Amiodarone Dosing in Advanced Life Support

Clinical Context and Indications

The American Heart Association recommends administering an initial dose of 300 mg IV/IO of amiodarone for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) unresponsive to CPR, defibrillation, and vasopressor therapy, followed by one additional dose of 150 mg IV/IO if the arrhythmia persists, in patients who have already received high-quality CPR, defibrillation attempts, and vasopressor therapy (epinephrine or vasopressin) 1, 2, 3, 4, 5
Amiodarone should be considered specifically for shock-refractory VF or pulseless VT after the patient has already received high-quality CPR, defibrillation attempts, and vasopressor therapy (epinephrine or vasopressin), with evidence showing it improves short-term survival to hospital admission compared to placebo or lidocaine in this specific population 1, 3, 5

The initial dose of amiodarone is 300 mg IV/IO, administered as a bolus, with a second dose of 150 mg IV/IO if VF/pulseless VT persists after the initial dose, as recommended by the American Heart Association 1, 2, 3, 4, 5

Amiodarone is a Class IIb recommendation, meaning the benefit-to-risk ratio is less well established, and should only be given after multiple defibrillation attempts, epinephrine administration, and continued high-quality CPR, as recommended by the American Heart Association 1, 2, 3, 4, 5
If amiodarone is unavailable, lidocaine may be considered as an alternative, with an initial dose of 1 to 1.5 mg/kg IV and additional doses of 0.5 to 0.75 mg/kg IV every 5-10 minutes, with a maximum total dose of 3 mg/kg, although it has no proven short- or long-term efficacy advantage 1, 2, 3, 4, 5

Hypotension is the most common adverse effect of amiodarone, occurring in approximately 26% of patients, primarily attributed to vasoactive solvents in the IV formulation, and vasopressors should be administered before amiodarone when possible to prevent hypotension 1, 3, 4, 5
Bradycardia occurs in approximately 4.9% of patients on IV amiodarone, and monitoring for heart block and AV conduction delays is recommended 1, 3, 4, 5

The initial dose of amiodarone should not exceed 300 mg during cardiac arrest, and only one 150 mg supplemental dose should be given during the arrest, as recommended by the American Heart Association 1, 2, 3, 4, 5