Atropine

dl-hyoscyamine

Antidote

Pediatric

Atropine

dl-hyoscyamine

Indications

Drug/Toxin-induced bradycardia.
Reversal of cholinergic toxidrome due to organophosphate and carbamate insecticides, muscarine containing mushrooms, pilocarpine, choline esters. Symptoms include: excessive bronchial secretions leading to respiratory compromise, excessive oral and GI secretions, and bradycardia. Pralidoxime, in conjunction with atropine, should be used in the treatment of moderate to severe organophosphate and certain carbamate poisonings.

Dosage

DRUG/TOXIN-INDUCED BRADYCARDIA:

Children less than 12 years: 0.02 mg/kg IV direct up to maximum of 0.5 mg. Repeat once if needed.
Children greater than 12 years: 1 mg IV direct. Repeat every 3 - 5 minutes, as needed. Maximum total dose of 3 mg.

ORGANOPHOSPHATE, CARBAMATE AND MUSHROOM POISONING:

Children less than 12 years: 0.02 - 0.05 mg/kg IV every 10 - 20 minutes until atropine effect (decreased secretions and/or wheezing, dry flushed skin, tachycardia, mydriasis, fever) is seen, then every 1 - 4 hours for at least 24 hours.

- Max single dose for neonate ( 0 -4 weeks): 0.03 mg/kg.
- Max single dose for children: 0.5 mg.

Children 12 years of age or older: 1 - 2 mg IV initially. If no response, the dose is doubled every 5 - 10 minutes until tracheobronchial secretions are dry and patient can be oxygenated.
Continue treatment until gradual reduction* in dose does not cause reappearance of cholinergic symptoms. In severe organophosphate poisoning, very large doses and treatment for days to weeks has been necessary (total of 9 to 11 g over 30 to 40 days). Administration by infusion in severe cases may be considered. Initial infusion rates of 0.02 - 0.08 mg/kg/hour have been recommended (up to 2.4 mg/kg/hour has been required).

*After prolonged use of high doses of atropine it must be tapered gradually and reinstated if cholinergic symptoms recur.

Endpoint of therapy: Resolution of excessive bronchial secretions and symptomatic bradycardia.

Administration

IV Direct: Administer undiluted over 1 minute. Cardiac monitoring is required.
Infusion: For a final concentration of 0.2 mg/mL: add 20 mg (34 mL of a 0.6 mg/mL solution) to 66 mL (remove 34 mL from 100 mL minibag) of sodium chloride 0.9% or dextrose 5% in water. Cardiac monitoring and an infusion device are required.
Other: May be administered via intraosseous line.

Compatibility, Stability

Compatible with sodium chloride 0.9% and dextrose 5% in water.
Mix infusion immediately before administering.
Decomposition occurs in alkaline solutions.

Potential Hazards of Administration

Dry mouth, dilated pupils, urinary retention, and constipation.
With large doses; severe tachycardia, respiratory depression, delirium, fever.
Local irritation at IV site.
Paradoxical bradycardia if injection too slow or dose too low (less than 0.5 mg).

Miscellaneous

Preservative-free product is preferred if large doses are required.
Atropine is primarily effective for the treatment of muscarinic effects of organophosphate poisoning and will not reverse nicotinic effects (muscular weakness, diaphragmatic weakness, etc.).
Contraindicated in patients with narrow-angle glaucoma, obstructive uropathy, myasthenia gravis, tachycardia secondary to cardiac insufficiency or thyrotoxicosis, acute hemorrhage associated with unstable cardiovascular status, severe ulcerative colitis or toxic megacolon, obstructive gastrointestinal disease (pyloric stenosis), paralytic ileus, or intestinal atony. In the case of life threatening symptoms potential benefit of use should be taken into account.

References…

Bailey, B., Blais, R., Gaudreault, P., Gosselin, S., & Laliberte, M. (2009). Antidotes en toxicologie d'urgence (3rd ed.). Quebec, Canada: Centre antipoison du Quebec.

Borron, S. W., Bronstein, A. C., Fernandez, M. C., & et all. (2014). Walter F. G. (Ed.), AHLS advanced hazmat life support, provider manual (4th ed.). Tucson, Arizona: The University of Arizona College of Medicine.

Eddleston, M., Buckley, N. A., Eyer, P., & Dawson, A. H. (2008). Management of Acute Organophosphorous pesticide poisoning: Lancet, 371 (9612)(February), 597-604.

Goel, P., Gupta, N., Singh, S., Bhalla, A., Sharma, N., & Gill, K. D. (2012). Regeneration of red cell cholinesterase activity following pralidoxime (2-pam) infusion in first 24 h in organophosphate poisoned patients. Indian Journal of Clinical Biochemistry, 27, 34-39.

Goldfrank, L. R., Nelson, L. S., Lewin, N. A., Howland, M. A., Hoffman, R. S., (2015). Goldfrank's toxicologic emergencies(Tenth ed.). New York: McGraw Hill.

Micromedex, T. H. A. (2014). Micromedex health care systems. Retrieved from http://www.micromedexsolutions.com

Olson, K. R. (2007). Poisoning & drug overdose (Sixth ed.). New York: McGraw Hill.

Parvez, Y., Mathew, A., & Kutti, S. K. (2012). Case report: Recurrent neonatal organophoshorus poisoning. Indian Pediatrics, 49, 752-753.

Phelps SJ, C. C. (2013). Teddy bear, pediatric injectable drugs. Retrieved from http://www.pharmpress.com/product/MC_PED/pediatric-injectable-drugs

Shannon, M. W., Borron, S. W., & Burns, M. J. (2007). Haddad and Winchester's clinical management of poisoning and drug overdose (Fourth ed.). Philadelphia: Saunders Elsevier.

Tang, X., Wang, R., Xie, H., Hu, J., & Zhao, W. (2013). Repeated pulse intramuscular injection of pralidoxamine chloride in severe acute organophosurus pesticide poisoning. American Journal of Emergency Medicine, 31, 946-949.

Trissel, Lawrence, A,. (2013). Handbook on injectable drugs (17th ed.). Bethesda, Maryland: American Society of Health-System Pharmacists

White, M. L., & Liebelt, E. L. (2006). Update on antidotes for pediatric poisoning. Pediatric Emergency Care, 22(11), 740-746.