Amiodarone and a little on PVCs.

First I would like to remind everyone that as EMS providers working in the emergency setting we must always follow our own protocols. Different services follow different rules when it comes to patient care and you should not only be very well versed in your protocols, but also in what your medical director specifically likes for treatment on patients. Always follow your protocol.

That being said, I am going to produce a case study to illustrate the use of Amiodarone in the stable but emergent patient presenting with unifocal bigeminy PVCs.

EMS provider is dispatched to a rural location for female patient complaining of chest pain. Upon their arrival elderly female is found in sitting position that is complaining of some, “stabbing,” pain to the left side of her chest with mild shortness of breath. Blood pressure is elevated and patient states she was sitting down watching television when it began approximately 30 minutes ago. 12 lead ECG is performed.

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Patient is placed on oxygen via nasal cannula at 2 litters per minute. IV is established and patient is given aspirin orally at 324 mg and one sublingual nitroglycerin tablet. Patient is transported quickly due to the prolonged transport time. The patient is a good 15 to 20 minutes from the nearest emergency room. During transport patient states this is the first time she has had anything like this. Patient states she was just cleared of any problems by her doctor a few weeks ago. Patient’s heart rhythm during transport:
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Patient states some relief of symptoms with treatment but states she still feels some chest pain. Currently a 5 on a scale of 1 to 10 with 10 being worse. Amiodarone is chosen as the antiarrhythmic of choice in this instance. 150 mg of Amiodarone is drawn up and placed in a 100 ml bag of D5w. It is given over 10 minutes and the results are almost immediate. The patient at first says she is feeling slightly light headed, she then states her chest pain is gone. Her blood pressure stabilizes and most importantly of all her heart rhythm goes into normal sinus rhythm with very few PVCs noted. Of course the patient was still going to require a cardiac work up but overall the stability of the patient was improved.

Follow up 12 lead done during transport:
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A few small notes on Amiodarone.

There are a few different dosages for the administration of Amiodarone in an adult patient. In ventricular fibrillation or ventricular tachycardia without a pulse the initial dosage is 300 mg. If the patient has a pulse we are to administer 150 mg over 10 minutes.

If the patient is converted from V-fib or V-tac then during return of spontaneous circulation(ROSC) we should begin a maintenance infusion. Maintenance infusion is usually 1 mg per minute.  A simple method I’ve learned is to establish a 1:1 ratio of Amiodarone to NS or D5w. So for example if you carry 150 ml bags of NS you can load it with 150 mg of Amiodarone and using a 60 drop set put it at 1 drop per second and you will be giving the patient 1mg per minute. You can figure out the math if you don’t have the right size bags to go with your Amiodarone but I like to keep it simple, especially in a hectic situation like a full arrest we just brought back.

So if you have a 250 ml NS bag you can load it with 250 mg of Amiodarone and still use the same one drop per second on a 60 drop set and have the 1 mg per minute ratio.

I hope this helps. I am still recording the podcast discussing Amiodarone as well as an interesting case study involving an internal defibrillator.

If you have any stories of your successes or what you have found to be useful in the field please feel free to pass them along. I’m always up for learning a new method to improve. Any topics you would like me to discuss in the future is also welcome.

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