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Atropine (Systemic)

Pronunciation

Pronunciation

(A troe peen)

Index Terms

  • Atropine Sulfate

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Device, Intramuscular, as sulfate:

AtroPen: 0.25 mg/0.3 mL (0.3 mL) [pyrogen free]

AtroPen: 0.5 mg/0.7 mL (0.7 mL); 1 mg/0.7 mL (0.7 mL); 2 mg/0.7 mL (0.7 mL) [pyrogen free; contains phenol]

Solution, Injection, as sulfate:

Generic: 0.05 mg/mL (5 mL); 0.1 mg/mL (5 mL, 10 mL); 0.4 mg/mL (1 mL [DSC], 20 mL); 1 mg/mL (1 mL)

Solution, Injection, as sulfate [preservative free]:

Generic: 0.4 mg/mL (1 mL); 0.8 mg/mL (0.5 mL); 1 mg/mL (1 mL)

Brand Names: U.S.

  • AtroPen

Pharmacologic Category

  • Anticholinergic Agent
  • Antidote
  • Antispasmodic Agent, Gastrointestinal

Pharmacology

Blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS; increases cardiac output, dries secretions. Atropine reverses the muscarinic effects of cholinergic poisoning due to agents with acetylcholinesterase inhibitor activity by acting as a competitive antagonist of acetylcholine at muscarinic receptors. The primary goal in cholinergic poisonings is reversal of bronchorrhea and bronchoconstriction. Atropine has no effect on the nicotinic receptors responsible for muscle weakness, fasciculations, and paralysis.

Absorption

Rapid and well absorbed from all dosage forms

Distribution

Widely distributes throughout the body; crosses the blood-brain barrier

Metabolism

Hepatic via enzymatic hydrolysis

Excretion

Urine (13% to 50% as unchanged drug and metabolites)

Onset of Action

Inhibition of salivation: IM: Within 30 minutes; maximum effect: 30 to 60 minutes (Mirakhur 1980; Volz-Zang 1995)

Increased heart rate:

IM: Within 15 to 30 minutes (Kentala 1990; Volz-Zang 1995); maximum effect: 45 to 60 minutes (Mirakhur 1980; Volz-Zang 1995)

IV: Immediate; maximum effect: 0.7 to 4 minutes (Lonnerholm 1975; Santini 1999)

Time to Peak

IM: Auto-injector: 3 minutes

Duration of Action

Inhibition of salivation: IM: ≤4 hours

Half-Life Elimination

Children <2 years: 6.9 ± 3 hours; Children >2 years: 2.5 ± 1.2 hours; Adults: 3 ± 0.9 hours; Elderly 65 to 75 years of age: 10 ± 7.3 hours

Protein Binding

14% to 22%

Use: Labeled Indications

Antidote: Antidote for anticholinesterase poisoning (carbamate insecticides, nerve agents, organophosphate insecticides); antidote for muscarine-containing mushroom poisoning.

Adjuvant use with anticholinesterases (eg, edrophonium, neostigmine) to decrease their adverse effects during reversal of neuromuscular blockade.

Cardiovascular conditions: Treatment of symptomatic sinus bradycardia, atrioventricular (AV) nodal block.

Note: Likely not effective for type II second-degree or third-degree AV block (AHA [Hazinski 2015]). Use is no longer recommended in the management of asystole or pulseless electrical activity (PEA) (ACLS 2010).

Respiratory tract: Preoperative/preanesthetic medication to inhibit salivation and secretions.

Contraindications

Conditions in which inhibition of postganglionic cholinergic nerves is undesirable (eg, glaucoma, tachycardia); asthma.

Note: No contraindications exist in the treatment of severe or life-threatening muscarinic effects, including life-threatening organophosphate or carbamate insecticide or nerve agent poisoning.

Dosing: Adult

IV doses <0.5 mg have been associated with paradoxical bradycardia (Boudet 1991; Lonnerholm 1975).

