What is the preferred antiarrhythmic medication, amiodarone (Amiodarone) or lidocaine (Lidocaine), for managing ventricular arrhythmias in traumatic cardiac arrest?

From the Guidelines

Amiodarone and lidocaine are considered equally effective for managing ventricular arrhythmias in traumatic cardiac arrest, with the choice between them depending on specific clinical circumstances and availability. The recommended dose of amiodarone is 300 mg IV bolus, which can be followed by a second dose of 150 mg if needed 1. Lidocaine is administered at 1-1.5 mg/kg IV bolus, with a maximum initial dose of 100 mg 1. Both medications have their own set of indications and contraindications, and the decision to use one over the other should be based on the individual patient's needs and the underlying cause of the cardiac arrest.

Key Considerations

• The 2018 American Heart Association guidelines suggest that both amiodarone and lidocaine may be considered for shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest 1.
• The choice between amiodarone and lidocaine should take into account the patient's specific clinical circumstances, including any potential contraindications or interactions with other medications.
• It is essential to address the underlying cause of traumatic arrest, such as hypovolemia, tension pneumothorax, or cardiac tamponade, as these medications treat the arrhythmia but not the primary traumatic cause.

Medication Administration

• Amiodarone: 300 mg IV bolus, followed by a second dose of 150 mg if needed 1.
• Lidocaine: 1-1.5 mg/kg IV bolus, with a maximum initial dose of 100 mg 1.

Clinical Context

• The use of antiarrhythmic medications in cardiac arrest is based primarily on the potential for benefit on short-term outcome, as no medication has been shown to increase survival or neurologic outcome after cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia 1.

From the FDA Drug Label

1 INDICATIONS & USAGE Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy.

The FDA drug label does not answer the question.

From the Research

Comparison of Amiodarone and Lidocaine for Ventricular Arrhythmias

• The choice between amiodarone and lidocaine for managing ventricular arrhythmias in cardiac arrest is a critical decision, with various studies providing insights into their effectiveness 2, 3, 4, 5, 6.
• A study published in 2016 found that neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia 2.
• Another study from 2020 suggested that an amiodarone-first strategy may be associated with the termination of ventricular fibrillation/pulseless ventricular tachycardia using fewer shocks, although the sample size was small 3.
• In contrast, a 2023 study found that lidocaine was associated with statistically significantly higher odds of return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone 4.
• A systematic review and meta-analysis published in 2016 found that amiodarone and lidocaine equally improved survival at hospital admission compared to placebo, but neither improved long-term outcome 5.
• A systematic review focusing on pediatric cardiac arrest due to ventricular arrhythmias found that the confidence in effect estimates was low, and it was suggested that either amiodarone or lidocaine could be used in this setting 6.

Key Findings

• The effectiveness of amiodarone and lidocaine may vary depending on the specific context, such as in-hospital or out-of-hospital cardiac arrest, and the patient population 2, 3, 4.
• The choice between amiodarone and lidocaine should be based on individual patient factors and clinical judgment, as the current evidence does not support a clear preference for one agent over the other 5, 6.
• Further research is needed to determine the optimal antiarrhythmic medication for managing ventricular arrhythmias in cardiac arrest, particularly in traumatic cardiac arrest 2, 3, 4, 5, 6.