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.
Thomas says
Stable patient in VT with a pulse. It would take more time to set up a bag of D5w and get that all situated than the time it would take to get to the hospital. Are you able to just iv push the 150mg of amiodarone?
Jeff with admin. says
When amiodarone is used for stable VT with a pulse, it would be given as a bolus over 10 minutes. 15 mg/min. for the infusion rate.
Kind regards,
Jeff
Mariana says
If I cardiovert a hypotensive patient with v-tach and converts after the first cardioversion to sinus rythm and stable bp without ever giving amiodarone… should I still give amiodarone bolus/drip after convertion???
Jeff with admin. says
No, you would not need to give amiodarone.
If you have a reoccurrence of any type of tachyarrhythmia then you would start the amiodarone drip protocol.
Kind regards,
Jeff
Dr. Ayman Nairoukh says
Thanks a lot for your nice answers. My questions is as follow:
to what degree do i have to worry about the stability of vital signs before deciding wether to give amiodarone intravenously or not!!!!
In another words, shall i give him amiodarone in case that he or she has pulse with acceptable B\P readings with v\tach????
thanks
Dr. ayman nairoukh
Jeff with admin. says
Amiodarone maybe given without regard to the stability of the vital signs. Amiodarone is used in both stable and unstable patients.
You can use amiodarone in the case that a patient has a pulse with acceptable blood pressure readings with ventricular tachycardia.
Kind regards,
Jeff
Nathan Silvers says
I am looking for the efficacy of giving lidocaine after the administration amiodarone in cardiac arrest. So giving the 300mg and then the 150mg and if that dose not convert the TV or V-FIB administering Lidocaine. What is the good or bad of doing this in patentes. Thanks for the help
Jeff with admin. says
There’s no literature for this specifically. No contraindications for switching from amiodarone to lidocaine or lidocaine over to amiodarone. Most people feel comfortable just sticking with one unless it’s not working.
Kind regards,
Jeff
Nifer says
Is there a specific preference to amio vs lidocaine? Can you give both at the same time, or is there a wait period between amio and lidocaine?
Jeff with admin. says
Amiodarone is the first choice for IV antiarrhythmics within ACLS protocol. If amiodarone is not available, lidocaine can be used as an alternative. Also, lidocaine can be used if amiodarone is not effective.
Kind regards,
Jeff
Jamie R says
What is the purpose of amiodarone in pulseless Vtach?
Jeff with admin. says
The purpose of amiodarone in the treatment of pulseless VT is to terminate the pulseless VT and reestablish a perfusing rhythm.
Kind regards,
Jeff
shiny kim says
If if give amiodarone 150mg as a first dose, how can I do next?
Do I give 150mg immediately after recognize a mistake or just do nothing ?
Jeff with admin. says
Give the other 150 mg rapid IV push as soon as possible.
Kind regards,
Jeff
Erin says
Hey in pulseless situations how much d5w should be used for dilution?
Jeff with admin. says
For pulseless arrest, the amiodarone may be diluted in 10 ml of D5W and given rapid IV push. Kind regards, Jeff
ehab elmoghazy says
Can we use amiodarone in supraventricular tachycardia ? If yes, what is the dose?
Jeff with admin. says
Amiodarone can be used for SVT when other standard measures (vagal maneuvers, adenosine, etc.) fail. One study states: “We conclude that amiodarone is efficacious and relatively safe for control of SVT refractory to conventional antiarrhythmic agents irrespective of the underlying electrophysiologic mechanism.” Reference
This would be beyond the scope of ACLS and consultation should be obtained before implementation of such interventions.
Standard bolus and infusion dosing referenced here would be applicable.
Kind regards, Jeff
Ni am says
If the vt persist/recur, How many time or much can we repeat the iv amio 150mg
Jeff with admin. says
You can give up to 6 doses of 150 mg after your initial 300 mg dose.
This would allow you to still be able to start and infuse the 6 hour and 18-hour infusions and not go over the 2.2 g in 24-hour limit.
Kind regards,
Jeff
Jenny says
Why we use amiodarone instead of epinephrine?
Jeff with admin. says
I’m not sure what your question was in reference too. You would not use Amiodarone instead of epinephrine. Amiodarone is an antiarrhythmic and epinephrine is a vasopressor. That you have completely different functions within the treatment of cardiac arrest.
Kind regards,
Jeff
Peter says
In a prolonged resuscitation how much time should there be between follow up boluses? I was in nearly an hour long code and we had no reference for the timing between later doses.. the patient was 80 kg and so we gave 4 more of the 150 mg boluses at 6-9 minute intervals without success. I just need to know for future codes as I teach ACLS and PALS and this was the first time it came up. Thank you.
In His Grace and service,
Peter RN
Jeff with admin. says
Initial boluses can be given as long as the amiodarone has had sufficient time to circulate. If the CPR is high quality, 3-5 minutes would be sufficient.
Also, you must realize that the half-life of amiodarone is around 58 days in healthy individuals. This is why there is a 2.2 gram per 24-hour maximum total dose. Honestly, if you are out past 10 minutes and you still have VF or VF, that would not be typical.
Typically, by this time, you will be dealing with PEA or Asystole and amiodarone will not be indicated.
Kind regards,
Jeff
Awwad Abu Awwad says
How many second doses (150 mg) of Amiodarone we can repeat at the same time of CPR?
I know that the total 2.2 g in 24 hrs, but I can give the 2.2 of the CPR time frame if needed.
Jeff with admin. says
AHA on recommends 1 dose at 150mg during cardiac arrest.
However, the 150 mg may be repeated as necessary for the treatment of arrhythmias.
Realize that you would be nearly 10 minutes into a code before even considering a 2nd 150mg of amiodarone. It is unlikely that a patient will remain in VT or VF for 10 minutes. The patient is most likely going to degrade into asystole.
Kind regards,
Jeff
TJ Ganoe says
I’m trying to reference the AHA guidelines where it recommends the rapid IVP of 300 mg amiodarone and then repeat 150 mg amiodarone in a pulseless patient vs the slow push diluted in 17 cc of saline for a patient in VT with a pulse. Are you able to provide a link to you source?
Jeff with admin. says
You may be able to find the reference here:
This would be the best AHA online resource to find the information.
Kind regards,
Jeff
Vanessa says
When you give 300mg, do you pull up 2 vials of 150mg for a total of 6 mls? Then IV push?
Jeff with admin. says
That is correct. After the push, make sure that you follow the push with 20 ml of NS to help get the med into the central circulation.
Kind regards,
Jeff