Inhibit salivation and secretions (preanesthesia): IM, IV, SubQ: 0.4 to 0.6 mg 30 to 60 minutes preoperatively and repeat every 4 to 6 hours as needed.

Bradycardia (off-label dose) (Note: Atropine may be ineffective in heart transplant recipients): IV: 0.5 mg every 3 to 5 minutes, not to exceed a total of 3 mg or 0.04 mg/kg (ACLS 2010)

Muscarine-containing mushroom poisoning (off-label dose): IV: 1 to 2 mg; titrate and repeat as needed (Goldfrank, 2015).

Neuromuscular blockade reversal: IV: 15 to 30 mcg/kg administered with neostigmine or 7 to 10 mcg/kg administered with edrophonium (Cronnelly 1982; Miller 2010; Mirakhur 1981; Naguib 1989)

Organophosphate or carbamate insecticide or nerve agent poisoning: Note: The dose of atropine required varies considerably with the severity of poisoning. The total amount of atropine used for carbamate poisoning is usually less than with organophosphate insecticide or nerve agent poisoning. Severely poisoned patients may exhibit significant tolerance to atropine; ≥2 times the suggested doses may be needed. Titrate to pulmonary status (decreased bronchial secretions); consider administration of atropine via continuous IV infusion in patients requiring large doses of atropine. Once patient is stable for a period of time, the dose/dosing frequency may be decreased. Pralidoxime is a component of the management of organophosphate insecticide and nerve agent toxicity; refer to Pralidoxime monograph for the specific route and dose.

IV, IM (off-label dose): Initial: 1 to 6 mg (ATSDR 2011; Roberts 2007); repeat every 3 to 5 minutes as needed, doubling the dose if previous dose did not induce atropinization (Eddleston 2004b; Roberts 2007). Maintain atropinization by administering repeat doses as needed for ≥2 to 12 hours based on recurrence of symptoms (Reigart, 1999).

IM (AtroPen):

Mild symptoms (≥2 mild symptoms): Administer 2 mg as soon as an exposure is known or strongly suspected. If severe symptoms develop after the first dose, 2 additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than 3 doses. If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld.

Severe symptoms (≥1 severe symptoms): Immediately administer three 2 mg doses in rapid succession.

Symptoms of insecticide or nerve agent poisoning, as provided by manufacturer in the AtroPen product labeling, to guide therapy:

Mild symptoms: Blurred vision, bradycardia, breathing difficulties, chest tightness, coughing, drooling, miosis, muscular twitching, nausea, runny nose, salivation increased, stomach cramps, tachycardia, teary eyes, tremor, vomiting, or wheezing

Severe symptoms: Breathing difficulties (severe), confused/strange behavior, defecation (involuntary), muscular twitching/generalized weakness (severe), respiratory secretions (severe), seizure, unconsciousness, urination (involuntary)

IV Infusion (off-label dose): Following atropinization, administer 10% to 20% of the total loading dose required to induce atropinization as a continuous IV infusion per hour; adjust as needed to maintain adequate atropinization without atropine toxicity (Eddleston 2004b; Roberts 2007)

Rapid sequence intubation (premedication) (off-label use): IV:0.01 to 0.02 mg/kg (minimum dose: 0.1 mg; maximum single dose: 0.5 mg) (AHA [Hazinski 2015])

Stress echocardiography (adjunct chronotropic agent) (off-label use): IV: 0.25 to 0.5 mg up to a total dose of 1 to 2 mg until 85% of target heart rate is achieved (ASNC [Henzlova 2009])

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: Doses <0.1 mg have been associated with paradoxical bradycardia.

Inhibit salivation and secretions (preanesthesia) (Nelson, 1996): Infants, Children, and Adolescents: IM, IV, SubQ: Administer dose 30 to 60 minutes preoperatively then every 4 to 6 hours as needed:

Infants <5 kg: 0.02 mg/kg/dose; use of a minimum dosage of 0.1 mg will result in dosages >0.02 mg/kg; there is no documented minimum dosage in this age group.

