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In this series of posts we will take extracts on medications and interventions from the 2010 CPR & ECC Guidelines and provide the links to their PubMed abstracts where available. We will also indicate which ones are available through open-access. A similar format is available directly through Circulation online (link below), but this does not utilise opening links through Read by QxMD.

Amiodarone

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IV amiodarone affects sodium, potassium, and calcium channels and has a- and b-adrenergic blocking properties. It can be considered for treatment of VF or pulseless VT unresponsive to shock delivery, CPR, and a vasopressor. In blinded randomized controlled clinical trials in adults with refractory VF/pulseless VT in the out-of-hospital setting,134,136 paramedic administration of amiodarone (300 mg134 or 5 mg/kg136) improved hospital admission rates when compared with administration of placebo134 or 1.5 mg/kg of lidocaine.136

Additional studies283–287 documented consistent improvement in termination of arrhythmias when amiodarone was given to humans or animals with VF or hemodynamically unstable VT. A higher incidence of bradycardia and hypotension was reported for amiodarone in one out-of-hospital study.134 A canine study288 noted that administration of a vasoconstrictor before amiodarone prevented hypotension. The adverse hemodynamic effects of the IV formulation of amiodarone are attributed to vasoactive solvents (polysorbate 80 and benzyl alcohol). When administered in the absence of these solvents, an analysis of the combined data of 4 prospective clinical trials of patients with VT (some hemodynamically unstable) showed that amiodarone produced no more hypotension than lidocaine.286

A formulation of IV amiodarone without these vasoactive solvents was approved for use in the United States. Amiodarone may be considered for VF or pulseless VT unresponsive to CPR, defibrillation, and a vasopressor therapy (Class IIb, LOE B). An initial dose of 300 mg IV/IO can be followed by 1 dose of 150 mg IV/IO. Although anecdotally administered IO without known adverse effects, there is limited experience with amiodarone given by this route.

References

134.  

 

Kudenchuk PJ1, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999 Sep 16;341(12):871-8. PMID: 10486418. Whether antiarrhythmic drugs improve the rate of successful resuscitation after out-of-hospital cardiac arrest has not been determined in randomized clinical trials. [...]

136.   

 

Dorian P1, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002 Mar 21;346(12):884-90. PMID: 11907287. Lidocaine has been the initial antiarrhythmic drug treatment recommended for patients with ventricular fibrillation that is resistant to conversion by defibrillator shocks. We performed a randomized trial comparing intravenous lidocaine with intravenous amiodarone as an adjunct to defibrillation in [...]

283.

 

Skrifvars MB1, Kuisma M, Boyd J, Määttä T, Repo J, Rosenberg PH, Castren M. The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2004 May;48(5):582-7. PMID: 15101852. The Resuscitation 2000 Guidelines recommends amiodarone as the antiarrhythmic drug of choice in treatment of resistant ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Amiodarone has been associated with side-effects and difficulty of administration, due to recommended diluti [...]

284.

 

Petrovic T, Adnet F, Lapandry C. Successful resuscitation of ventricular fibrillation after low-dose amiodarone. Ann Emerg Med. 1998 Oct;32(4):518-9. PMID: 9774944.

285.  

 

Levine JH1, Massumi A, Scheinman MM, Winkle RA, Platia EV, Chilson DA, Gomes A, Woosley RL. Intravenous amiodarone for recurrent sustained hypotensive ventricular tachyarrhythmias. Intravenous Amiodarone Multicenter Trial Group. J Am Coll Cardiol. 1996 Jan;27(1):67-75. PMID: 8522712. We sought to determine the response rate and safety of intravenous amiodarone in patients with ventricular tachyarrhythmias refractory to standard therapies. [...]

286.

 

Somberg JC1, Bailin SJ, Haffajee CI, Paladino WP, Kerin NZ, Bridges D, Timar S, Molnar J; Amio-Aqueous Investigators. Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia. Am J Cardiol. 2002 Oct 15;90(8):853-9. PMID: 12372573. The effectiveness of intravenous amiodarone for the treatment of incessant (shock resistant) ventricular tachycardia (VT) has not been established. This study evaluated the efficacy of a water-soluble amiodarone preparation or lidocaine for the treatment of shock-resistant VT. The trial was a double [...]

287.

 

Somberg JC1, Timar S, Bailin SJ, Lakatos F, Haffajee CI, Tarjan J, Paladino WP, Sarosi I, Kerin NZ, Borbola J, Bridges DE, Molnar J; Amio-Aqueous Investigators. Lack of a hypotensive effect with rapid administration of a new aqueous formulation of intravenous amiodarone. Am J Cardiol. 2004 Mar 1;93(5):576-81. PMID: 14996582. Hypotension is the most frequent adverse event reported with intravenous amiodarone. Hypotension has been attributed to the vasoactive solvents of the standard formulation (Cordarone IV) and is not dose related, but related to the rate of infusion. Drug labeling calls for intravenous amiodarone to b [...]

288.

 

Paiva EF1, Perondi MB, Kern KB, Berg RA, Timerman S, Cardoso LF, Ramirez JA. Effect of amiodarone on haemodynamics during cardiopulmonary resuscitation in a canine model of resistant ventricular fibrillation. Resuscitation. 2003 Aug;58(2):203-8. PMID: 12909383. Amiodarone has been shown to be superior to both placebo and lidocaine in improving survival to hospital admission for victims of out-of-hospital refractory ventricular fibrillation. Concern had been expressed about the known vasodilatatory effects of amiodarone if given without precedent vasoconstr [...]