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.
Miguel Delgado says
My Question I guess is a simple one….
If Pt. happen to received an Amio drip ( 150mg / 10 to 15 m. ) and pt received the full dose. Now pt. evolved to cardiac arrest , 300 mg. is given and then 150 mg second dose while arrest is been worked. Due to change in Pt. Does we give the full 450 mg. while the arrest take place, or do we count the 150 that was drip.
ACLS says
In the emergency you can give the amiodarone per the cardiac arrest algorithm. Important to consider that the maximum dose in the 24 hour period is 2.2 g.
You can give the 300 mg dose and then the 150 mg dose while the arrest is taking place.
Kind regards,
Jeff
Dave says
Thank you for all the information above. How do you recommend delivering the Amio over 10 minutes? The math on the drip rate is “high” to say the least, so would it just be wide open?
Thank you
ACLS says
150 mg of amiodarone may be diluted in
150 mg over the FIRST 10 minutes (15 mg/min).
Add 3 mL of Cordarone I.V. (150 mg) to 100 mL D5W (concentration = 1.5 mg/mL). Infuse 100 mL over 10 minutes
Kind regards,
Jeff
Kylie Wagstaff says
I am a practice nurse at an Aboriginal Health Service in Australia and I have spent hours today searching for some evidence about how to give Amiodarone in an arrest situation. I know the dose, I know when, I just didn’t know whether it had to be diluted. I know that it can only go int 5%Dext so I thought it had to be diluted. Worked out that I can give it as a push and one of the comments here answered the next question about given it with a n/saline IV running and can I use a n/saline flush!! All answered!! Just wanted to add some information to our emerg trolley because we dont really have any ALS specialists and I am sure not one. So just want to say a big thankyou!!
ACLS says
You’re welcome! Kind regards, Jeff
jeffrey kasbohm says
those were the most jam-packed exciting run on sentences I’ve ever read! 🙂 Pulled right out of an ER script. (I practiced in a Los Angeles Level One ER for 10 years where they filmed more than one episode of the TV show “ER” 🙂 — But I agree fully (but I’m not a cardiologist) with both Marilyn’s logic and Jeff’s answer. Looking at it physiologically I gotta ask though if a heart can only produce fine V-fib, bathing it in a “numbing” medicine like amiodarone seems like with the little bit of nerve transmission that’s taking place (as in fine v-fib) you’re going to flatten out even that activity. So being hypoxic and now with fully spent sodium channels – even more spent and blocked with amiodarone – its a losing battle. That’s my guess. But as Jeff and the ACLS committee said if its all you got and you’re losing the pt, it’s time to improvise. Who know, it could work.
Jun says
Why did you call amiodarone a “numbing” medicine– how does it flatten out the nerve transmission activity like you said? (Just trying to figure out how it works) Thanks!
Marilyn says
Hi Jeff!