Infants and Children ≥5 kg: 0.01 to 0.02 mg/kg/dose; maximum single dose: 0.4 mg; minimum dose: 0.1 mg

Alternate dosing:

3 to 7 kg (7 to 16 lb): 0.1 mg

8 to 11 kg (17 to 24 lb): 0.15 mg

11 to 18 kg (24 to 40 lb): 0.2 mg

18 to 29 kg (40 to 65 lb): 0.3 mg

>30 kg (>65 lb): 0.4 mg

Bradycardia:

IV, I.O.: Infants, Children, and Adolescents: 0.02 mg/kg, minimum dose recommended by PALS: 0.1 mg; however, use of a minimum dosage of 0.1 mg in patients <5 kg will result in dosages >0.02 mg/kg and is not recommended (Barrington 2011); there is no documented minimum dosage in this age group; maximum single dose: 0.5 mg; may repeat once in 3 to 5 minutes; maximum total dose: 1 mg (PALS 2010).

Endotracheal (off-label route): Infants, Children, and Adolescents: 0.04 to 0.06 mg/kg; may repeat once if needed (PALS 2010)

Muscarine-containing mushroom poisoning (off-label dose): Infants, Children, and Adolescents: IV: 0.02 mg/kg/dose; minimum dose: 0.1 mg. Titrate and repeat as needed (Goldfrank 2015).

Organophosphate or carbamate insecticide or nerve agent poisoning: Infants, Children, and Adolescents: Note: The dose of atropine required varies considerably with the severity of poisoning. The total amount of atropine used for carbamate poisoning is usually less than with organophosphate insecticide or nerve agent poisoning. Severely poisoned patients may exhibit significant tolerance to atropine; ≥2 times the suggested doses may be needed. Titrate to pulmonary status (decreased bronchial secretions); consider administration of atropine via continuous IV infusion in patients requiring large doses of atropine. Once patient is stable for a period of time, the dose/dosing frequency may be decreased. Pralidoxime is a component of the management of organophosphate insecticide and nerve agent toxicity; refer to Pralidoxime monograph for the specific route and dose.

IV, IM (off-label dose): Initial: 0.05 to 0.1 mg/kg; repeat every 5 to 10 minutes as needed, doubling the dose if previous dose does not induce atropinization (Hegenbarth 2008; Rotenberg 2003). Maintain atropinization by administering repeat doses as needed for ≥2 to 12 hours based on recurrence of symptoms (Reigart, 1999).

IV infusion (off-label dose): Following atropinization, administer 10% to 20% of the total loading dose required to induce atropinization as a continuous IV infusion per hour; adjust as needed to maintain adequate atropinization without atropine toxicity (Eddleston 2004b; Roberts 2007).

IM (AtroPen):

Mild symptoms (≥2 mild symptoms): Administer the weight-based dose listed below as soon as an exposure is known or strongly suspected. If severe symptoms develop after the first dose, 2 additional doses should be repeated in rapid succession 10 minutes after the first dose; do not administer more than 3 doses. If profound anticholinergic effects occur in the absence of excessive bronchial secretions, further doses of atropine should be withheld.

Severe symptoms (≥1 severe symptoms): Immediately administer three weight-based doses in rapid succession.

Weight-based dosing:

<6.8 kg (15 lb): 0.25 mg/dose

6.8 to 18 kg (15 to 40 lb): 0.5 mg/dose

18 to 41 kg (40 to 90 lb): 1 mg/dose

>41 kg (>90 lb): 2 mg/dose

Symptoms of insecticide or nerve agent poisoning, as provided by manufacturer in the AtroPen product labeling, to guide therapy:

Mild symptoms: Blurred vision, bradycardia, breathing difficulties, chest tightness, coughing, drooling, miosis, muscular twitching, nausea, runny nose, salivation increased, stomach cramps, tachycardia, teary eyes, tremor, vomiting, or wheezing

Severe symptoms: Breathing difficulties (severe), confused/strange behavior, defecation (involuntary), muscular twitching/generalized weakness (severe), respiratory secretions (severe), seizure, unconsciousness, urination (involuntary); Note: Infants may become drowsy or unconscious with muscle floppiness as opposed to muscle twitching.

