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CLASS: Antiarrhythmic (Group III)
ACTION: Amiodarone is a "class III antiarrhythmic" meaning it affects the potassium channels in the heart. It inhibits adrenergic stimulation via its alpha- and beta-blocking properties; it affects sodium, potassium, and calcium channels, lengthens both the action potential and refractory period in the myocardium, and depresses AV conduction and sinus node function. It increases the refractory period (time between beats).
INDICATIONS: In the EMS setting Amiodarone is only used for life-threatening cardiac arrhythmias. In patients with a pulse, it is used prior to attempting electric cardioversion. In patients without a pulse, it is often used within the ACLS algorithm* or may be used as a "last resort" in atrial fibrillation when electrical defibrillation fails.
The rhythms that mandate amiodarone use are ventricular tachycardia in any of its various forms. 'Medical command' may request its use in unstable patients with paroxysmal supraventricular tachycardia.
* Dependent on your local jurisdiction
CONTRAINDICATIONS: Amiodarone is not to be used in patients with severe sinus node dysfunction (bradycardia, sick sinus syndrome), or in patients with second/third-degree heart block. In these patients the action potential slowing effect can lead to complete heart block or further bradycardia, both of these effects increase the risk of cardiac arrest.
PRECAUTIONS: Heart Failure. Extravasation Be alert for patients with heart failure, the side effects of hypotension and potential bradycardia can cause these patients to decompensate. Watch for extravasation of this medication into the subcutaneous space (blown IV). If this occurs aspirate the fluid with a syringe as it may cause significant damage to the skin.
SIDE EFFECTS: The side effects of amiodarone are varied, the most relevant is the risk of hypotension, bradycardia, and ventricular escape beats. Although it is an anti-arrhythmic it is impossible to predict how a patient's heart will react to the medication.
The other side effects; Nausea, anorexia, malaise, fatigue, tremors, and pulmonary toxicity with long term use are less relevant in critically ill patients.
DOSAGE: Amiodarone has different indications in adults and pediatric patients; it is not for routine use with pediatric arrhythmia.
Hemodynamically stable ventricular tachycardia: IV 15mg/min for 10 min, then 1mg/min 6 hours
Pulseless ventricular tachycardia/fibrillation: 300mg bolus IV/IO at time of arrest, If VF continues or recurs after electrical cardioversion/defibrillation administer 150mg.
Hemodynamically stable tachycardia: 5mg/kg (max 30mg) via IV over 20 to 60 mins. May repeat twice up to a total dose of 15mg/kg.
Pulseless ventricular tachycardia/fibrillation: 5mg/kg bolus IV/IO (max 300mg) Repeat twice up to a total dose of 15 mg/kg if VF/VT recurs following or does not respond to electrical cardioversion/defibrillation.