Adult Dosing

Organophosphate, carbamate insecticide poisoning

Atropen

• >41 Kg
• Start with 2 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms administer 2 mg up to 3 times

Organophosphate nerve agent poisoning

Atropen

• >41 Kg
• Start with 2 mg IM for mild symptoms; on progressing of symptoms repeat q10 mins up to 2 times
• For severe symptoms administer 2 mg up to 3 times

• Notes:
• Immediate evacuation from the contaminated environment is necessary. Decontamination of the poisoned individual should occur as early as possible
• Should be used only by persons having adequate training in the recognition and treatment of nerve agent or insecticide intoxication
• Administer as soon as symptoms of organophosphorous or carbamate poisoning appear
• For moderate-severe poisoning, the administration of more than one dose may be required until atropinization is achieved
• In severe poisoning, it may be desirable to concurrently administer an anticonvulsant if there is suspicion of seizure in the unconscious individual as the classic tonic-clonic jerking may not be apparent due to the effects of the poison
• Concurrently administer a cholinesterase reactivator such as pralidoxime chloride in poisonings due to organophosphorous nerve agents and insecticides
• Keep 3 AtroPen Auto-Injectors ready for use in each person at risk for nerve agent or organophosphate insecticide poisoning; one for mild symptoms plus two more for severe symptoms. Do not use more than three AtroPen injections unless the patient is under the supervision of a trained medical provider

Advanced cardiac life support (ACLS), asystole/ Pulseless electrical activity (PEA)

Atropine sulfate

• 1 mg IV/IO q3-5 mins as required
• Max: 3 mg total

ACLS, bradycardia

Atropine sulfate

• 0.5 mg IV q3-5min as required
• Max: 3 mg total

Adjunct to anesthesia

Atropine sulfate

• Antisialogogue
• 0.4-0.6 mg SC/IM/IV q4-6 hrs as required
• Administer 1st dose 30-60min prior to surgery

Adjunct to neuromuscular blockade reversal

Atropine sulfate

• 0.6-1.2 mg IV for q 0.5-2.5 mg neostigmine, 10-20 mg pyridostigmine, or 10-20 mg edrophonium

Organophosphate nerve agent poisoning

Atropine sulfate

• Start with 2-4 mg IM for mild-moderate symptoms
• For severe symptoms, administer 6 mg
• For geriatric patients: Start with 1 mg IM for mild-moderate symptoms; administer 2-4 mg IM for severe symptoms

Organophosphate or carbamate insecticide poisoning

Atropine sulfate

• Start with 2 mg IM/IV for mild-moderate symptoms
• For severe symptoms, administer 4-6 mg IM/IV

• Administration of < 0.5 mg can produce a paradoxical bradycardia
• Titration intervals of 1-2 hrs are recommended in normal circumstances

Pediatric Dosing

Organophosphate, carbamate insecticide poisoning

Atropen

• 7-18 kg, 6 months-4yrs
• Start with 0.5 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms, administer 0.5 mg up to 3 times

• 18-41 kg, 4-10 yrs
• Start with 1 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms, administer 1 mg up to 3 times

• >41 kg, >10 yrs
• Start with 2 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms, administer 2 mg up to 3 times

Organophosphate nerve agent poisoning

Atropen

• 7-18 kg, 6 months-4yrs
• Start with 0.5 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms, administer 0.5 mg up to 3 times

• 18-41 kg, 4-10 yrs
• Start with 1 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms, administer 1 mg up to 3 times

• >41 kg, >10 yrs
• Start with 2 mg IM for mild symptoms; on progression of symptoms, repeat q10 mins up to 2 times
• For severe symptoms, administer 2 mg up to 3 times

Pediatric advanced life support (PALS), bradycardia

Atropine sulfate

• 0.02 mg/kg IV/IO
• Alt: 0.03 mg/kg ETT x1
• Min: 0.1 mg/dose; Max: 0.5 mg/dose (child), 1 mg/dose (adolescent)
• May repeat the dose once

Adjunct to anesthesia

Atropine sulfate

• As an antisialogogue, <5 kg
• 0.02 mg/kg SC/IM/IV q4-6 hrs as needed; administer first dose 30-60 min prior to surgery

• As an antisialogogue, >5 kg
• 0.01-0.02 mg/kg SC/IM/IV q4-6 hrs; administer first dose 30-60 min prior to surgery