Endotracheal (off-label route): Increase the recommended dose by 2 to 3 times the usual IV dose. Mix with 3 to 5 mL of NS and administer. Flush with 3 to 5 mL of NS and follow with 5 assisted manual ventilations (Rotenberg 2003).

Dosing: Renal Impairment

No dosage adjustment provided in manufacturer’s labeling.

Dosing: Hepatic Impairment

No dosage adjustment provided in manufacturer’s labeling.

Reconstitution

Preparation of bulk atropine solution for mass chemical terrorism: Add atropine sulfate powder to 100 mL of NS in polyvinyl chloride bags to yield a final concentration of 1 mg/mL (Dix 2003).

Administration

IM: AtroPen: Administer to the outer thigh. Firmly grasp the autoinjector with the green tip (0.5 mg, 1 mg, and 2 mg autoinjector) or black tip (0.25 mg autoinjector) pointed down; remove the yellow safety release (0.5 mg, 1 mg, and 2 mg autoinjector) or gray safety release (0.25 autoinjector). Jab the green tip at a 90° angle against the outer thigh; may be administered through clothing as long as pockets at the injection site are empty. In thin patients or patients <6.8 kg (15 lb), bunch up the thigh prior to injection. Hold the autoinjector in place for 10 seconds following the injection; remove the autoinjector and massage the injection site. After administration, the needle will be visible; if the needle is not visible, repeat the above steps. After use, bend the needle against a hard surface (needle does not retract) to avoid accidental injury.

IV: Administer undiluted by rapid IV injection; slow injection may result in paradoxical bradycardia. In bradycardia, atropine administration should not delay treatment with external pacing.

Endotracheal: Dilute in NS or sterile water. Absorption may be greater with sterile water. Stop compressions (if using for cardiac arrest), spray the drug quickly down the tube. Follow immediately with several quick insufflations and continue chest compressions.

Compatibility

Stable in NS.

Y-site administration: Incompatible with thiopental.

Compatibility in syringe: Incompatible with pantoprazole.

Storage

Store injection at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F); avoid freezing. In addition, AtroPen should be protected from light. Preparation of bulk atropine solution for mass chemical terrorism at a concentration of 1 mg/mL is stable for 72 hours at 4°C to 8°C (39°F to 46°F); 20°C to 25°C (68°F to 77°F); 32°C to 36°C (90°F to 97°F) (Dix 2003).

Drug Interactions

AbobotulinumtoxinA: Anticholinergic Agents may enhance the anticholinergic effect of AbobotulinumtoxinA. Monitor therapy

Acetylcholinesterase Inhibitors: Anticholinergic Agents may diminish the therapeutic effect of Acetylcholinesterase Inhibitors. Acetylcholinesterase Inhibitors may diminish the therapeutic effect of Anticholinergic Agents. Monitor therapy

Aclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Analgesics (Opioid): Anticholinergic Agents may enhance the adverse/toxic effect of Analgesics (Opioid). Specifically, the risk for constipation and urinary retention may be increased with this combination. Monitor therapy

Anticholinergic Agents: May enhance the adverse/toxic effect of other Anticholinergic Agents. Monitor therapy

Cannabinoid-Containing Products: Anticholinergic Agents may enhance the tachycardic effect of Cannabinoid-Containing Products. Exceptions: Cannabidiol. Monitor therapy

Chloral Betaine: May enhance the adverse/toxic effect of Anticholinergic Agents. Monitor therapy

Cimetropium: Anticholinergic Agents may enhance the anticholinergic effect of Cimetropium. Avoid combination