Im sure you’ve seen all the studies out there that showed patients that went into sudden witnessed cardiac arrest with the presenting rhythm being asystole, where they immediately applied ultrasound and in many cases what showed as asystole on the monitors, actually was proven by ultrasound to be fine or very fine VF for a short period of time before turning into asystole since asystole has such a near zero survival rate. So my question is, since the AHA is still strongly against defibrillating asystole due to the risk of myocardial damage and not worth losing the time from having to stop ; is it or is it not reasonable, in a sudden witnessed cardiac arrest with a presenting rhythm on the monitor, to immediately begin the asystole algorithm, and after a couple cycles of immediate aggressive CPR and epi administration, to then give every possible attempt to save the patient by (after zero response to a couple cycles of aggressive CPR and epi every 3-4 mins) to try the ACLS dose of the only ACLS approved antiarrythmic, amiodarone, since we did not have an ultrasound at our disposal, just in case this witnessed, asystolic presenting (verified on other leads and gain up) arrest was, as these peer reviewed studies are showing, another case of fine or very fine vf unable to be picked up by the sensitivity of the trans thoracic monitor- in the hopes of it (worst case scenario) at least unmasking the fine vf so we can justifiably switch to the pulseless VF algorithm including shocking, or best case scenario, do what its purpose in the VF algorithm is and either unmask a return of SR (or at least unmask the very potential fine VF as ANY rhythm that would then allow us to switch to that appropriate algorithm. Our logic was (1) as explained above and (2) since it is well known and documented that preceding amiodarone with full doses of epi (and rounds of CPR) cancel out that amiodarone would exert cardiac depressive effects, is that not a reasonable, safe, and appropriate action to give every possible attempt at saving that patients life- again after atropine was given initially as well as a couple immediate doses of epilepsy every 3-4 mins and nonstop aggressive CPR- and knowing that the period of very fine vf masked as asystole on the monitor is short lived before degrading to true asystole; and all studies show the near zero rates of survival from an asystole presenting sudden witnessed arrest? Our logic being the limits of the asystole algorithm (aggressive CPR and epi) had no effect and knowing the current studies of patients presenting, especially witnessed, with asystole yet were proven by ultrasound to be in fine vf masked as asystole on our transthoracic external monitors, that as even the AHA says about its own algorithms, they are only guidelines and providers are not just allowed but encouraged to amended an algorithm to specific situations that have possibility of helping to save the patient. And therefore, with a nonresponse to an initial dose of atropine, and epi given every 3-4 mins without ever interrupting aggressive CPR, then it was a safe and appropriate attempt to address the proven possibility of fine vf masked as asystole with the ACLS dose of amiodarone to give every possibility of life by seeing ANY conversion to, or at least unmasking of, ANY rhythm besides asystole, knowing the preceding multiple doses of epi would not “risk any amiodarone depression of the asystolic or possibly fine vf heart”, and thereby making it a safe and appropriate intervention to give every possible shot at saving an witnessed, asystolic (on monitor) sudden cardiac arrest? Especially seeing them not respond to just episode and aggressive CPR, and further knowing the well established chances of asystolic cardiac arrest has a near zero survival rate just following the asystole algorithm strictly, without trying to address the possibility of a short initial period of fine vf unable to be picked up by limited sensitivity of our trans thoracic defib and anesthesia machine monitors?
ACLS says
Hi Marilyn,
Thank you for the comment. I appreciate thoughtful comments like yours. You are absolutely justified in making every attempt to save the patient and the American heart Association as you say encourages providers to deviate from algorithm if the situation warrants deviation. Your scenario would be a candidate for deviation from the specific ACLS algorithm. You can’t make a dead heart more dead with amiodarone or even a defibrillation. I say go for it.
Kind regards,
Jeff
Ramin says
Great article!
Question 1): Why is atropine not recommended during CPR?
Question 2): Why wait for third shock before administrating Amiodarone? My gut feeling tells me it should be more reasonable to give Amiodarone directly after first failed shock.
With kind regards,
Ramin
kathleen Hayes says
Can you give amiodarone iv push if your running IV with normal saline?
ACLS says
Yes amiodarone can be given IV push through a running IV. Just ensure that the amiodarone is given at the closest injection port to the patient in order to reduce the amount of dwelltime of the medication in the IV tubing.
These medications are being pushed as fast as you can push the plunger. They are also being followed with high flow normal saline or 20 mL of normal saline. Thus, the risk of medication precipitation is extremely low.
Kind regards,
Jeff
Ty says
Why is Amiodarone not given for PEA? Are there negative outcomes for giving Amiodarone in PEA? Is it contraindicated, or does it just not work in PEA so there is no point in giving it? Cant find any research that answers this question.
ACLS says
Amiodarone is used for its anti-arrhythmic properties. It helps to stabilize irritability in the heart and reduce risk of ventricular fibrillation and ventricular tachycardia. It’s mechanism of action is not fully understood.
