Is amiodarone (antiarrhythmic medication) indicated in pulseless electrical activity (PEA) arrest?

Amiodarone in PEA Arrest

Amiodarone is not indicated for pulseless electrical activity (PEA) arrest and should not be administered in this scenario. 1

Rationale for Not Using Amiodarone in PEA

• Amiodarone is specifically indicated for ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) that is unresponsive to CPR, defibrillation, and vasopressor therapy 1
• The American Heart Association (AHA) guidelines clearly state that amiodarone should be considered only for VF or pulseless VT, not for PEA or asystole 1
• There is no evidence supporting the use of any antiarrhythmic drugs, including amiodarone, for PEA arrest 1

Appropriate Management of PEA Arrest

The correct approach to PEA arrest focuses on:

• High-quality CPR with minimal interruptions (push hard at 100-120/min with complete chest recoil) 1
• Vasopressor administration (epinephrine 1 mg IV/IO every 3-5 minutes) 1
• Identifying and treating potential reversible causes (the "H's and T's") 1
• Avoiding inappropriate medications that have no proven benefit in PEA 1

Evidence on Antiarrhythmic Use in Cardiac Arrest

• Clinical trials demonstrating benefit of amiodarone were specifically conducted in patients with refractory VF/pVT, not PEA 1, 2
• The 2010 AHA guidelines state: "Amiodarone may be considered for VF or pulseless VT unresponsive to CPR, defibrillation, and a vasopressor therapy" with no mention of use in PEA 1
• No antiarrhythmic drug given during cardiac arrest has been shown to increase survival to hospital discharge 1

Common Pitfalls to Avoid

• Administering amiodarone for non-shockable rhythms (PEA/asystole) is a common error that diverts attention from appropriate interventions 1
• Focusing on medication administration rather than high-quality CPR and identifying reversible causes can worsen outcomes in PEA arrest 1
• Failure to recognize that the pathophysiology of PEA (absence of mechanical cardiac activity despite electrical activity) is fundamentally different from VF/VT and requires different management 1

Summary of Recommendations

• For PEA arrest: Focus on high-quality CPR, epinephrine administration, and identifying/treating reversible causes 1
• For VF/pVT arrest: Consider amiodarone 300 mg IV/IO after unsuccessful defibrillation attempts and epinephrine administration 1
• If initially in PEA but rhythm changes to VF/pVT during resuscitation, then amiodarone may be considered at that point 1