Eluxadoline: Anticholinergic Agents may enhance the constipating effect of Eluxadoline. Avoid combination

EPHEDrine (Systemic): Atropine (Systemic) may enhance the therapeutic effect of EPHEDrine (Systemic). Monitor therapy

Gastrointestinal Agents (Prokinetic): Anticholinergic Agents may diminish the therapeutic effect of Gastrointestinal Agents (Prokinetic). Monitor therapy

Glucagon: Anticholinergic Agents may enhance the adverse/toxic effect of Glucagon. Specifically, the risk of gastrointestinal adverse effects may be increased. Avoid combination

Glycopyrrolate (Oral Inhalation): Anticholinergic Agents may enhance the anticholinergic effect of Glycopyrrolate (Oral Inhalation). Avoid combination

Ipratropium (Oral Inhalation): May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Itopride: Anticholinergic Agents may diminish the therapeutic effect of Itopride. Monitor therapy

Levosulpiride: Anticholinergic Agents may diminish the therapeutic effect of Levosulpiride. Avoid combination

Mianserin: May enhance the anticholinergic effect of Anticholinergic Agents. Monitor therapy

Mirabegron: Anticholinergic Agents may enhance the adverse/toxic effect of Mirabegron. Monitor therapy

Nitroglycerin: Anticholinergic Agents may decrease the absorption of Nitroglycerin. Specifically, anticholinergic agents may decrease the dissolution of sublingual nitroglycerin tablets, possibly impairing or slowing nitroglycerin absorption. Avoid combination

OnabotulinumtoxinA: Anticholinergic Agents may enhance the anticholinergic effect of OnabotulinumtoxinA. Monitor therapy

Oxatomide: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Potassium Chloride: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride. Avoid combination

Pramlintide: May enhance the anticholinergic effect of Anticholinergic Agents. These effects are specific to the GI tract. Consider therapy modification

Ramosetron: Anticholinergic Agents may enhance the constipating effect of Ramosetron. Monitor therapy

RimabotulinumtoxinB: Anticholinergic Agents may enhance the anticholinergic effect of RimabotulinumtoxinB. Monitor therapy

Secretin: Anticholinergic Agents may diminish the therapeutic effect of Secretin. Management: Avoid using drugs with substantial anticholinergic effects in patients receiving secretin whenever possible. If such agents must be used in combination, monitor closely for a diminished response to secretin. Consider therapy modification

Thiazide and Thiazide-Like Diuretics: Anticholinergic Agents may increase the serum concentration of Thiazide and Thiazide-Like Diuretics. Monitor therapy

Tiotropium: Anticholinergic Agents may enhance the anticholinergic effect of Tiotropium. Avoid combination

Topiramate: Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. Monitor therapy

Umeclidinium: May enhance the anticholinergic effect of Anticholinergic Agents. Avoid combination

Adverse Reactions

Frequency not always defined. Severity and frequency of adverse reactions are dose related.

Cardiovascular: Asystole, atrial arrhythmia, atrial fibrillation, atrioventricular dissociation (transient), bigeminy, bradycardia, cardiac dilatation, chest pain, decreased blood pressure, ECG changes (prolonged P wave, shortened PR segment, R on T phenomenon, shortened RT duration, prolonged QT interval, widening of QRS Complex, flattened T wave, repolarization abnormalities, ST segment elevation, retrograde conduction), ectopic beats (atrial), extrasystoles (nodal, ventricular, superventricular), flushing, increased blood pressure, left heart failure, myocardial infarction, nodal arrhythmia (no P wave on ECG), palpitations, sinus tachycardia, supraventricular tachycardia (including junctional tachycardia), tachycardia, trigeminy, ventricular arrhythmia, ventricular fibrillation, ventricular flutter, ventricular premature contractions, ventricular tachycardia, weak pulse (or impalpable peripheral pulses)

