13.3 Amiodarone, Lidocaine & Adenosine

AHA PALS Provider Pediatric Advanced Life Support

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1 Chapter 1: Course Overview & Exam Logistics

1.1 Current Exam Facts 1.2 Audience, Prerequisites & Study Plan

2 Chapter 2: Systematic Pediatric Assessment

2.1 Pediatric Assessment Triangle (PAT) 2.2 Evaluate–Identify–Intervene Sequence 2.3 Primary Assessment: ABCDE 2.4 Secondary Assessment, SAMPLE & Vitals by Age

3 Chapter 3: Respiratory Distress & Failure

3.1 Respiratory Distress vs Failure 3.2 Recognition & Immediate Intervention Priorities 3.3 Oxygen Delivery & Basic Airway Support

4 Chapter 4: Airway Problems & Ventilation Strategies

4.1 Upper Airway Obstruction 4.2 Lower Airway, Lung Tissue Disease & Disordered Control 4.3 Bag-Mask Ventilation & Advanced Airways During CPR

5 Chapter 5: Shock Fundamentals & Hypovolemia

5.1 Compensated vs Hypotensive (Decompensated) Shock 5.2 Hypovolemic Shock 5.3 Isotonic Fluid Bolus 10–20 mL/kg & Reassessment

6 Chapter 6: Distributive, Cardiogenic & Obstructive Shock

6.1 Distributive & Septic Shock Pathway 6.2 Cardiogenic Shock 6.3 Obstructive Shock

7 Chapter 7: Pediatric BLS & High-Quality CPR

7.1 High-Quality CPR Metrics 7.2 Compression-Ventilation Ratios 7.3 CPR Quality Monitoring: ETCO2 & Diastolic BP

8 Chapter 8: Pediatric Cardiac Arrest Algorithm

8.1 Arrest Recognition & Systematic Approach 8.2 VF/pVT & Defibrillation Energy 8.3 Asystole & PEA 8.4 Epinephrine in Arrest: Dose & Timing

9 Chapter 9: Bradycardia & Narrow-Complex Tachycardia

9.1 Bradycardia with Poor Perfusion 9.2 Sinus Tachycardia vs SVT 9.3 Stable SVT: Vagal Maneuvers & Adenosine

10 Chapter 10: Unstable Tachycardia & Wide-Complex Rhythms

10.1 Unstable Tachycardia & Synchronized Cardioversion 10.2 Wide-Complex Tachycardia & VT with Pulse 10.3 Antiarrhythmics for Tachycardia with Pulse

11 Chapter 11: Reversible Causes & Special Circumstances

11.1 Reversible Causes: The H's and T's 11.2 Special Circumstances at Exam Level 11.3 Extracorporeal CPR (ECPR) Overview

12 Chapter 12: Post–Cardiac Arrest Care

12.1 Post-ROSC Oxygenation & Ventilation 12.2 Post-Arrest Hemodynamic Support 12.3 Temperature Control & Glucose 12.4 Neuroprognostication & Transport

13 Chapter 13: Vascular Access & Core Pharmacology

13.1 IV and Intraosseous Access 13.2 Epinephrine Dosing in Depth 13.3 Amiodarone, Lidocaine & Adenosine 13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

14 Chapter 14: Team Dynamics & Megacode Readiness

14.1 High-Performance Team Roles 14.2 Closed-Loop Communication 14.3 Constructive Intervention, Debriefing & Exam Integration

13.3 Amiodarone, Lidocaine & Adenosine

Key Takeaways Explain This Topic AI

For shock-refractory VF/pVT in arrest, amiodarone 5 mg/kg IV/IO bolus (max 300 mg, may repeat up to 3 doses with subsequent doses capped at 150 mg) or lidocaine 1 mg/kg IV/IO may be considered—either antiarrhythmic is acceptable in current teaching.

Adenosine for SVT: first 0.1 mg/kg rapid IV/IO, then 0.2 mg/kg if needed, with common teaching maxima often 6 mg then 12 mg .

Adenosine requires rapid push plus immediate flush because of its ultrashort half-life.

