Amiodarone in code

[madchemist89]

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Does anyone know if there any advantages to using amiodarone in addition to epinephrine in vfib/vtach during a code?

 

[colbgw02]

Yes. It's indicated for vfib and vtach, assuming that 1) defibrillation/epi haven't worked and 2) the vtach isn't polymorphic.

I don't want to sound rude, but your status says that you're a resident, and this is ACLS 101. Pediatrician maybe?

 

[Psai]

nvm was wrong, was thinking of vasopressin not amio

 

[colbgw02]

I think they took it out of acls

Really? Link? I just recertified a few months ago and amiodarone was definitely still in there, and I can't find anything online about it being removed.

 

[nlax30]

I think they took it out of acls

It's still in ACLS for shock-refractory VF/pVT.

http://circ.ahajournals.org/content/132/18_suppl_2/S444

2015 Recommendations—Updated

Amiodarone may be considered for VF/pVT that is unrespon- sive to CPR, de brillation, and a vasopressor therapy (Class IIb, LOE B-R).

Lidocaine may be considered as an alternative to amioda- rone for VF/pVT that is unresponsive to CPR, de brillation, and vasopressor therapy (Class IIb, LOE C-LD).

The routine use of magnesium for VF/pVT is not recom- mended in adult patients (Class III: No Bene t, LOE B-R).

No antiarrhythmic drug has yet been shown to increase survival or neurologic outcome after cardiac arrest due to VF/pVT. Accordingly, recommendations for the use of anti- arrhythmic medications in cardiac arrest are based primarily on the potential for bene t on short-term outcome until more de nitive studies are performed to address their effect on sur- vival and neurologic outcome.

 

[madchemist89]

My question was in regards to possible advantages of amio not whether it is part of the guidelines. Thank you for the link. It states that there is no evidence that it improves ROSC or neurological outcome.

 

[Gurby]

My question was in regards to possible advantages of amio not whether it is part of the guidelines. Thank you for the link. It states that there is no evidence that it improves ROSC or neurological outcome.

I don't know if you can draw that conclusion?

"In blinded RCTs in adults with refractory VF/pVT in the out-of-hospital setting, paramedic administration of amiodarone in polysorbate (300 mg or 5 mg/kg) after at least 3 failed shocks and administration of epinephrine improved hospital admission rates when compared to placebo with polysorbate100 or 1.5 mg/kg lidocaine with polysorbate. Survival to hospital discharge and survival with favorable neurologic outcome, however, was not improved by amiodarone compared with placebo or amiodarone compared with lidocaine, although these studies were not powered for survival or favorable neurologic outcome."

"Improved hospital admission rate" seems to suggest that the amiodarone may indeed have increased ROSC, but not long term survival/neuro.

Out-of-hospital cardiac arrest brings a different set of challenges and problems compared to an arrest inside the hospital - often prolonged downtime prior to starting compressions, crappy CPR quality in the back of a moving ambulance or during extrication, inconsistent timing of med administration, aspiration due to poor BVM technique and delay in obtaining advanced airway, etc. I don't think you can necessarily extrapolate the results of this study to anything other than prehospital arrest. Just because Amiodarone didn't improve long-term survival in patients from the study, doesn't mean it couldn't be useful in other situations.

This is a kind of dangerous road to go down IMO. You should be able to defend your reasoning on whether you did or didn't do something. When you withhold amiodarone from a refractory VF patient and they die, and someone asks why you didn't give the amiodarone that was indicated in the protocols, what do you say? Do you think your response will hold up in court?

 

[nlax30]

I guess to back up a little bit, are we talking about using amio in refractory, ongoing VF/pVT or using amio for an initial VF/VT arrest but that's not having continued VF/VT?

 

[Tenk]

If you are using amio in a code you might as well put some essential oils on them and harness your inner chi because the only thing that is going to get them walking again is good compressions and electricity.

 

[Raryn]

My question was in regards to possible advantages of amio not whether it is part of the guidelines. Thank you for the link. It states that there is no evidence that it improves ROSC or neurological outcome.

There's no evidence that anything other than compressions, defibrillation, and avoiding post-code fevers helps neurologic outcomes or survival to hospital discharge. (Epi does help ROSC iirc, but not the outcomes that actually matter)

That said, the guidelines are the guidelines, and while amio is a generally terrible drug in long-term use (side-effect wise, still damn efficacious), you're not doing any harm to the already dead patient by giving it.