ACLS Amiodarone Dose: Complete 2026 Guide to Dosing, Administration, Indications & Clinical Pearls

The correct ACLS amiodarone dose is one of the most frequently tested concepts on the AHA Advanced Cardiovascular Life Support exam, and for good reason — amiodarone is the first-line antiarrhythmic for shock-refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) in the 2020 AHA Guidelines, which remain authoritative through the 2026 update cycle. Knowing the exact milligram amounts, dilution requirements, and timing windows can mean the difference between return of spontaneous circulation and a prolonged code.

For shock-refractory VF or pulseless VT, the initial dose is 300 mg IV/IO push, ideally given after the third defibrillation attempt and a round of CPR. If the rhythm persists, a second dose of 150 mg IV/IO is administered roughly three to five minutes later, after additional shocks and epinephrine. These doses are given undiluted during cardiac arrest because speed matters more than vascular access etiquette when the patient has no pulse.

For stable wide-complex tachycardia with a pulse, the dosing changes dramatically. Here you give 150 mg IV diluted in 100 mL of D5W infused over 10 minutes, not as a rapid push. Pushing amiodarone in a patient with a pulse can cause profound hypotension, bradycardia, or torsades — exactly the complications you are trying to avoid. The slow infusion preserves blood pressure while restoring sinus rhythm.

The maintenance infusion that follows successful conversion runs at 1 mg/min for the first six hours, then 0.5 mg/min for the next eighteen hours, totaling 1,050 mg over 24 hours. Maximum cumulative dose in 24 hours is 2.2 grams, including all bolus and infusion amounts. Exceeding this threshold dramatically increases the risk of QT prolongation, hepatotoxicity, and pulmonary fibrosis with prolonged use.

Amiodarone is a Class III antiarrhythmic that also blocks sodium, potassium, calcium channels, and alpha and beta receptors, giving it broad spectrum efficacy across ventricular and supraventricular arrhythmias. This pharmacologic promiscuity is also why it has so many adverse effects — pulmonary toxicity, thyroid dysfunction, corneal deposits, blue-gray skin discoloration, and hepatic injury — but for the brief ACLS dosing window, acute adverse events are manageable. Review the full ACLS Drugs reference for context on how amiodarone fits with epinephrine, lidocaine, and adenosine.

This guide breaks down every dose you need to memorize for ACLS certification and clinical practice in 2026. We cover cardiac arrest dosing, stable arrhythmia dosing, pediatric considerations, drug interactions, and the precise sequencing that AHA testers expect. You will also find practice questions, real-world clinical pearls, and the most common dosing errors that cost candidates points on the megacode evaluation.

Whether you are preparing for initial certification, recertification, or simply want to refresh before your next shift in the ED, ICU, or cath lab, this article gives you the clinically defensible, exam-ready dosing knowledge you need. Bookmark it, print the dosing card, and quiz yourself with the embedded practice questions below.

Cardiac arrest dosing of amiodarone follows a strict sequence built into the 2020 AHA adult cardiac arrest algorithm. The drug only enters the picture after the patient has received high-quality CPR, at least two defibrillation attempts, and the first dose of epinephrine 1 mg IV/IO. Giving amiodarone earlier wastes a critical antiarrhythmic on a rhythm that may convert with electricity alone, and giving it later misses the window when myocardial perfusion from CPR can deliver the drug to the heart.

The first amiodarone dose in shock-refractory VF or pulseless VT is 300 mg IV/IO push. Push it fast — within 10 to 20 seconds — and follow with a 20 mL normal saline flush plus 10 to 20 seconds of arm elevation to speed central delivery. Resume chest compressions immediately. The 300 mg figure comes from the ARREST and ALIVE trials, which demonstrated improved survival to hospital admission compared to placebo and lidocaine respectively.

If VF or pulseless VT persists through another two-minute CPR cycle and shock, give a second amiodarone dose of 150 mg IV/IO using the same rapid push technique. The total cardiac arrest loading dose is therefore 450 mg, given over roughly six to ten minutes of resuscitation. There is no role for a third bolus during the arrest itself — additional amiodarone moves into the maintenance phase if ROSC is achieved.

Lidocaine is the recommended alternative when amiodarone is unavailable, contraindicated, or already given without effect. The lidocaine dose is 1 to 1.5 mg/kg IV/IO for the first dose and 0.5 to 0.75 mg/kg for subsequent doses, up to a maximum of 3 mg/kg total. The AHA considers amiodarone and lidocaine essentially equivalent for shock-refractory VF/pVT based on the ALPS trial, although amiodarone remains the historic first choice.

Once ROSC is achieved after amiodarone administration, the patient transitions to a maintenance infusion to prevent rearrhythmia. Mix 900 mg amiodarone in 500 mL D5W to yield a 1.8 mg/mL concentration, then infuse at 1 mg/min (33 mL/hr) for six hours followed by 0.5 mg/min (17 mL/hr) for eighteen hours. Use a central line when possible because peripheral infusions over 24 hours commonly cause phlebitis.

