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In this lesson, we'll go over the medication amiodarone and all of its effects, including indications, precautions and contraindications, and adult dosages. And at the end of the lesson, we give you a Word on rhythm checks after defibrillation.
Amiodarone is an effective treatment for a wide variety of atrial and ventricular tachyarrhythmias in pediatric patients. It can prolong AV conduction and ultimately slow the heart rate by elongating the AV refractory period, QRS, and the Q to T intervals.
Because amiodarone is an alpha and beta-blocker (while also blocking sodium, potassium, and calcium channels), it is a well-known drug for its multi-channel blocking capabilities.
Amiodarone Indications
Some indications for the drug amiodarone, as an antiarrhythmic drug, is that it will be used specifically for its broad range of electrophysiological effects.
Pro Tip #1: Amiodarone is primarily chosen for ACLS as a first-line antiarrhythmic agent for cardiac arrest because it has shown to be clinically effective and reliable for improving the rate of return of spontaneous circulation (also known as ROSC) and improved ROSC to hospital admission in adults with refractory VFib or pulseless V-tach.
Amiodarone may also be considered when VFib and V-tach are unresponsive to:
- CPR
- Defibrillation
- Epinephrine
Amiodarone Precautions and Contraindications
Now let's look at some amiodarone precautions and contraindications.
Warning: With amiodarone, there are multiple complex drug interactions, so care must be taken when using this medication. And do not administer amiodarone with other drugs that prolong the QT interval, such as procainamide.
A rapid infusion of amiodarone could lead to hypotension. However, during cardiac arrest, there isn't any blood pressure and therefore the American Heart Association recommendation is still to use an amiodarone rapid IV push for the treatment of antiarrhythmias.
It's important to remember that when using multiple doses of amiodarone, which can be cumulative doses of greater than 2.2 grams over a 24-hour period, significant hypotension has been noted in clinical trials.
Because the terminal elimination and half-life of amiodarone is so long – having a half-life sometimes lasting as long as 40 days – amiodarone can be a complicated medication to work with and around when treating a patient who has experienced a return of spontaneous circulation. Which means that using amiodarone may eliminate the option of using other medications until it has been effectively eliminated from the body.
Adult Dosage of Amiodarone
When using amiodarone to treat V-Fib or pulseless V-tach cardiac arrest which is unresponsive to CPR, shock, and vasopressors, a first dose is given at 300 mg via IV or IO push. And a second dose is delivered at half that, or 150 mg, also via IV or IO push.
For life-threatening arrhythmias, a maximum accumulated dose is 2.2 grams via IV over a 24-hour period.
For patients with a pulse but also suffering from a life-threatening arrhythmia, administer amiodarone via rapid infusion and delivered at 150 mg IV over the first 10 minutes, which equals 15 mg per minute.
This dose can be repeated also via rapid infusion every 10 minutes as needed, up to the maximum dose of 2.2 grams in a 24-hour period.
When administering amiodarone via slow infusion, deliver the medication at 360 mg IV over a 6-hour period, or 1 mg per minute. A maintenance infusion can be given at 540mg IV over 18 hours, or 0.5 mg per minute.
Pro Tip #2: Remember, these infusions should not exceed 2.2 grams over a 24-hour period. And when delivered at this maximum dosage, the effects can last up to 40 days.
A Word About the Resumption of CPR and Rhythm Checks Post-Defibrillation
Resume CPR
After defibrillating an adult patient, you should:
- Immediately resume CPR, starting with chest compressions
- Not perform a rhythm check or pulse check at this time unless the patient is beginning to show signs of life or advanced monitoring indicates ROSC
- Establish IV or IO access
The American Heart Association guidelines recommend that healthcare providers tailor the sequence of their rescue actions based on the presumed etiology of the arrest.
Also, ACLS providers that are functioning within a high-performance resuscitation team may choose the optimal approach for minimizing interruptions in chest compressions. Examples of optimizing CCF and high-quality CPR are the use of different protocols such as:
- 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts
- Compression-only CPR in the first few minutes after the arrest
- Continuous chest compressions with asynchronous ventilation once every 6 seconds with the use of a bag-mask device
A default compression-to-ventilation ratio of 30:2 should be used by healthcare providers with less training or experience or if the 30:2 ratio is your established protocol.
Rhythm Checks
Conduct a rhythm check after 2 minutes of CPR and be careful to minimize interruptions in chest compressions. Remember, the pause in chest compressions when checking the patient's rhythm should not exceed 10 seconds.
If a non-shockable rhythm is present and the rhythm is organized, one of the team members should try to palpate a pulse. And if there is any doubt about the presence of a pulse, immediately resume CPR.
Remember to perform a pulse check, ideally during rhythm analysis, only if an organized rhythm is present. If the rhythm is organized and you detect a palpable pulse, proceed to post-cardiac arrest care.
If your rhythm check reveals a shockable rhythm, resume chest compressions if indicated while the defibrillator is charging.