Amiodarone for perfusing VT is the same 5 mg/kg order of magnitude but given over time (infusion) , not as a careless arrest-style slam in a child with a pulse and tenuous blood pressure.

Do not use adenosine as a default for irregular wide-complex tachycardia or as a substitute for defibrillation in pulseless VT.

Last updated: August 2026

Antiarrhythmics in Context: Arrest vs Pulse-Present

PALS learners often memorize drug names without mapping them to the correct algorithm box . Amiodarone, lidocaine, and adenosine appear in multiple chapters; this section is the dose-and-technique table that ties them together.

High-level map

Drug Primary PALS use Core dose teaching
Amiodarone Refractory VF/pVT (arrest bolus); selected VT with pulse (infusion) 5 mg/kg IV/IO
Lidocaine Alternative to amiodarone for refractory VF/pVT; some VT pathways 1 mg/kg IV/IO loading dose

Adenosine Stable regular narrow-complex SVT (and diagnostic/therapeutic AV nodal block) 0.1 mg/kg then 0.2 mg/kg rapid push

Epinephrine Arrest and bradycardia (not an SVT converter) 0.01 mg/kg IV/IO
Shock-refractory VF / pulseless VT

When VF or pVT persists despite high-quality CPR and defibrillation , an antiarrhythmic may be given during CPR:

Amiodarone 5 mg/kg IV/IO bolus , maximum 300 mg ; the 2025 Pediatric Cardiac Arrest Algorithm permits repeating up to 3 doses , with subsequent doses capped at 150 mg each, or

Lidocaine 1 mg/kg IV/IO loading dose as the accepted alternative —current teaching is that either may be considered ; do not treat the exam as "amiodarone only forever" or "lidocaine is obsolete."

The amiodarone caps in practice

Weight-based math and the 300 mg first-dose ceiling cross at 60 kg . Below that weight the cap never binds; above it, the cap does the work:

Weight First bolus (5 mg/kg) Subsequent bolus
20 kg 100 mg 100 mg
60 kg 300 mg (exactly at the cap) 150 mg (subsequent-dose cap)
80 kg 300 mg (capped, not 400 mg) 150 mg

Priorities that still outrank debating amiodarone vs lidocaine:

Continuous high-quality CPR
Correct energy shocks ( 2 J/kg , then 4 J/kg , up to max per algorithm)
Epinephrine on interval
Reversible causes

Antiarrhythmics are adjuncts for refractory shockable arrest—not substitutes for defibrillation.

Worked amiodarone arrest examples

Weight Amiodarone 5 mg/kg
10 kg 50 mg
16 kg 80 mg
20 kg 100 mg
30 kg 150 mg

Give IV/IO during CPR; flush; minimize interruptions. Watch for post-ROSC hypotension and bradycardia—amiodarone is not hemodynamically free.

Adenosine for SVT: Dose, Maxima, and Rapid-Push Technique

Adenosine briefly blocks the AV node. It can terminate reentrant SVT that uses the AV node and can reveal underlying atrial activity. It is not the drug for sinus tachycardia, not first-line for unstable SVT (use synchronized cardioversion—Chapter 10), and not appropriate as casual therapy for irregular wide-complex rhythms concerning for pre-excited AF.

Dosing table (PALS teaching)

Dose order Amount Common teaching maximum
First 0.1 mg/kg rapid IV/IO Often 6 mg
Second 0.2 mg/kg rapid IV/IO Often 12 mg
Worked examples

8 kg infant: first 0.8 mg , second 1.6 mg (well under adult-style maxima).

40 kg child: first 4 mg , second 8 mg .

70 kg adolescent near adult size: first dose may hit the 6 mg teaching cap; second may hit 12 mg —know that weight-based dose and maximum both constrain the syringe.

Rapid push technique (as important as the milligrams)

Adenosine’s half-life is only seconds. Technique failures look like "drug didn’t work" when the drug never reached the heart:

Use the most proximal IV practical (or IO with vigorous flush).

Draw drug in one syringe; saline flush in another (or use a stopcock system).

Push adenosine as fast as possible.

