atropine IV/IM (Rx)

Frequency Not Defined

Anticholinergic symptoms (mydriasis, hyperthermia, tachycardia, cardiac arrhythmia, delayed gastric emptying)

Ataxia

Fever

Headache

Insomnia

Dry mouth

Anhidrosis

Urticaria

Urinary hesitancy

Dry skin

Blurred vision

Cycloplegia

Photophobia

Anhidrosis

Palpitation

Dyspnea

Paralytic ileus

Pulmonary edema

Nasal dryness

Xerophthalmia

Constipation

May increase IOP in predisposed patients

May cause CNS disturbances (especially in pediatric patients)

Contraindications

No absolute contraindications for ACLS

• Ineffective in hypothermic bradycardia

Narrow-angle glaucoma, tachycardia, asthma, GI obstruction, severe ulcerative colitis, toxic megacolon, bladder outlet obstruction

Cautions

Caution in hepatic/renal impairment, BPH, CHF

Not for effective treatment of type II second or third-degree AV block with or without a new wide QRS complex

Use caution in autonomic neuropathy, myocardial ischemia, heart failure, paralytic ileus, hepatic impairment, hiatal hernia associated with reflux esophagitis, hyperthyroidism, myasthenia gravis, and renal impairment

May inhibit sweating which, in a warm environment or with excessive exercise, can lead to hyperthermia and heat injury; to the extent feasible, avoid excessive exercise and heat exposure

Psychosis reported in sensitive individuals and with excessive doses

When recurrent use of atropine is essential in patients with coronary artery disease, total dose should be restricted to 2 to 3 mg (maximum 0.03 to 0.04 mg/kg) to avoid detrimental effects of atropine-induced tachycardia on myocardial oxygen demand

May cause acute glaucoma; administer with caution in patients at risk for acute glaucoma or who have severe narrow angle glaucoma; monitor for signs and symptoms of intraocular pressure, as appropriate

May convert partial organic pyloric stenosis into complete obstruction; patients should be monitored for gastrointestinal symptoms following administration of

May cause urinary retention; administer with caution to patients with clinically significant bladder outflow obstruction

May cause thickening of bronchial secretions and formation of dangerous viscid plugs in individuals with chronic lung disease; respiratory status should be monitored in individuals with chronic lung disease following administration of therapy

Drug can cause hypersensitivity reactions, including anaphylactic reactions; medical supervision necessary in patients who have had previous anaphylactic reactions to drug and require treatment for organophosphorus or nerve agent poisoning

Cardiovascular risks

• Cardiovascular adverse reactions reported include, but are not limited to, sinus tachycardia, palpitations, premature ventricular contractions, atrial flutter, atrial fibrillation, ventricular flutter, ventricular fibrillation, cardiac syncope, asystole, and myocardial infarction
• In patients with a recent myocardial infarction and/or severe coronary artery disease, there is possibility that atropine-induced tachycardia may cause ischemia, extend or initiate myocardial infarcts, and stimulate ventricular ectopy and fibrillation
• Use with caution in patients with known cardiovascular disease or cardiac conduction problems

Pregnancy

Drug readily crosses the placental barrier and enters fetal circulation; there are no adequate data on developmental risk associated with use of atropine in pregnant women; adequate animal reproduction studies have not been conducted with atropine

Lactation

Drug reported to be excreted in human milk; there are no data on effects of atropine on breastfed infant or effects on milk production; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed infant from therapy or from underlying maternal condition

Pregnancy Categories

A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA: Information not available.

Mechanism of Action

Competitively inhibits action of ACh on autonomic effectors innervated by postganglionic nerves; reverses muscarinic effects of cholinergic poisoning caused by agents with cholinesterase inhibitor activity by acting as a competitive antagonist of acetylcholine ast muscarinic receptors; blocks action of acetylcholiine at parsympathetic sites in secretory glands, and CNS; inhibits salivation, tracheobronchial secretions, bradycardia, hypotension

Antimuscarinic agent

Pharmacokinetics

Half-life: 2-3 hr (>2 years and adults); 7 hr (<2 years); 10 hr (65-75 years)

Peak plasma time: 3 min (IM)

Onset: Rapid (IV/IM)

Bronchodilation: Within 15 min; max within 15 min-1.5 hr (oral inhalation)

Distribution: Throughout the body; crosses blood brain barrier

Absorption: Principally from the upper small intestine

Metabolites: Tropic acid, tropine, and possibly esters of tropic acid and glucuronide conjugates

Metabolism: Liver via enzymatic hydrolysis

Excretion: Urine (30-50%); small amounts may also be eliminated in expired air as carbon dioxide and in feces

IV Incompatibilities

Additive: floxacillin

Syringe: cimetidine with pentobarbital

Y-site: thiopental

Not spec: ampicillin, diazepam, epinephrine, norepinephrine

IV Compatibilities

Additive: dobutamine, furosemide, meropenem, netilmicin, Na bicarb, verapamil

Syringe: (partial list) cimetidine, fentanyl, glycopyrrolate, heparin, hydroxyzine, meperidine, morphine, pentobarbital

Y-site: abciximab, amiodarone, argatroban, etomidate, famotidine, fenoldopam, fentanyl, heparin, hydrocortisone, hydromorphone, inamrinone, meropenem, methadone, morphine, nafcillin, KCl, propofol, sufentanil, tirofiban, vit B/C

IV Administration

Give into large vein or IV tubing over 1-2 min

Autoinjector

Should have available three (3) autoinjectors, one for mild symptoms plus 2 for severe symptoms, for use in each patient at risk for nerve agent or organophosphate insecticide poisoning

Only administer to patients experiencing symptoms of organophosphorus poisoning in a situation where exposure is known or suspected

The autoinjector is intended as an initial treatment of muscarinic symptoms of insecticide or nerve agent poisonings as soon as symptoms appear; definitive medical care should be sought immediately

Not to be administered until cyanosis has been overcome; atropine may produce ventricular fibrillation and possible seizures in presence of hypoxia

To be used by persons who have had adequate training in recognition and treatment of nerve agent or insecticide intoxication; may be administered by a caregiver or by self-administration if a trained provider is not available

Close supervision of all treated patients indicated for at least 48 to 72 hours

In severe poisonings, concurrent administration of an anticonvulsant (preferably a benzodiazepine) may be warranted if seizure is suspected in the unconscious individual because overt jerking may not be apparent because of the effects of the poison

In poisonings caused by organophosphorous nerve agents and insecticides it may also be helpful to concurrently administer a cholinesterase reactivator such as pralidoxime chloride

The injection site is the mid-lateral thigh area; the autoinjector can inject through clothing; however, make sure pockets at the injection site are empty; people who may not have a lot of fat at injection site should also be injected in mid-lateral outer thigh; before giving the injection, bunch up the thigh to provide a thicker area for injection.