Central nervous system: Abnormal electroencephalogram (runs of alpha waves, increase in photic stimulation, and signs of drowsiness), agitation (children), amnesia, anxiety, ataxia, behavioral changes, coma, confusion, decreased deep tendon reflex, delirium, dizziness, drowsiness, dysarthria, dysmetria, excitement, feeling hot, hallucination (visual or aural), headache, hyperpyrexia, hyperreflexia, hypertonia, insomnia, intoxicated feeling, irritability (children), lack of concentration, lethargy (children), mania, mental disorders, myoclonus, neurologic abnormality, nocturnal enuresis, opisthotonus, paranoia, positive Babinski sign, restlessness, seizure (generally tonic-clonic), stupor, unsociability, vertigo

Dermatologic: Anhidrosis, cold skin, dermatitis, dry and hot skin, erythematous rash, hyperhidrosis, macular eruption, maculopapular rash, papular rash, scarlatiniform rash, skin rash

Endocrine & metabolic: Dehydration, hyperglycemia, hypoglycemia, hypokalemia, hyponatremia, increased thirst, loss of libido

Gastrointestinal: Abdominal and bladder distension, abdominal pain, constipation, delayed gastric emptying, diminished bowel sounds, dry mucous membranes, dysphagia, malabsorption, nausea, oral lesion, paralytic ileus, salivation, vomiting, xerostomia

Genitourinary: Difficulty in micturition, impotence, urinary hesitancy, urinary retention, urinary urgency

Hematologic & oncologic: Decreased hemoglobin, increased hemoglobin, increased red blood cell count, leukocytosis, petechiae

Hypersensitivity: Hypersensitivity reaction

Local: Injection site reaction

Neuromuscular & skeletal: Laryngospasm, muscle twitching, weakness

Ophthalmic: Abnormal eye movements (cyclophoria and heterophoria), angle-closure glaucoma (acute), blepharitis, blindness, blurred vision, conjunctivitis, crusted of eyelid, cycloplegia, decreased accommodation, decreased visual acuity, dry eye syndrome, eye irritation, keratoconjunctivitis sicca, lacrimation, mydriasis, photophobia, strabismus

Renal: Increased blood urea nitrogen

Respiratory: Bradypnea, changes in respiration (labored respiration), cyanosis, dyspnea, laryngitis, pulmonary edema, respiratory failure, stridor (inspiratory), tachypnea

Miscellaneous: Failure to thrive, fever (secondary to decreased sweat gland activity), swelling (children), tongue biting

Warnings/Precautions

Concerns related to adverse effects:

• Hyperthermia: In the presence of a high environmental temperature, heat prostration can occur.

• Psychosis: Can occur in sensitive individuals or following use of excessive doses.

• Urinary retention: Avoid use if possible in patients with obstructive uropathy or in other conditions resulting in urinary retention; use is contraindicated in patients with prostatic hypertrophy.

Disease-related concerns:

• Anticholinesterase poisoning: Atropine reverses the muscarinic but not the nicotinic effects associated with anticholinesterase toxicity.

• Arrhythmias: Avoid relying on atropine for effective treatment of type II second-degree or third-degree AV block (with or without a new wide QRS complex). Asystole or bradycardic PEA: Although no evidence exists for significant detrimental effects, routine use is unlikely to have a therapeutic benefit and is no longer recommended (ACLS, 2010).

• Autonomic neuropathy: Use with caution in patients with autonomic neuropathy.

• Cardiovascular disease: Use with caution in patients with myocardial ischemia, HF, tachyarrhythmias (including sinus tachycardia), and/or hypertension; treatment-related blood pressure increases and tachycardia may lead to ischemia, precipitate an MI, or increase arrhythmogenic potential.

• Gastrointestinal disease: Avoid use in patients with paralytic ileus, intestinal atony of the elderly or debilitated patient, severe ulcerative colitis, and toxic megacolon complicating ulcerative colitis.