Documentation matters as much as administration. Record the exact time of each dose, the cumulative milligrams given, the rhythm response, and any hemodynamic changes. Code documentation is reviewed in mortality and morbidity conferences, and incorrect amiodarone dosing is one of the most common documentation errors found in retrospective code review. Reference the ACLS Guidelines for the most current dosing recommendations and any 2026 updates.

One subtle exam point: amiodarone is given after epinephrine, not before. Epinephrine restores coronary perfusion pressure so that subsequent antiarrhythmics actually reach the myocardium. Reversing this order is a classic distractor on AHA megacode scenarios and written exams, and it reflects a real-world misunderstanding that can prolong arrests.

Amiodarone has a substantial contraindication and caution profile that ACLS providers must recognize, especially in the post-arrest and stable arrhythmia settings. Absolute contraindications include known hypersensitivity to amiodarone or iodine, second or third-degree AV block without a functioning pacemaker, sinus node dysfunction with marked bradycardia, and cardiogenic shock. In cardiac arrest, the only meaningful contraindication is documented severe allergic reaction — toxicity concerns are secondary when the patient is pulseless.

Drug interactions are extensive because amiodarone inhibits CYP3A4, CYP2C9, CYP2D6, and P-glycoprotein. Warfarin levels can double, leading to bleeding; digoxin levels can rise 70-100%, causing toxicity; and statin myopathy risk increases substantially, particularly with simvastatin doses above 20 mg daily. Concurrent QT-prolonging drugs such as fluoroquinolones, macrolides, methadone, and ondansetron can precipitate torsades de pointes when combined with amiodarone.

Pulmonary toxicity is the most feared long-term complication, occurring in 5-15% of patients on chronic therapy. It can manifest as interstitial pneumonitis, organizing pneumonia, or ARDS, and high cumulative doses are the primary risk factor. For ACLS-level acute dosing, pulmonary toxicity is not a concern, but inpatients continued on infusion for more than 48-72 hours should have baseline and follow-up chest imaging and pulmonary function testing.

Thyroid dysfunction occurs in 15-20% of patients on long-term therapy because each 200 mg tablet contains approximately 75 mg of organic iodine — roughly 250 times the recommended daily intake. Both hyperthyroidism and hypothyroidism can develop, and the dysfunction may persist for months after discontinuation due to the drug's lipophilic storage in adipose tissue. Acute IV dosing does not cause thyroid problems but does affect free T4 and TSH measurements for several weeks.

Hepatotoxicity ranges from mild transaminase elevation, seen in 25% of patients, to fulminant hepatic failure, which is rare but reported with rapid IV loading. Pre-existing liver disease and concurrent hepatotoxic medications increase risk. Check baseline LFTs before initiating chronic therapy, but during cardiac arrest there is no time or indication for this — the risk-benefit calculation favors immediate administration when VF/pVT persists despite shocks and epinephrine.

Hypotension during IV administration is the most common acute adverse effect, occurring in 15-20% of patients. The mechanism is primarily vasodilation from the polysorbate 80 vehicle rather than direct myocardial depression. Slow the infusion rate or pause briefly, give a crystalloid bolus, and consider low-dose vasopressors if needed. Most hypotensive episodes resolve within minutes without permanent sequelae.

QT prolongation occurs in nearly all patients receiving amiodarone, but torsades de pointes is paradoxically rare — perhaps 1-2% incidence — because amiodarone homogeneously prolongs repolarization across the myocardium rather than creating the dispersion that triggers polymorphic VT. Monitor the QTc and discontinue if it exceeds 500 ms or increases by more than 60 ms from baseline. Correct hypokalemia and hypomagnesemia aggressively to minimize torsades risk.

Mastering ACLS amiodarone dosing for the exam requires memorizing both the absolute numbers and the conditional logic that determines which dose applies to which rhythm. The AHA exam loves to test boundary cases — stable patient becomes unstable, VF converts to PEA, pediatric patient with adult-sized body habitus — so understanding the underlying rationale matters as much as rote memorization. Use the dosing card mnemonic 300-150-150-1.0-0.5 to capture all four scenarios in a single string.

The first three numbers are cardiac arrest and stable VT bolus doses in milligrams. The last two numbers are the maintenance infusion rates in mg/min for the first six and subsequent eighteen hours. Adding the maximum daily dose of 2.2 grams gives you everything you need for any written exam question on amiodarone. Repeat this string until it is automatic, then test yourself with the embedded practice quizzes throughout this article.

For megacode scenarios, the sequence of drugs matters as much as the doses. After identifying shock-refractory VF, the standard order is shock, CPR, epinephrine 1 mg, shock, CPR, amiodarone 300 mg, shock, CPR, epinephrine 1 mg, shock, CPR, amiodarone 150 mg. Note that epinephrine and amiodarone alternate after the first amiodarone dose, with epinephrine given every 3-5 minutes throughout the arrest and amiodarone capped at two doses.

