amiodarone administration vs. lidocaine

[zzyzx]

When a patient is in stable VT and you have the choice of giving amiodarone or lidocaine, wouldn't it be better to give lidocaine since it won't take so long to set up and administer as the amiodarone drip? In the area where I work we are usually just 5 to 10 minutes from the hospital.

[chbare]

Zzyzx, I do not follow you on this one. It is not hard to mix an amiodarone drip. In addition, if you are only a few minutes from the hospital you may only have enough time to get the slow IVP of amiodarone in prior to hanging the maintenance infusion, so you just saved your self time and energy going with amiodarone. A good question to as would be, "what situations would warrant the infusion of amiodarone and what situations would warrant the infusion of lidocaine?"

Take care,

chbare.

[OVeractiveBrain]

yet another Amio vs Lido! Get ready to be assailed!

The short of it is that Amiodarone is more effective (not so proven) than lidocaine without the nasty side effect of seizures (very proven). The problem with Amio is that it is a slow infusion and requires the patient to be very stable, with worsening hypotension prior to correcting the rhythm.

When it comes down to it, right now the choice is provider preference. The one clinical decision maker should be how hypotensive they are prior to choosing. The more stable, the more you should lean to amiodarone, the less stable, the more you should lean towards lidocaine, until they arrest, then it doesnt matter again.

To be honest though, how much longer does it take to hang a bag of saline and inject amio into the bag than it does to hang a bag of saline and inject lidocaine IV? Its just about the same time-wise. Its just that administration of Amio guarentees hospital admission (since the half-life is so long), where as lidocaine runs the risk of seizure.

until more research is done ACLS says take your pick!

P.S. Amio is way more expensive than lido as a drug, and the hopsital admission can go upwards of 300,000 dollars (society)

[chbare]

We must; however, consider the multiple well known problems associated with amiodarone. Problems such as, pulmonary toxicity, QT interval prolongation and Torsades, multiple medication interactions, and very long half life must be considered prior to amiodarone administration.

Take care,

chbare.

[ERDoc]

yet another Amio vs Lido! Get ready to be assailed!

The short of it is that Amiodarone is more effective (not so proven) than lidocaine without the nasty side effect of seizures (very proven). The problem with Amio is that it is a slow infusion and requires the patient to be very stable, with worsening hypotension prior to correcting the rhythm.

When it comes down to it, right now the choice is provider preference. The one clinical decision maker should be how hypotensive they are prior to choosing. The more stable, the more you should lean to amiodarone, the less stable, the more you should lean towards lidocaine, until they arrest, then it doesnt matter again.

To be honest though, how much longer does it take to hang a bag of saline and inject amio into the bag than it does to hang a bag of saline and inject lidocaine IV? Its just about the same time-wise. Its just that administration of Amio guarentees hospital admission (since the half-life is so long), where as lidocaine runs the risk of seizure.

until more research is done ACLS says take your pick!

P.S. Amio is way more expensive than lido as a drug, and the hopsital admission can go upwards of 300,000 dollars (society)

I think you need to go over your ACLS updates again because there are several errors in your post. The new guidelines have actually taken lidocaine out of the algorhythms. Amio is the preferred med based on several studies. Here is a small excerpt from the guidelines published in Circulation:

Evidence in support of amiodarone comes from 3 observational studies (LOE 5)28–30 that indicate that amiodarone is effective for the termination of shock-resistant or drug-refractory VT. One randomized parallel study (LOE 2)31 indicated that aqueous amiodarone is more effective than lidocaine in the treatment of shock-resistant VT. Amiodarone administration is also supported by extrapolated evidence (LOE 7) from studies of out-of-hospital cardiac arrest with shock-refractory VF/VT, which showed that amiodarone improved survival to hospital admission (but not discharge) compared with placebo32 or lidocaine.33

28. Schutzenberer W, Leisch F, Kerschner K, Harringer W, Herbinger W. Clinical efficacy of intravenous amiodarone in the short term treatment of recurrent sustained ventricular tachycardia and ventricular fibrillation. Br Heart J. 1989; 62: 367–371.[Abstract]

29. Credner SC, Klingenheben T, Maus O, Sticherling C, Hohnloser SH. Electrical storm in patients with transvenous implantable cardioverter- defibrillators: incidence, management and prognostic implications. J Am Coll Cardiol. 1998; 32: 1909–1915.[Abstract/Free Full Text]

30. Helmy I, Herre JM, Gee G, Sharkey H, Malone P, Sauve MJ, Griffin JC, Scheinman MM. Use of intravenous amiodarone for emergency treatment of life-threatening ventricular arrhythmias. J Am Coll Cardiol. 1989; 12: 1015–1022.

