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.

Testicular Torsion

 Testicular torsion occurs when the spermatic cord twists, cutting off blood supply to the testis. 

 SYMPTOMS: 

Pain and swelling of the scrotal sac are usually the main symptoms of testicular torsion. 

Most people, in general, do not understand the difference between testicular torsion and infection, and when they have pain, they assume it is due to infection and they start themselves on analgesics and antibiotics. 

 CAUSES: 

Torsion could occur while people are asleep. Torsion tends to occur early in the morning when testosterone levels are at their peak, and the cremasteric reflex is strongest. Occasionally, a tumor or prior trauma may be present and risk factor includes a congenital malformation known as a “bell-clapper deformity” wherein the testis is attached to the epididymis vertically instead of longitudinally allowing it to move freely and thus potentially twist. Cold temperatures may also be a risk factor. 

 Torsion of the testes is a medical emergency, but many adolescent males are hesitant to say they are having pains on their testes or seek treatment right away. You should never ignore sharp testicular pain. It’s possible for some men to experience what is known as intermittent torsion.

 This causes a man to have a testicle twist and untwist. Due to the fact that the condition is likely to recur, it is important to seek treatment. Seek to consult with a urologist, even if the pain becomes sharp and then subsides