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.
JustAnotherResident says
I just wanted to point out something that a lot of people tend to forget about ACLS. Just because ACLS is typically difficult to remember doesn’t mean that doing everything per ACLS protocol should be the ultimate goal of every provider. ACLS is a set of guidelines. Just like your gastroenterologist may ignore the guidelines and have you come in for a colonoscopy early, a doctor may not always follow ACLS guidelines. It is okay to not follow ACLS guidelines as long as you know what you are doing.
Here’s an example:
Most electrophysiologists believe that lidocaine provides better anti-arrhythmic effect than Amiodarone in patients with ischemia. If a patient developed chest pain and then went into V.fib or VT, most cardiologists would prefer that Lidocaine be used over Amiodarone.
In one of the comments, there was a question about SVT being treated with Amiodarone. If the EKG is suspicious for pre-excitation and you give adenosine, you will most likely kill the patient (presuming patient isn’t dead already). Amiodarone or Procainamide are better options.
ACLS is a two minute summary of electrophysiology which requires a 4-year MD, 3-years of Internal Medicine, 3-years of Cardiology and 2 years of Electrophysiology training. Please keep that in mind.
Chris says
Great analysis. I have been a paramedic for 26 years. I really saw better results with Bretyllium than any other med for refractory v-fib. I don’t know if it’s because we keep these patients on other meds prior to arrest now and the etiology of the arrest is different or just because we stopped using Bretyllium. I would love to see a comparison of the two drugs. Every time I ever used Bretyllium that patient walked out of the hospital at some point. I have yet to see that result with Amiodorone.
Siti says
Hi, if given amiodarone but the patient’s pulse rate is still high, what should be done?
Jeff with admin. says
There are a number of things that can be done. Much of it depends on how high the rate is, what the patient symptoms are, and what pre-existing comorbidities the patient has. The most common intervention would probably be the administration of a beta blocker or calcium channel blocker if the patient’s blood pressure is within normal limits. It would be wise to consult with a cardiologist at this point. Kind regards, Jeff
Vito says
Just wondering why only 450-600mg of amiodarone in cardiac arrest. I was always told it’s metabolically related but am looking for a more concrete answer. Thank you very much.
Jeff with admin. says
I did some searching and I cannot find a definitive answer regarding your question. Kind regards, Jeff
JustAnotherResident says
The loading dose of Amiodarone has to do with the volume of distribution and the time it takes to redistribute in the cells. Rapid IV pushes will attain adequate concentrations in the serum with a much smaller dose than 24-hour loading protocols.
Anti-arrhythmics are more complicated than typical medications because it’s not just about the serum concentration but also the concentration that builds up in the myocardium.
M says
Based on the the mechanism of action of the class 3 antiarrythmics drug, Amiodarone,
it will prolongs the action potential duration and the QT interval. An article in the JACC journal also mentioned that it will prolongs the QT interval.
But, from what I know is, prolonged QT will increase the risk of developing ventricular arrhythmias.
Can u explain more on it? Thanks. 🙂
Jeff with admin. says
Prolonged QT interval means that there is delayed repolarization of the heart following a heartbeat and an increased absolute refractory period. Delayed repolarization and the increased absolute refractory period can increase the risk for torsades de pointes and VF. During this absolute refractory period of the muscle cells, a second action potential cannot be initiated. This means another part of the heart may depolarize during repolarization, and this can propagate an arrhythmia such as VF or Torsades. Hope that makes sense. Kind regards, Jeff
UEFA1 says
Great site
A says
I saw a doctor give Amiodarone when a patient went into SVT. Is that a mistake? or can it also convert SVT? It did not convert the patient’s SVT whom he gave it to.
Jeff with admin. says
It would not normally be the medicaton or first choice. The common SVT can be treated quite effectively using adenosine and if vagal maneuvers fail, the drug of first choice would be adenosine. No sure why the physician decided to use amiodarone.
Amiodarone would not be contraindicated, but it would not be the drug of first choice according to AHA protocol.
Kind regards,
Jeff
Hayat says
You said that amiodarone not contraindicated in stable SVT can you tell me how I can get that reference according AHA.I want to know about it. Thanks
Jeff with admin. says
Amiodarone and SVT
Autumn says
If you have given 300 mg Amiodarone, how long do you wait before giving second dose of 150mg? Thanks!