Amiodarone would have no effect for the treatment of asystole or pulseless electrical activity and so there is no use giving it.
Kind regards,
Jeff
Dee says
What is the time frame between the first and second doses of amiodarone?
ACLS says
The first dose of amiodarone is given after the third shock during CPR. The second dose of amiodarone is given during CPR anytime after the fourth shock. There’s no timeframe except to make sure that the first dose had enough time for permeation into the central circulation. Kind regards, Jeff
Jeremy says
Amiodarone is a very complex drug, with serious long term effects on the body. And it stays in your system for much longer than most would guess. Why would one not choose lidocaine as their first choice anti-arrythmic every time?
ACLS says
Both lidocaine and amiodarone are considered acceptable antiarrhythmic medications that can be given. AHA has stated that these two medications are equivalent as antiarrhythmics in cardiac arrest. Kind regards, Jeff
Kevin Chikrista says
There is only the first and second dose for Amiodarone in Cardiac Arrest Guideline. Why is that so? Harmful to give the third dose?
ACLS says
It’s not that a third dose would be harmful. These protocols have been developed with regard to research that has been performed and the protocols that showed improved survival to hospital discharge or improved ROSC are implemented. No added benefit was shown for further bolus doses. That would not exclude a third bolus and this would be up to the discretion of the provider. The only thing that they would have to be careful about is not to exceed the 2.2 g per day max cumulative dose.
Kind regards,
Jeff
Sandy Dunlap says
Amiodarone infusion 150 mg in 10 min is diluted in ? ml of D5W.
Sandy
Thanks
ACLS says
Yes, that is correct. D5W is the only diluent that can be used with amiodarone. Kind regards, Jeff
Denise Haun says
Amiodarone can be safely mixed in normal saline
ACLS says
Can you provide me with the literature that supports this? Everything that I have stated that amiodarone is to be mixed with D5W.
Kind regards,
Jeff
Violet says
Other than D5W, can sterile water for injection/distilled water be used for dilution for IV bolus of amiodarone? Or only D5W can be used for dilution even for IV bolus (to be given for 10 mins) ? Thank you
ACLS says
D5W is the only fluid that should be used to reconstitute and dilute amiodarone. This is because other fluids may cause precipitation of solid particles within the liquid.
Kind regards,
Jeff
Alhaj says
In pulseless VT if the second dose given as the Firs dose what will happened 300/300
ACLS says
I do not understand your question can you please restate the question more clearly.
Kind regards,
Jeff
Olivia Hodgins says
I think the person above meant that 300 mg of Amiodarone was given for the 1st and 2nd dose.
However, my question is do they still use IV bottles for the amiodarone drip considering the fact that the amiodarone is absorbed into the plastic and is a fairly consistent dose after that. O
ACLS says
They now have types of plastic that prevent the amiodarone from being absorbed and this has led to new packaging for amiodarone and there are now companies that produce amiodarone that comes in individual liquid filled plastic IV bags.
Kind regards,
Jeff
Tara says
Hi,
In a code can you give amiodarone 300mg , not diluted as an IV push followed by a flush of NACL?
ACLS says
Yes, it can be given undiluted and followed with a 20 ml NS flush.
Kind regards,
Jeff
Hand says
If a patient is in vfib, is amiodarone or epinephrine better? Are there different indications for which should be used?
ACLS says
Epinephrine and amiodarone are both used in the left branch of the cardiac arrest algorithm for the treatment of vfib and pulse less VT. Indications for use is cardiac arrest and both are required for in hospital cardiac arrest. The first dose of epinephrine should be given after the 2nd shock and the first dose of amiodarone should be given after the 3rd shock.
Kind regards,
Jeff
Kale says
The onset of amiodarone is about 2 hours. Why do we give it if it takes so long to work?
ACLS says
Amiodarone has rapid onset of action within minutes following a rapid IV bolus.
Kind regards,
Jeff