What to do after max dose of Amiodarone?

[mgaska84]

Ive always had this question with no clear answer. When working a code and you've reached the max dose, and you're still working the code, do you switch to Lidocaine or do you do an amio infusion? Thoughts?

 

[sirengirl]

Ive always had this question with no clear answer. When working a code and you've reached the max dose, and you're still working the code, do you switch to Lidocaine or do you do an amio infusion? Thoughts?

So I'm to understand that you're working a code and have already bolused your 300, and 150 of ami? Going by current ACLS per AHA you would just continue on with epi only (5 cycles cpr, rhythm check, defib if applicable, 5 cycles CPR, rhythm check, Epi if applicable, defib if applicable, repeat etc).

I have been taught that if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards), then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).

 

[mgaska84]

Yes thats what I was taught as well, if ROSC than do one more round of CPR and hang an infusion of AMI. Thanks for the clarification!

 

[GaMedic]

My protocol wont allow me to stop or call it. So I would just keep doing Epi q 3-5, CPR and defib (if shockable rhythm) while working through my H's & T's until I reached the ER.

 

[TomB]

If the patient is in referactory VF hook up a second defibrillator and give a double shock. By the time you've given two doses of amiodarone you've probably shocked at least 6 times (probably more). The patient doesn't need more drugs. The patient needs more electricity (or better CPR or a shorter peri-shock pause).

 

[abckidsmom]

So I'm to understand that you're working a code and have already bolused your 300, and 150 of ami? Going by current ACLS per AHA you would just continue on with epi only (5 cycles cpr, rhythm check, defib if applicable, 5 cycles CPR, rhythm check, Epi if applicable, defib if applicable, repeat etc).

I have been taught that if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards), then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).

Have I missed something? If you get ROSC, keep doing CPR for one more round?

 

[GaMedic]

If the patient is in referactory VF hook up a second defibrillator and give a double shock. By the time you've given two doses of amiodarone you've probably shocked at least 6 times (probably more). The patient doesn't need more drugs. The patient needs more electricity (or better CPR or a shorter peri-shock pause).

Stacked shocks??????

 

[Medic Tim]

Stacked shocks??????

double sequential defibrillation

http://www.emsworld.com/article/10318805/hold-the-coroner

 

[mgaska84]

Not a whole 2 minutes of CPR, but finish the cycle that you're currently on

 

[Hunter]

Have I missed something? If you get ROSC, keep doing CPR for one more round?

Prime the pump. Helps prevent the heart from going back into previous rhythm

 

[WTEngel]

Wrong all the way around.

After you have exhausted amiodarone, you may switch to another anti-dysrhythmic.

I typically switch to mag sulfate, because generally if amiodarone does not work, lidocaine has not been shown to be any more or less effective, so my determination is that the patient could possibly be in a subtle polymorphic v-tach that I failed to identify on the first analysis. Administer the 1-2 grams of mag sulfate over 3-5 minutes and see if they convert.

If the mag fails, or I am certain it is not polymorphic (Torsades) then procainimide is an option also. Sotalol is another option, based on patient presentation.

So a code could run like this:

Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->300 mg Amiodarone--->CPR for 2 minutes and analyze
Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->150 mg Amiodarone--->CPR for 2 minutes and analyze
Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->Mag or Procainimide or Sotalol--->CPR for 2 minutes and analyze
Etc...Etc...Etc...

Continue alternating vasopressor and anti-dyrhythmic therapy until patient converts, changes rhythms, resuscitation is terminated, or patient politely asks you to stop chest compressions.

Any ACLS instructor who is teaching that after you have exhausted amiodarone, you give epi exclusively is 100% incorrect. Just because AHA does not list alternative medications on the algorithm card does not mean they are no longer an option.

Check out section 8 of the Circulation Journal article from November of 2010 detailing the changes to ACLS.

 

[WTEngel]

I have been taught that if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards), then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).

I think you misunderstood what they were saying, or they misunderstood what they were teaching.

If after your second dose of amiodarone (which should be given early after the shock to allow for 2 minutes of circulation with good CPR) at the next rhythm check you see a rhythm that could produce a pulse, you check for a pulse and go immediately into post resuscitation care if a pulse is in fact present. If a pulse is not present, you transition to the PEA/Asystole algorithm.

Now, where it gets hairy, and where most instructors miss the mark, is that we are no longer to check for a pulse immediately after shocking. We immediately resume CPR after defibrillation and treat based on the rhythm we analyzed prior to the shock.

The reason this is applicable is, for example, if immediately after the shock, in the brief moment between when the shock was delivered and CPR was resumed, you happened to notice an organized rhythm on the monitor, you are to ignore that, and continue treating based on the rhythm you analyzed prior to the shock. This is because the overwhelming evidence demonstrates that very nearly 100% of patients who convert from VF/VT convert into PEA, meaning that a pulse check and delaying resumption of CPR would most likely result in them being refractory.

So, to recap, if at the end of two minutes of CPR you analyze and see an organized rhythm, check for a pulse, and if a pulse is detected, go into ROSC algorithm (not resumption of CPR.)

If you happen to momentarily catch the patient converting between the shock and the chest compressions resuming, always treat based on rhythm analyzed prior to the shock and anticipate ROSC on the next analysis.

 

[abckidsmom]

I think you misunderstood what they were saying, or they misunderstood what they were teaching.

