are we allowed to give amiodarone immediately to replace epinephrine? Thank you
Jeff with admin. says
It would be unlikely that epinephrine would not be available, but if it was not available, you could still follow the algorithm give amiodarone per the algorithm guidelines.
Kind regards,
Jeff
Felipe says
Hello, great site and responses!
I have a question, when going to PEA/Asystole, you should think about the 5 H’s and 5 T’s, so, you would go for Calcium, Bica, Magnesium or Potassium? lets assume you cant figure out whats the cause, which one you would go first? And, lets say you are in a Asystole, and did 4 cicles of compressions and 3 epinephrines, and now you go for in the 5th cicle, in the 6th cicle you go for epinephrine or already chose Bica or Magnesium?
thanks!
Jeff with admin. says
If you have completed 4 cycles of compression and given epi 3 times and you are starting the 5th cycle of CPR you can give epi and another medication back to back. Flush rapidly with 20 ml of NS between each one.
If you are not sure what the cause of the PEA and there is no clear indication of low Calcium, bicarb, magnesium, or potassium then you would not give these medications. You would only give these medications if there is some indication that one may be involved.
Evaluate underlying comorbidities that may be contributing to the PEA. Evaluate underlying circumstances and if you can do a review of the recent med. History to see if you can identify a possible cause.
It would not be wise to just start randomly give medications without any justification for doing so.
Here is another way to evaluate PEA and find a cause. You might find this helpful. New Diagnostic Tool for PEA
Kind regards,
Jeff
Sangeetha says
Hi
Can you clarify with regards to VFib in patients with known long QT syndrome? As per my understanding both epinephrine and amiodarone are contraindicated. So will treatment only involve CPR and defibrillation? Also is IV Mg useful?
Jeff with admin. says
Treatment of known qt syndrome with active v tach or v fib is treated with magnesium to shorten qt, defibrillation, and if in cardiac arrest, CPR. Here’s a good reference:
Long QT Syndrome
Kind regards, Jeff
LIAQAT ALI says
Hi
Can we use Amiodarone for SVT/ PSVT?
Jeff with admin. says
Amiodarone would not be the medication of first choice for the treatment of The most common forms of SVT/PSVT. Adenosine would be the medication of first choice.
Amiodarone is used for the stabilization of refractory SVT. In other words, when SVT becomes a common reoccurrence for someone, amiodarone is often used with good results to prevent the reoccurrence of the SVT.
Kind regards,
Jeff
Subidas says
Can we administer undiluted amiodarone 300mg into intravenously during cpr found ventricular fibrillation or pulseless ventricular tachycardia
Jeff with admin. says
During cardiac arrest, the amiodarone can be drawn up and pushed without being diluted. Make sure that the amiodarone rapid IV push is followed by 20 mL of normal saline.
Kind regards,
Jeff
silas says
hi jeff
When the rhythm is PEA you immediately perfom high quality CPR for 2mins then give epinephrine, then resume high quality CPR for another 2 mins. Then after the second cycle of CPR wat do you give because epinephrine is given 3-5mins and i have given a dose 2 mins ago…so should i repeat another dose before 3mins?
Iam confused. Mayb my question is not clear.
Jeff with admin. says
After the second cycle of CPR is completed then you would perform a rhythm check and pulse check. If patient remains in PEA then you would begin a third cycle of CPR then when the three-minute mark has been reached the epinephrine can be repeated.
Remember, once the first dose of epinephrine is given epinephrine is basically on its own timetable and should be given every 3 to 5 minutes. This is one important reason why a recorder will typically call out when the three-minute mark between doses has been reached.
Kind regards,
Jeff
GAIL SAVOIE says
Since Lidocaine has been removed from the pulseless arrest and is to be used only in the event that Amiodarone is not available or may be ineffective. Is Amiodarone a drug that can be put down the ET tube? I know that Lido can be increased to 2.5 times the dose and put down the tube. I have not seen anything on whether Amiodarone can be put down the ET tube or not. Do you have a link that lists the medications being put down the ET Tube? I just see you have listed under certain medications whether they can go down the tube and their dosage but that is all. I just wanted to make sure I have the complete list. NAVEL is the mnemonics I previously used to memorize this list.
Thank You!
Jeff with admin. says
The pneumonic NAVAL covers all of the medications that can be given via endotracheal tube.
Amiodaron cannot be given via endotracheal tube.
Kind regards,
Jeff
Santiago says
According to Aha, amigo is given in for refractory VF/VT. Refractory is defined as stubborn, unmangeable…aka returning. So in the aspect of cardiac arrest, why isn’t amiodorone not given after the 2nd shock encountered and is given after the 3rd?
Jeff with admin. says
The American Heart position is to deemphasize The importance of medications in an effort to ensure that rapid defibrillation and high-quality CPR is provided.
In order to do this, they have placed Amiodarone to be given after the third shock. The only interventions that have ever been shown to improve survival to hospital discharge are high-quality CPR and defibrillation. Medications have not shown any effectiveness for improving survival to hospital discharge therefore they should not be emphasized.
Kind regards,
Jeff
Chloe says
Hi Jeff. I would like to clarify on the dosing: “300mg IV/IO push → (if no conversion) 150 mg IV/IO push → (after conversion) infusion….”