• Hepatic impairment: Use with caution in patients with hepatic impairment; effects of atropine may be prolonged in severe hepatic impairment.

• Hiatal hernia: Use with caution in patients with hiatal hernia associated with reflux esophagitis.

• Hyperthyroidism: Use with caution in patients with hyperthyroidism.

• Myasthenia gravis: In patients with myasthenia gravis, use atropine with extreme caution when used to treat side effects of acetylcholinesterase inhibition or avoid; may precipitate a myasthenic crisis.

• Renal impairment: Use with caution in patients with renal impairment; effects of atropine may be prolonged in severe renal impairment.

Special populations:

• Heart transplant recipients: Atropine will likely be ineffective in treatment of bradycardia due to lack of vagal innervation of the transplanted heart. Cholinergic reinnervation may occur over time (years), so atropine may be used cautiously; however, some may experience paradoxical slowing of the heart rate and high-degree AV block upon administration (ACLS, 2010; Bernheim, 2004).

• Pediatric: Children may be more sensitive to the anticholinergic effects of atropine. Use with caution in children with spastic paralysis.

Dosage form specific issues:

• AtroPen®: There are no absolute contraindications for the use of atropine in severe and life-threatening organophosphate or carbamate insecticide or nerve agent poisonings; however, in mild poisonings, use caution in those patients where the use of atropine would be otherwise contraindicated. Formulation for use by trained personnel only.

Other warnings/precautions:

• Appropriate use: Anticholinesterase poisoning: Clinical symptoms consistent with highly-suspected organophosphate or carbamate insecticides or nerve agent poisoning should be treated with antidote immediately; administration should not be delayed for confirmatory laboratory tests. Signs of atropinization include flushing, mydriasis, tachycardia, and dryness of the mouth or nose. Monitor effects closely when administering subsequent injections as necessary. The presence of these effects is not indicative of the success of therapy; inappropriate use of mydriasis as an indicator of successful treatment has resulted in atropine toxicity. Reversal of bronchial secretions is the preferred indicator of success. Adjunct treatment with a cholinesterase reactivator (eg, pralidoxime) may be required in patients with toxicity secondary to organophosphorus insecticides or nerve agents. Treatment should always include proper evacuation and decontamination procedures; medical personnel should protect themselves from inadvertent contamination. Antidotal administration is intended only for initial management; definitive and more extensive medical care is required following administration. Individuals should not rely solely on antidote for treatment, as other supportive measures (eg, artificial respiration) may still be required.

Monitoring Parameters

Heart rate, blood pressure, pulse, mental status; intravenous administration requires a cardiac monitor

Organophosphate or carbamate insecticide or nerve agent poisoning: Heart rate, blood pressure, respiratory status, oxygenation secretions. Maintain atropinization with repeated dosing as indicated by clinical status. Crackles in lung bases, or continuation of cholinergic signs, may be signs of inadequate dosing. Pulmonary improvement may not parallel other signs of atropinization. Monitor for signs and symptoms of atropine toxicity (eg, fever, muscle fasciculations, delirium); if toxicity occurs, discontinue atropine and monitor closely.

Consult individual institutional policies and procedures.

Pregnancy Risk Factor

B/C (manufacturer specific)

Pregnancy Considerations

Adverse events were not observed in animal reproduction studies (studies not conducted by all manufacturers). Atropine has been found to cross the human placenta (Kanto 1981). In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant women if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (Jeejeebhoy [AHA] 2015).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience blurred vision, sensitivity to light, constipation, lack of sweating, dry mouth, nasal dryness, flushing, headache, enlarged pupils, injection site pain, nausea, or vomiting. Have patient report immediately to prescriber urinary retention, change in amount of urine passed, tachycardia, abnormal heartbeat, severe dizziness, passing out, difficulty breathing, slow breathing, shallow breathing, confusion, change in balance, hallucinations, severe loss of strength and energy, agitation, tremors, abdominal edema, sexual dysfunction, decreased libido, or depression (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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