Amiodarone: Infusion or Bolus ?

You’re dispatched for a 55 y/o male complaining of palpitations. You find him in a-fib at a rate of 150 but otherwise stable. You load the patient and get a line, but soon after, you note a change to VT with no major change in patient condition. Your partner draws up 150 mg of amio, but without cross-checking, pushes it IV. The patient goes unresponsive and experiences a brief PEA arrest that, luckily, is remedied with a few compressions and some epi. Oops 🫣

Based on a true story. 

Amio is an antiarrhythmic that affects sodium, potassium and calcium channels. It prolongs action potential and depolarization, and suppresses sinus node function and AV conduction. Whew 🥵

This drug is a source of confusion among students & new providers, as it has multiple different modes of administration. Let’s break it down. 

🙂STABLE PATIENTS:

•Amio suppresses cardiac function and is dissolved in a solvent that can also precipitate hypotension - give SLOWLY 🐢 

•Via: s l o w infusion. 150 mg bolus ✨over 10 minutes✨

•Not ideal to try to push 3 mLs over 10 mins (typical concentration: 50 mg/mL), so we mix it in something. 

•If you have a pump, mix it in a small bag (if not prepackaged) and run the bolus over 10.

•No pumps? Put it in a 100 mL bag and run it in over 10(ish) mins with a macroset. Other size bags are acceptable based on IV access and fluid tolerance. 

•Can be mixed in D5W or NS (yes, NS)

•It worked!? Maintenance drip💧 (after finishing bolus)

☠️DEAD PATIENTS:

•Since perfusion sucks and we’re mechanically controlling cardiac output (compressions), just push it. 

•300 mg for refractory vf/VT, then 150 mg if it’s still happening. 

•It worked!? Maintenance drip💧 

🥳IT WORKED:

•For patients who convert with an amio bolus, we can MAINTAIN the bolus’ effects and keep the bad juju away with a maintenance drip

•1 mg/min

•No pump? Put 100 mg (usually 2mL) in a 100 mL bag. That’s 1mg/mL. Spike with a 60 gtt set, run at one drop a second (aka 1 mL/min) and voilà. 

⚠️: Amio is not to be used with Torsades, as it prolongs QT further and can cause deterioration into vfib. 

🤓: If using lidocaine instead, same concept of bolus before maintenance drip applies.