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Now let’s talk about Amiodarone. This drug can prolong AV conduction, the AV refractory period and QRS and Q-T intervals, which ultimately slows the heart rate. Because Amiodarone blocks sodium, potassium and calcium channels, as well as being an alpha and beta blocker, it is well known a multichannel blocker. The drug Amiodarone is an antiarrhythmic drug. It’s used specifically for it’s broad range of electrophysiologic effects. Amiodarone is primarily chosen for ACLS as the first-line antiarrhythmic agent for cardiac arrest because it has reliably and clinically shown effectiveness in improving the rate of return of spontaneous circulation otherwise known as ROSC and improved ROSC to hospital admission in adults with refractory V-fib or pulseless V-tach. Amiodarone may be considered when V-fib and V-tach is unresponsive to CPR, defibrillation, and epinephrine. With Amiodarone, there are multiple complex drug interactions, so care must be given when using this drug. Rapid infusion may lead to hypotension but of course during cardiac arrest, there is no blood pressure anyway and therefore the American Heart Association recommendation is still the give it rapid IV push for anti-arrhythmic treatment. Remember that with the use of multiple doses, which could be a cumulative dose of greater than 2.2 g over a 24 hour period, significant hypotension has been noted in clinical trials. Do not administer Amiodarone with other drugs that prolong Q-T interval such as procainamide. Because terminal elimination is extremely long, sometimes known to have a half life lasting up to 40 days, it can be a complicated medication to work around when treating a patient who has experienced return of spontaneous circulation as it may eliminate the option to use certain medications until Amiodarone has been effectively eliminated from the body. When using Amiodarone to treat V-fib or pulseless V-Tach cardiac arrest which is unresponsive to CPR, Shock and Vasopressors, the first dose to be given is 300 mg IV or IO push. The second dose is delivered at half that, which is 150mg IV or IO push. For life threatening arrhythmias, the maximum cumulative dose is 2.2g IV over 24 hours. For patients with a pulse but are suffering life threatening arrhythmias, give Amiodarone rapid infusion delivered 150 mg IV over the first 10 minutes which equals 15 mg per minute. This may be repeated rapid infusion every 10 minutes as needed up to a total of that 2.2 g in a 24 hour period. To give Amiodarone slow infusion, deliver 360 mg IV over 6 hours or 1 mg per minute. The maintenance infusion is 540 mg IV over 18 hours which is .5 mg per minute. Remember, these infusions over time must not exceed that 2.2 g in a 24 hour period and when delivered as such, it’s effects can last upwards of 40 days.
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.
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:
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.
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.
After defibrillating an adult patient, you should:
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:
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.
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.