Adjunct to neuromuscular blockade reversal

Atropine sulfate

• 0.02 mg/kg IV for q 0.04 mg/kg neostigmine or 0.5-1 mg/kg edrophonium

Organophosphate nerve agent poisoning

Atropine sulfate

• <2 yrs
• 0.05 mg/kg IM or 0.02 mg/kg IV q5-10 mins as required
• Start with 0.05 mg/kg IM x1 for mild-moderate symptoms
• For severe symptoms administer 0.1 mg/kg

• 2-10 yrs
• 1 mg IM/IV q5-10min as required
• Start with 1 mg IM x1 for mild-moderate symptoms
• For severe symptoms administer 2 mg

• >10 yrs
• 2 mg IM/IV q5-10 mins as required
• Start with 2 mg IM x1 for mild-moderate symptoms
• For severe symptoms administer 4 mg

Organophosphate or carbamate insecticide poisoning

Atropine sulfate

• <2 yrs
• 0.05 mg/kg IM or 0.02 mg/kg IV q10-30 mins as required

• 2-10 yrs
• 1-2 mg IM/IV q10-30 mins as required
• Start with 1 mg IM/IV x 1

• >10 yrs
• 1-2 mg IM/IV q10-30 mins as required
• Start with 2 mg IM/IV x 1

• Administration of < 0.1 mg can produce paradoxical bradycardia

[Outline]

• Adult Dosing
• Pediatric Dosing

• Atropine sulfate
• As an antisialogogue when reduction of secretions of the respiratory tract are needed; routine use as a preanesthetic agent is discouraged
• To blunt the increased vagal tone produced by intra-abdominal traction or ocular muscle traction; routine use to prevent such events is discouraged
• To temporarily increase heart rate or decrease AV-block until definitive intervention, when bradycardias or AV-block are judged to be hemodynamically significant and thought to be due to excess vagal tone
• As an antidote for inadvertent overdose of cholinergic drugs or for cholinesterase poisoning such as from organophosphorous insecticides
• Antidote for the rapid type of mushroom poisoning due to the presence of the alkaloid, muscarine, in certain species of fungus such as Amanita muscaria
• To alleviate the muscarinic side effects of anticholinesterase drugs used for reversal of neuromuscular blockade

• Atropen
• Treatment of poisoning by susceptible organophosphorous nerve agents having cholinesterase activity, organophosphorous or carbamate insecticides
• Initial treatment of the muscarinic symptoms of insecticide or nerve agent poisonings (breathing difficulties due to increased secretions); definitive medical care should be provided immediately

• Hypersensitivity to any of the ingredients of the product
• Acute angle-closure glaucoma
• Obstructive uropathy
• Paralytic ileus
• Toxic megacolon
• Asthma or COPD
• Myasthenia gravis
• Pyloric stenosis
• Prostatic hypertrophy

• N/A

Renal Dose Adjustment

• Renal impairment: Dose adjustments not defined

Hepatic Dose Adjustment

• Hepatic adjustment: Dose adjustments not defined

• Wear protective garments including masks for primary protection against exposure to chemicals nerve agent and insecticides
• Do not rely solely upon the availability of antidotes such as atropine and pralidoxime to provide complete protection from chemical nerve agent and insecticide poisoning
• Immediate medical attention should be sought after injection with Atropen
• Treat patients with previous anaphylactic reactions to atropine having mild symptoms of organophosphorous or nerve agent poisoning with adequate medical supervision
• Children and the geriatric patients are more prone to the pharmacologic effects of atropine
• Artificial respiration is required in addition to atropine for severe difficulty in breathing
• Precipitation of acute glaucoma in susceptible individuals, conversion of partial pyloric stenosis into complete pyloric obstruction, precipitation of urinary retention in individuals with prostatic hypertrophy, or inspissation of bronchial secretions and formation of dangerous viscid plugs in individuals with chronic lung disease have occurred on conventional systemic doses
• Take utmost care to avoid overdosage, especially with intravenous administration
• IV administration decreases the rate of mexiletine absorption without altering the relative oral bioavailability; this delay in mexiletine absorption is reversed by the combination of atropine and IV metoclopramide during pretreatment for anesthesia
• Initiate treatment of organophosphorous nerve agent and insecticide poisoning without waiting for the results of laboratory tests
• Measure red blood cell, plasma cholinesterase, and urinary paranitrophenol in the case of parathion exposure for confirming the diagnosis and following the course of the illness
• A reduction in red blood cell and cholinesterase levels to less than 50% of normal is seen only with organophosphorous ester poisoning