If after your second dose of amiodarone (which should be given early after the shock to allow for 2 minutes of circulation with good CPR) at the next rhythm check you see a rhythm that could produce a pulse, you check for a pulse and go immediately into post resuscitation care if a pulse is in fact present. If a pulse is not present, you transition to the PEA/Asystole algorithm.

Now, where it gets hairy, and where most instructors miss the mark, is that we are no longer to check for a pulse immediately after shocking. We immediately resume CPR after defibrillation and treat based on the rhythm we analyzed prior to the shock.

The reason this is applicable is, for example, if immediately after the shock, in the brief moment between when the shock was delivered and CPR was resumed, you happened to notice an organized rhythm on the monitor, you are to ignore that, and continue treating based on the rhythm you analyzed prior to the shock. This is because the overwhelming evidence demonstrates that very nearly 100% of patients who convert from VF/VT convert into PEA, meaning that a pulse check and delaying resumption of CPR would most likely result in them being refractory.

So, to recap, if at the end of two minutes of CPR you analyze and see an organized rhythm, check for a pulse, and if a pulse is detected, go into ROSC algorithm (not resumption of CPR.)

If you happen to momentarily catch the patient converting between the shock and the chest compressions resuming, always treat based on rhythm analyzed prior to the shock and anticipate ROSC on the next analysis.

Thanks for that. I completely misunderstood what they were getting at.

Most recently my ROSCs have been detected by EtCO2 changes. It's fairly unmistakable.

 

[jwk]

double sequential defibrillation

http://www.emsworld.com/article/10318805/hold-the-coroner

I guess it can't hurt, since they're "dead" anyway. But this is anecdotal evidence at best, hardly something to hang your hat on.

Old farts like me remember some of the old giant ER LifePak debrillators that could go to 500 joules. There's a reason everything has been dialed back down. Not everything functions along the lines of "if a little is good a lot must be better".

 

[WTEngel]

Thanks for that. I completely misunderstood what they were getting at.

Most recently my ROSCs have been detected by EtCO2 changes. It's fairly unmistakable.

Yes...excellent point that I forgot to mention. EtCO2 changes are reliable enough to be considered a "sign of life."

Generally we look at a sudden increase of 20-25 mmHg or more in order to be considered remarkable.

Be careful to consider what medications you have just pushed also. Bicarb administration (not routinely recommended anymore) can lead to variances in EtCO2, perfusion status not withstanding.

 

[TomB]

I guess it can't hurt, since they're "dead" anyway. But this is anecdotal evidence at best, hardly something to hang your hat on.

It's not like there's a mountain of high quality to support epinephrine, amiodarone, lidocaine, magnesium sulfate, sotalol, procainamide, or any other intervention save high quality chest compressions and defibrillation. If the patient is in refractory VF there's a good chance that a critical mass of the myocardium is not being depolarized, whether due to poor pad placement, skin prep, body habitus, heart anatomy, whatever (as opposed to recurrent VF which is a different problem). So it seems to me that in this case "more is better" meaning more current and more coverage from a second set of pads.

 

[WTEngel]

It's not like there's a mountain of high quality to support epinephrine, amiodarone, lidocaine, magnesium sulfate, sotalol, procainamide, or any other intervention save high quality chest compressions and defibrillation.

This is true...however the area of resuscitation outcomes research is growing. I am looking forward to some eye opening ROC data in 2015...

 

[GaMedic]

double sequential defibrillation

http://www.emsworld.com/article/10318805/hold-the-coroner

Hrm interesting. I will def read about it. Thanks for the link!

 

[TomB]

This is true...however the area of resuscitation outcomes research is growing. I am looking forward to some eye opening ROC data in 2015...

I think there's already lots of eye opening data. Drugs don't work. Early CPR, defibrillation, and expert post-resuscitation care are key, including early identification of STEMI, PCI, therapeutic hypothermia, and CABG or ICD placement if necessary.

 

[GaMedic]

Wrong all the way around.

After you have exhausted amiodarone, you may switch to another anti-dysrhythmic.

I typically switch to mag sulfate, because generally if amiodarone does not work, lidocaine has not been shown to be any more or less effective, so my determination is that the patient could possibly be in a subtle polymorphic v-tach that I failed to identify on the first analysis. Administer the 1-2 grams of mag sulfate over 3-5 minutes and see if they convert.

If the mag fails, or I am certain it is not polymorphic (Torsades) then procainimide is an option also. Sotalol is another option, based on patient presentation.

So a code could run like this:

Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->300 mg Amiodarone--->CPR for 2 minutes and analyze
Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->150 mg Amiodarone--->CPR for 2 minutes and analyze
Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->Mag or Procainimide or Sotalol--->CPR for 2 minutes and analyze
Etc...Etc...Etc...

Continue alternating vasopressor and anti-dyrhythmic therapy until patient converts, changes rhythms, resuscitation is terminated, or patient politely asks you to stop chest compressions.

Any ACLS instructor who is teaching that after you have exhausted amiodarone, you give epi exclusively is 100% incorrect. Just because AHA does not list alternative medications on the algorithm card does not mean they are no longer an option.

Check out section 8 of the Circulation Journal article from November of 2010 detailing the changes to ACLS.

Yes you are correct but I think my response was alil vague, I consider Mag,Calcium chloride etc to fall into when trying to rule out causes. My instructor swears by Mag Sulfate.. He claims to have got more people back after giving mag than anything.. Torsades is a fun one I remember the 1st time I ever saw it was when I was doing mega code practice for my ACLS test and my instructor decided to throw me a curve ball... Fun times..