Jeff with admin. says
It can be given any time after the 4th shock during CPR. The important thing is to ensure that the first dose had plenty of time to circulate. 3-5 minutes is sufficient for this.
Kind regards,
Jeff
Tammy12 says
I made a screen shot of your ACLS drug table and printed it to add my notes to it. It is curious to see the main drugs (Epi, Atropine, Amiodarone, etc) in red on your table print faintly, yet the secondary drugs (magnesium, diltiazem, digoxin, etc) print out more defined. I appreciate the red print emphasizing the important drugs, but when printed, it results in the de-emphasis of those drugs. Great teaching site!
Jeff with admin. says
Thanks for pointing this out. The text is red due to the fact that they are text links that point to other pages. I will try and come up with a solution for this. I can see your point about the printed text. This has never been pointed out to me before. Thank you for the feedback. Kind regards, Jeff
Brock says
Pediatric dose???
Jeff with admin. says
At this time, this website is only for Adult ACLS. However, to answer your question. Amiodarone 5 mg/kg IV/IO; may repeat twice up to 15 mg/kg Maximum single dose 300 mg.
Lourdesrn says
I have given the 150 mg iv/10 min for VT with pulse, and it works beautifully, usually followed with drip. For VT without pulse your write: 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). If pt does not convert, what dosage can be given next and how many times. thank you for this amazing website.
Jeff with admin. says
The 150mg can be repeated a 2nd time during the code. The maximum 24 hour cumulative dose is 2.2 grams.
It is unlikely that the patient will convert with extra amio. if they do not convert after giving 300mg then 150mg then 150mg, I have never seen anything beyond the 2nd dose of 150 mg of amiodarone given.
Kind regards,
Jeff
ealinet@gmail.com says
just for clarification? Amiodarone can be diluted with NS for initial emergency bolus, but if used in an IV drip must be used with D5W.
dan edgar says
I learned a lot just reading this thread. Thank you for providing us with this education and the benefit of your knowledge
Jeff with admin. says
Glad to help! Kind regards, Jeff
sat says
in post resuscitation care, after treating VF with DC shock , can we give amiodarone as a prophylaxis?
Jeff with admin. says
You can, but it is no longer recommended by the AHA to give amiodarone for the prophylactic treatment of arrhythmias. AHA recommends its use if arrhythmias persist in the post resuscitation period.
Kind regards,
Jeff
Gabe says
Hello,
Current Paramedic student. I am doing a presentation on Amiodarone.
You stated that it is no longer recommended by the AHA to administer Amiodarone for preventative treatments .
” (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)”
Wouldn’t this be considered prophylactic treatment ?
Much appreciated for the clarification , great page!
Jeff with admin. says
The above-recommended infusions are referring to the use of amiodarone for conversion of tachyarrhythmias within the tachycardia algorithm or for tachyarrhythmias that reoccur in the post-cardiac arrest period. This would not be considered prophylactic use since you are directly treating an existing tachyarrhythmia.
Kind regards,
Jeff
N Mac says
When given during an active resus (1 x 300 MG and 1 x 150 MG, I.O. Route) with a non shockable rhythm is this detrimental to the overall outcome of the casualty….less than 20 minutes submersion with 45 mins basic low quality Intermittent CPR?
Many thanks
Jeff with admin. says
You would not use amiodarone in the case of a non-shockable rhythm during a resuscitation. Amiodarone is an antiarrhythmic and within ACLS protocol it would be used in the treatment of rhythms that would be considered shockable. VT, Pulseless VT, and VF.
Kind regards,
Jeff
Lisa says
Patient came from ED to ICU on an Amiodarone gtt. Had been shocked once successfully in ED. Continued persistent runs of vfib vs vtach. Began to experience bradycardia low 40’s (not just pauses). Should amio have been immediately turned off?
Jeff with admin. says
Not necessarily. It really depends on the cause of the bradycardia. In this situation, amiodarone may be a relative contraindication and a cardiologist should be the one to make the call to turn off the amiodarone. Amiodarone may have been absolutely necessary to prevent any further VF or VT. This would be a hard call, and there would be no definite right answer.
Kind regards,
Jeff