Cautions: Use cautiously in:

• Significant renal insufficiency
• Recent myocardial infarction
• Disorders of heart rhythm such as atrial flutter
• Arrhythmias
• GI obstruction
• Prostatic hypertrophy
• Severe ulcerative colitis
• High environmental temperature
• Hyperthyroidism
• Pediatric patients
• Geriatric patients
• Down syndrome
• Brain damage

Atropen interacts with :

	Aricept
	Aricept ODT
	Donepezil
	Exelon
	Galantamine
	Razadyne
	Razadyne ER
	Rivastigmine

Pregnancy Category:C

Breastfeeding: Literature unavailable on the use of atropine during breastfeeding. Prolonged use of atropine might reduce milk production/milk letdown, but a single systemic or ophthalmic dose is unlikely to interfere with breastfeeding. During prolonged use, observe for signs of decreased lactation such as insatiety, poor weight gain. This information is available at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT last accessed 23 December 2010). Atropine is excreted in human milk in trace amounts. Manufacturer advises caution when administered in nursing mothers.

• CNS: Coma, hallucinations, depression, headache, dizziness, ataxia, seizures, insomnia, confusion, impaired body temperature regulation, restlessness, tremor, fatigue, motor difficulties, delirium, medullary paralysis
• PSYCHIATRIC: Psychosis, behavioral disturbances
• CV: Severe bradycardia, circulatory collapse, hypotension, arrhythmias, tachycardia, palpitations
• EENT: Blurred vision, increased IOP, mydriasis
• GI: Abdominal distension, constipation, nausea, vomiting, paralytic ileus, dry mouth
• DERM: Flushing, anhidrosis
• RESP: Respiratory failure, pulmonary edema, laryngospasm
• LOCAL: Injection site pain
• GU: Urinary hesitancy and retention, decreased libido. impotence
• MISC: Anaphylaxis, photophobia, rash, exfoliation

• Antimuscarinic; inhibits the muscarinic actions of acetylcholine and other cholinergic stimuli at postganglionic cholinergic receptors and on smooth muscles, which respond to endogenous acetylcholine but are not so innervated
• Metabolized by liver
• Excreted in urine (30-50% unchanged)
• Half life:
• Children >2 yrs: 2.5 +/- 1.2 hrs
• Adults: 3 +/- 0.9 hrs
• Geriatric patients: 10 +/- 7.3 hrs

US Trade Name(s)

• Atropen

US Availability

atropine sulfate

• INJ: 0.05 mg/mL
• INJ: 1 mg/mL

Atropen

• INJ: 0.25 mg/0.3 mL
• INJ: 0.5 mg/0.7 mL
• INJ: 1 mg/0.7 mL
• INJ: 2 mg/0.7 mL

Canadian Trade Name(s)

• Only generic available

Canadian Availability

atropine sulfate

• INJ: 0.1 mg/mL
• INJ: 0.3 mg/mL
• INJ: 0.4 mg/mL
• INJ: 0.6 mg/mL
• INJ: 1 mg/mL

UK Trade Name(s)

• Only generic available

UK Availability

atropine (generic)

• INJ: 0.1 mg/mL (5, 10, 30 mL)
• INJ: 0.5 mg/mL (1 mL amp)
• INJ: 0.6 mg/mL (1 mL amp)
• INJ (prefilled syringes): 0.1 mg/mL (5, 10, 30 mL)
• INJ (prefilled syringes): 0.2 mg/mL (5 mL)
• INJ (prefilled syringes): 0.3 mg/mL (10 mL)
• INJ (prefilled syringes): 0.6 mg/mL (1 mL)

Australian Trade Name(s)

• Only generic available

Australian Availability

atropine (generic)

• INJ: 0.4 mg/mL (1 mL amp)
• INJ: 0.5 mg/mL (1 mL amp)
• INJ: 0.6 mg/mL (1 mL amp)
• INJ: 1.2 mg/mL (1 mL amp)
• INJ (prefilled syringes): 0.1 mg/mL (10 mL)

[Outline]

Gastrointestinal

Anticholinergics/Antispasmodics (GI)

Emergency/Critical Care

Antidotes