Immediately push a rapid saline flush to clear the line into central circulation.

Elevate the extremity if using a distal peripheral IV and that is your system’s method.

Record a continuous rhythm strip ; warn the team to expect brief asystole, pauses, or ventricular escape beats.

If SVT persists after two appropriate doses, reassess stability. Unstable → synchronized cardioversion 0.5–1 J/kg then 2 J/kg . Expert consultation for refractory cases; 2025 materials may mention additional advanced options (e.g., IV sotalol in highly selected refractory pathways)—not first-line stable SVT care.

Adenosine is not a wide-complex panacea

Rhythm situation Adenosine role
Regular narrow SVT, stable Yes—after/with vagal maneuvers
Unstable SVT Electricity first

Undifferentiated regular monomorphic wide complex (selected expert diagnostic use) Only with expertise and readiness for deterioration

Irregular wide tachycardia / pre-excitation concern Avoid as default therapy
Pulseless VT Defibrillate —not adenosine

Loading diagram... Amiodarone / Lidocaine / Adenosine Decision Snapshot

Pulse vs Arrest Administration: Amiodarone’s Critical Difference

The milligram number 5 mg/kg appears for amiodarone in both arrest and some pulse-present VT pathways. The administration method changes with perfusion status—and exams love that distinction (Chapter 10 preview, reinforced here).

Arrest (no pulse, refractory VF/pVT)

Give amiodarone as a resuscitation bolus IV/IO during CPR.

Goal: deliver drug rapidly into low-flow circulation while shocks and compressions continue.

Hemodynamic side effects are secondary to the fact that the child currently has no output .

Pulse present (perfusing VT / selected wide-complex pathways)

Same 5 mg/kg IV/IO teaching dose order of magnitude.

Give over a period of time (controlled infusion) , not as a reckless slam that drops blood pressure.

Monitor continuous ECG and blood pressure; have pads on; prepare for cardioversion if the child destabilizes.

Expert consultation is preferred before stacking agents.

Do not casually combine amiodarone with procainamide or other antiarrhythmics—additive proarrhythmia and hypotension risk.

Lidocaine notes

Lidocaine remains an accepted alternative antiarrhythmic for shock-refractory VF/pVT and appears in some pulse-present ventricular arrhythmia protocols. Know:

It is a valid either/or partner to amiodarone in refractory arrest teaching—not a "wrong answer" by default.

Local cards list exact mg/kg bolus and infusion limits—memorize amiodarone 5 mg/kg cold; know lidocaine is the named alternative without inventing non-card numbers if your materials vary.

Toxicity includes neurologic symptoms (tinnitus, seizures) and myocardial depression at high levels—another reason dosing aids matter (Section 13.4).

Side-effect and safety cluster

Drug Key acute concerns
Amiodarone Hypotension, bradycardia, further arrhythmias; long half-life complicates stacking
Lidocaine CNS toxicity, myocardial depression

Adenosine Transient asystole/pauses, flushing, chest discomfort; bronchospasm caution in severe active wheeze (clinical judgment)

Clinical scenarios

Refractory VF: 18 kg child, still VF after CPR and defibrillation attempts with epinephrine on board. During CPR give amiodarone 5 mg/kg = 90 mg IV/IO (or lidocaine alternative), flush, continue shocks/CPR.

Stable SVT: 12 kg infant, rate 280, good perfusion. After ice to face fails: adenosine 1.2 mg rapid push + flush; if needed 2.4 mg second dose; strip recording on.

Perfusing VT: 25 kg child, monomorphic VT, BP acceptable, mentating. Expert-guided amiodarone 5 mg/kg = 125 mg over time , pads in place—not a 125 mg slam identical to arrest technique while ignoring blood pressure.

Bottom line for 13.3: Refractory VF/pVT → amiodarone 5 mg/kg bolus or lidocaine ; SVT → adenosine 0.1 then 0.2 mg/kg rapid push + flush (maxima often 6/12 mg); pulse-present amiodarone → 5 mg/kg over time ; never let drug choice replace electricity when the algorithm demands a shock.