If there’s still no conversion after 150mg IV push (already given 300mg IV push initially), can we repeat another 150mg ? What’s the interval in between each IV push? Maximum how many times this 150mg IV push can be repeated?
Thank you.
Jeff with admin. says
The limitation of amiodarone is determined by the 24-hour maximum dose limit which is 2.2 grams.
Considering that the half-life of amiodarone is 58 days, after the 300 mg, 150 mg, and a 2nd 150 mg the options would be to continue giving 150 mg 2-3 more times or begin the post-arrest infusion dosing while continuing with treating the cardiac arrest. Due to the short time that cardiac arrest typically lasts, I have never seen more than the second dose of amiodarone given. Patients just don’t stay in pulseless VT or VF long enough to get more doses than that in. The rhythms typically will degrade to PEA or asystole before more could be given.
There should be 3-5 minutes between the doses of amiodarone. Ensure high-quality CPR to circulate the medications adequately before giving more.
Kind regards,
Jeff
Ryan Jamison says
If epinephrine has been given twice in the PEA/Asystole algorithm and at the next rhythm check patient is in VF, you shock, continue CPR, can amiodarone be given as the next med, or should another epi be given as the first med of the VF/pVT algorithm prior to a dose of amiodarone?
Jeff with admin. says
If the rhythm changes to VF or pVT, AHA protocol would have you start at the top of the algorithm and give amiodarone after the 3rd shock.
Epinephrine would basically be on the every 3-5 minute timetable that started when the patient was in PEA or Asystole.
Ultimately, this would be up to the provider’s discretion since the AHA guidelines do not specifically cover how to address such rhythm change sequences.
You would be ok with either of your suggestions. The most important thing is high-quality CPR and appropriate defibrillation when indicated.
Kind regards,
Jeff
Ashley says
Hello!
When pushing amio 300mg during a code, do you need to dilute it with anything or just draw up 300mg and push it right into the IV and then flush.
Thanks
Jeff with admin. says
Draw it up and push it. Make sure to follow the push with 20 ml of NS rapid IV push. Kind regards, Jeff
Paulo Kraemer says
Hi Jeff.
Then, from your statement above on the previous answer, which I agree in one hundred percent, I can conclude that maybe you agree that the Adult CPR Algorithm is somewhat wrong, because it should lead to step number 3 (first shock) everytime an asystole/PEA rhythm turned to VF. This way, with the flowchart restarting from the top, on 3, amiodarone would be administered after the third shock, according to the present sequence on left column of the algorithm.
Unless I am misunderstanding the algorithm…
I would appreciate your final considerations on this.
Thanks!
Jeff with admin. says
I think it would be wise of the American Heart Association to clarify on what happens when there is a rhythm change and a different algorithm must be started.
Kind regards,
Jeff
Celine says
In a red box it says
“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.”
I’m a bit confused.
Is this statement only for polmorphic VT with a pulse in the tachycardia algorithm?
If no pulse VT (no distinction between mono or polymorphic) has not responded to shock and epinephrine, the cardiac arrest algorithm says amiodarone after 3rd shock.
Would magnesium be a better choice if VT is polymorphic or do we follow the algorithm to the letter and give amiodarone?
GREAT web site by the way. ACLS tomorrow. Obviously anxious, but confident after reading this.
Thank you soooooo very much!
Jeff with admin. says
Yes, in the situation with polymorphic ventricular tachycardia magnesium would be a better choice. The algorithm does include the use of magnesium when polymorphic VT is present. Amiodarone maybe attempted if other measures fail, but awareness of the risk for the long QT issue is important.
Thanks so much for your encouraging words. I’m so glad that the site has been helpful for you.
Kind regards,
Jeff
Paulo Kraemer says
Hi Jeff,
I have a question concerning the use of amiodarone according to the adult cardiac arrest algorithm, where the steps are didactically designated by numbers. The fist rhythm analysis shows a PEA, non shockable rhythm. After 2 minutes of CPR, the rhythm persists being PEA. CPR for 2 minutes more, until the third rhythm analysis is performed and reveals Ventricular Fibrilation. At this point, the algorithm leads to 7, where a shock (the first one in this case) must be administered, followed by CPR again and then the administration of the first 300 mg amiodarone dose. But, shouldn’t the first dose of amiodarone be administered only after the third shock? Thank you.
Jeff with admin. says
Yes, the first dose of amiodarone (300mg) should be administered after the third shock during CPR.
However, since previous doses of epinephrine have already been given, a team may determine that amiodarone can be given after the second shock during CPR.
Technically speaking, it is correct to give the first dose of amiodarone after the third shock, but team discretion would leave room for changing the administration time to after the second shock.
Kind regards,
Jeff
Paulo Kraemer says
Jeff,
To me, the right side of the algorithm is still confusing at the end… Note, should I go to number 7 in the algorithm, I will be administering the first dose of amiodarone after the FIRST shock…
Could you please try to clarify this point?
Thanks a lot.
Jeff with admin. says
The easiest and most correct thing to do is when the rhythm changes and you have to change algorithms, start at the top of the algorithm. This is the absolute correct way to do it.
Kind regards,
Jeff