Amiodarone & Lidocaine in Arrest
Objective: Put amiodarone and lidocaine on the shock-refractory VF/pVT shelf — not on asystole, not on sine-wave hyperK, and not instead of defibrillation.
Why This Is Hard
The arrest bag has “the antiarrhythmic.” Crews push it into asystole, into sine-wave hyperK, and before the second shock. AHA 2025 ALS: for VF/pVT unresponsive to defibrillation, amiodarone or lidocaine may be considered. Data are insufficient to say one is better. Neither replaces high-quality CPR and defibrillation (see shockable arrest and high-quality CPR).
- Still VF/pVT after shocks? Then the antiarrhythmic class may fit
- Asystole / PEA — this is not that drug
- Wide and slow in a dialysis patient — think calcium, not amio
- Read the vial: amiodarone and lidocaine are not interchangeable concentrations
When They Fit (Education)
- Shock-refractory VF or pulseless VT — after defibrillation attempts per protocol, during CPR.
- Either agent. Your protocol picks one so the team does not mix both as a cocktail unless medical direction says so.
- This site does not publish milligrams. ACLS cards list bolus-then-repeat patterns; follow your card and close the loop out loud.
When They Do Not
- Asystole or PEA as a “just in case” antiarrhythmic.
- Hyperkalemic wide-complex / sine wave — membrane stabilization with calcium (see hyperK).
- Perfusing stable wide-complex tachycardia is a different algorithm (expert/protocol antiarrhythmic infusion, not an arrest bolus by habit).
- Polymorphic VT from long QT (torsades) is a mag/shock problem, not first-line amio (see magnesium).
Street Safety
- Amiodarone is vasoactive; hypotension after ROSC is a known theme. That does not mean withhold it in refractory VF if protocol includes it.
- Lidocaine toxicity is a CNS/seizure story in overdose — another reason not to stack “a little more” from memory.
- If interrupted mid-draw, restart. Rights still apply in a code (med rights).
Field Pitfalls
- Antiarrhythmic before the first shock.
- Giving both amio and lido because the drawer had both.
- Calling fine VF asystole so you skip both shocks and the drug (see fine VF).
Practice
60-second drill
Partner: (1) VF after three shocks; (2) asystole; (3) sine-wave PEA, missed dialysis. Drug class yes/no and the actual first intervention.
Related: Shockable Arrest, WCT, Epinephrine.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- AHA 2025 Part 9: Adult Advanced Life Support — amiodarone or lidocaine for shock-refractory VF/pVT; insufficient evidence to prefer one
- Protocol owns which drug and the dose. Defibrillation and CPR still come first.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.