Pediatric amiodarone dosing follows a weight-based formula: 5 mg/kg IV/IO bolus, which can be repeated up to three times for a maximum cumulative dose of 15 mg/kg per day. Never exceed a single adult dose of 300 mg even in large adolescents. PALS providers should also know that pediatric stable SVT is treated with adenosine first, with amiodarone reserved for refractory cases under cardiology consultation.

Real-world pearls separate competent ACLS providers from exceptional ones. Always have a vasopressor ready before starting an amiodarone infusion in a hemodynamically marginal patient. Use an in-line filter when available because amiodarone can leach plasticizers from PVC tubing during prolonged infusions. Switch to a glass or polyolefin bag if the maintenance infusion will run more than two hours. Run through a dedicated line because amiodarone is incompatible with heparin, aminophylline, and several other common ICU drugs.

For recertification candidates, the major changes to amiodarone dosing from earlier guideline versions are minimal — the 300 mg/150 mg cardiac arrest dosing has been stable since the 2010 AHA guidelines. What has changed is the emphasis on lidocaine as an equally acceptable alternative based on the 2016 ALPS trial. Either drug is acceptable on the megacode, but most testing centers expect amiodarone as the default answer unless the scenario specifies amiodarone failure or contraindication. Check options at ACLS Renewal Near Me if your certification is approaching expiration.

Finally, practice the dosing scenarios in your head during low-stress shifts so that during a real code you are calm and confident. Visualize drawing two 150 mg prefilled syringes when the code coordinator calls for amiodarone. Mentally rehearse the saline flush, arm elevation, and documentation steps. The cognitive load during a real resuscitation is enormous, and automated knowledge of the exact dosing sequence frees up mental bandwidth for the harder decisions about reversible causes, advanced airway management, and family communication.

Practical preparation for the amiodarone questions on your ACLS exam should combine targeted memorization, scenario-based practice, and clinical reasoning drills. Start by writing the four key dosing scenarios on a 3x5 index card: 300 mg push for first VF/pVT dose, 150 mg push for second VF/pVT dose, 150 mg over 10 minutes for stable VT, and the 1 mg/min then 0.5 mg/min maintenance infusion. Review the card at the start and end of every study session for two weeks before the exam.

Next, work through megacode scenarios with a study partner or self-administered simulation. Have the partner call out a rhythm — "VF, third shock just delivered, epinephrine 1 mg given two minutes ago" — and verbalize your next steps including drug name, dose, route, and timing. Then switch roles. This active recall under simulated pressure builds the reflexive responses that the megacode evaluator is grading you on. Aim for at least ten complete megacode runs before exam day.

Use the practice quizzes embedded throughout this article and on the broader site to test boundary conditions. The AHA loves questions that pivot on a single word — "pulseless" versus "stable," "first dose" versus "second dose," "adult" versus "pediatric." Read each question stem twice before looking at the answer choices, and underline the rhythm and stability descriptors before reasoning to the correct dose. This habit catches the distractor traps that account for most missed questions on amiodarone topics.

Pair amiodarone study with the related ACLS drugs that appear in the same algorithms. Know epinephrine 1 mg IV/IO every 3-5 minutes for any arrest rhythm, atropine 1 mg IV up to 3 mg total for symptomatic bradycardia, and adenosine 6 mg then 12 mg rapid push for stable narrow-complex SVT. The exam often presents scenarios where you must choose between amiodarone and another drug based on subtle rhythm features, so cross-training across the full ACLS pharmacology set is essential.

Spend additional time on contraindications and adverse effects because these higher-order questions are common on the written exam. Know that amiodarone is contraindicated in second-degree Mobitz II and third-degree AV block without a pacemaker, in sinus node dysfunction, and in cardiogenic shock outside of cardiac arrest. Know that hypotension is the most common acute adverse effect and that pulmonary toxicity, thyroid dysfunction, and hepatotoxicity are the major long-term concerns.

On exam day, manage your time efficiently. Most ACLS written exams give 60-90 minutes for 50 questions, so you have about 90 seconds per question. Amiodarone questions are typically among the easier pharmacology items if you have memorized the dosing card, so aim to spend less than 60 seconds on these and bank the saved time for harder algorithm or ethics questions. Mark uncertain items and return to them after completing the first pass.

Finally, treat your ACLS preparation as an investment in patient safety, not just a credential to renew. Every minute spent solidifying amiodarone dosing today is a minute saved during a real code tomorrow, when seconds determine whether a patient survives. The 300-150 sequence is not just an exam answer — it is a lifesaving intervention you may execute dozens of times across your career. Master it now and you will execute it confidently when it matters most. Compare program options at ACLS Certification Cost to find the best training value for your situation.