31. Somberg JC, Bailin SJ, Haffajee CI, Paladino WP, Kerin NZ, Bridges D, Timar S, Molnar J. Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia. Am J Cardiol. 2002; 90: 853–859.[CrossRef][Medline] [Order article via Infotrieve]

32. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray WA, Olsufka M, Walsh T. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999; 341: 871–878.[Abstract/Free Full Text]

33. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002; 346: 884–890.[Abstract/Free Full Text]

Administering either one guarantees admission. If a pt needs either one, they are not going home. What golden palace do you work at where a hospital admission costs $300,000? They can be expensive, but that's a little excessive. I think you need to check your facts a little more before posting, there have been a few posts where you have gotten the info wrong.

[Ridryder 911]

Actually, ER Doc AHA still allows Lido in lieu of Cordorone, they do prefer Cordorone however; but still discuss that is the providers choice. (We had a big pow-wow of Instructors, attempting to clear this misconception up).

As well, ever heard of pre-mixed Lidocaine? It only has been out about 18 years.

Personally, I have little success of Cordorone over Lido nor have I ever seen seizures r/t Lido as well. I do believe Corodorone is a better antiarrhythmic medication, but in V-fib, no difference. This was even in pre-hospital, ER, & ICU/CCU settings. Yet again proper dosage and all drips should be on a IV pump.

The problem I have with Cordorone is if the patient is on anticoagulants (especially Coumadin) it can screw up their PTT/INR..

I believe Cordorone within time will be the same as Bretylium hype was to replace Lido etc.. and we seen were that went.

R/r 911

[ERDoc]

Actually, ER Doc AHA still allows Lido in lieu of Cordorone, they do prefer Cordorone however; but still discuss that is the providers choice. (We had a big pow-wow of Instructors, attempting to clear this misconception up).

As well, ever heard of pre-mixed Lidocaine? It only has been out about 18 years.

Personally, I have little success of Cordorone over Lido nor have I ever seen seizures r/t Lido as well. I do believe Corodorone is a better antiarrhythmic medication, but in V-fib, no difference. This was even in pre-hospital, ER, & ICU/CCU settings. Yet again proper dosage and all drips should be on a IV pump.

The problem I have with Cordorone is if the patient is on anticoagulants (especially Coumadin) it can screw up their PTT/INR..

I believe Cordorone within time will be the same as Bretylium hype was to replace Lido etc.. and we seen were that went.

R/r 911

Touche. I was actually referring to the actual algorhythms. The only one they put on there is Amio. I have also never seen seizures with Lido. As far as the INR, I wouldn't sweat it too much. We have ways of fixing that. :wink:

[chbare]

Allow me to pose a question for the simple sake of mental master... With what we know regarding the mechanisms of action of these two medications, are there situations where lido would be more beneficial and visa versa.

Take care,

chbare.

[AZCEP]

Long term Cordarone carries the problems that chbare eluded to. For the immediate management situation, these are not as great a concern.

Amiodarone is preferred for the patient with hypotension. It has a better profile when given to these patients than Lidocaine, due in part to it's slow administration. Even rapid bolusing has been shown to not have as great an effect on cardiac output as was suspected.

Seizures are a possibility, but the greater danger with Lidocaine would be the allergic reaction to it.

I like Amiodarone for it's long half life. IV doses over 10 minutes will maintain an effect for 20+ minutes. If you are considering an infusion of Amiodarone prehospital, you will need more resources than a simple bag of NS. Amiodarone leaches the PVC out of standard infusion sets, adding to liver issues later.

I've yet to discover situational superiority with either agent. Both are effective when used appropriatley, and consideration is given to what they are capable of doing. Neither are great for an immediate termination of a sustained dysrhythmia, but are pretty good at prevent recurrence.

[chbare]

Yet one more long term problem to consider with amiodarone treatment, thyroid dysfunction. Amiodarone is actually similar in structure to thyroxine. I personally have had several patients develop serious reactions to amiodarone when used to treat "stable ventricular tachycardia." I have seen torsades to syncopal episodes, to severe refractory vomiting. I try to avoid amiodarone if possible; however, my feelings are based more on personal experience than sound EBM.

Take care,

chbare.