Atropine: Uses, Indications, Dosages, Precautions, Contraindications, Side Effects & Interactions

Atropine

(at-roe-peen)
Classification 
Pharmacotherapeutic: Acetylcholine antagonist
Clinical: Antiarrhythmic, antispasmodic, antidote, cycloplegic, antisecretory, anticholinergic, ophthalmics, preanesthetics

Atreza

AtroPen

Atropine Sulfate

Sal-Tropine

Isopto-Atropine

CATEGORY AND SCHEDULE

Pregnancy Risk Category: C

Do not confuse:

Atropine with Akarpine or Aplisol

General Information

Atropine is an anticholinergic drug. Due to its antispasmodic action, which relaxes the muscle wall of the intestine, the drug has been used to relieve abdominal cramps in irritable bowel syndrome. Atropine can also be prescribed in combination with diphenoxylate, an antidiarrheal drug. However, this combination can be dangerous in the event of an overdose, particularly in young children. Atropine eye drops are used to enlarge the pupil during eye exams and are part of the treatment of inflammatory eye disorders such as uveitis. Atropine can be used as part of premedication before a general anaesthetic. The drug is occasionally injected to restore normal heart rhythm in the heart block. Atropine should be used with caution in children and the elderly due to their sensitivity to the effects of the drug

Atropine can cause serious reactions, such as: Overdose can cause rapid heartbeat or, tachycardia, palpitations, hot / dry / red skin, no bowel sounds, increased breathing rate, nausea, vomiting, confusion, drowsiness, slurred speech, dizziness, CNS stimulation. Overdose can also produce psychosis evidenced by agitation, restlessness, rambling speech, visual hallucinations, paranoid behavior, delusions, followed by depression. Ophthalmic form can rarely cause  increased IOP

Action

An acetylcholine antagonist that inhibits acetylcholine action by competing with acetylcholine for common binding sites on muscarinic receptors, found in exocrine glands, cardiac and smoothmuscle ganglia, and intramural neurons. This action blocks all muscarinic effects

Therapeutic Effect

Decreases gastrointestinal motility and secretory activity and genitourinary muscle tone (ureter, bladder); abolishes various types of reflex vagal cardiac slowing or asystole, produces ophthalmic cycloplegia and mydriasis

Availability (Rx)

Injection: 0.05 mg/mL, 0.1 mg/mL, 0.4 mg/mL, 1 mg/mL

Injection (Autoinjectors): 0.25 mg, 0.5 mg, 1 mg, 2 mg

Ophthalmic Ointment: 1%

Ophthalmic Solution: 1%

Tablets: 0.4 mg

Uses

Bradycardia ＜40-50 bpm, bradydysrhythmia, reversal of anticholinesterase agents, insecticide poisoning, blocking cardiac vagal reflexes, decreasing secretions before surgery, antispasmodic with GU and biliary surgery, bronchodilator, AV heart block

Unlabeled uses: Cardiac arrest, CPR, diarrhea, pulseless electrical activity, ventricular asystole, asthma

Precautions

Pregnancy C, breastfeeding, child ,6 yr, geriatric, renal disease, CHF, hyperthyroidism, COPD, hypertension, intraabdominal infections, Down syndrome, spastic paralysis, gastric ulcer

Make sure to tell your doctor if:

• You have long-term liver or kidney problems

• You have prostate problems

• You have gastro-oesophageal reflux

• You have glaucoma

• You have urinary difficulties

• You have ulcerative colitis

• You wear contact lenses (eye drops)

• You have heart problems

• You are taking other medicines

Indications and Dosages

‣ To Treat Asystole, slow pulseless electrical activity

IV

• Adults, Elderly. 1 mg; may repeat q3-5min up to total dose of 0.04 mg/kg. Normal maximum: 3 mg total

‣ To Treat Bradycardia/bradydysrhythmias

IV

• Adult: bol 0.5-1 mg given q3-5min, not to exceed 3 mg

• Child: bol 0.01-0.03 mg/kg up to 0.4 mg or 0.3 mg/m2; may repeat q4-6hr, min dose 0.1 mg to avoid paradoxical reaction, max single dose 0.5 mg

‣ To Treat reduction salivation and bronchial secretions

PO

• Adults: 0.4 mg

• Children: Weight-based doses: 7-16 lb, 0.1 mg; 17-24 lb, 0.15 mg; 24-40 lb, 0.2 mg; 40-65 lb, 0.3 mg; 65-90 lb, 0.4 mg; over 90 lb, 0.4 mg

‣ To Treat Cycloplegia/mydriasis

OPHTHALMIC

• Adults: 1 drop of solution in the eye 3 times a day or small amount of ointment in the eye once or twice daily

‣ To Treat Organophosphate nerve agent or insecticide poisoning

IM (AUTO-INJECTOR)

• Adults, Elderly, and Children > 41kg or over 10 yr of age: 2 mg; may repeat up to 3 doses as directed until under medical care

• Children 18-41 kg or roughly 4-10 yr of age: 1 mg; may repeat up to 3 doses as directed

• Children 7-18 kg or roughly 6 mo-4 yr of age: 0.5 mg; may repeat up to 3 doses as directed

• Infants < 7 kg or < 6 mo of age: 0.25 mg; may repeat up to 3 doses as directed

‣ Presurgery

SUBCUT/IM/ IV

• Adult and child .20 kg:0.4- 0.6 mg 30-60 min before anesthesia

IM/SUBCUT

• Child ,20 kg: 0.01 mg/kg up to 0.4 mg ½-1 hr preop, max 0.6 mg/dose

‣ Dosage in Renal/Hepatic Impairment

• No dose adjustment

Pharmacokinetics

Rapidly absorbed after oral administration. Crosses blood-brain barrier. Renally eliminated. Not removed by hemodialysis. Half-life: 2.5 h

Implementation

PO route

• PO without regard to meals

• Give increased bulk, water in diet if constipation occurs (anticholinergic effect)

IM route

• Expect atropine flush 15-20 min after inj; it may occur in children and is not harmful

AtroPen

• Use no more than 3 AtroPen injections unless under the supervision of trained provider

• Use as soon as symptoms appear (tearing, wheezing, muscle fasciculations, excessive oral secretions)

IV route

• Give IV undiluted or diluted with 10 ml sterile water; give at a rate of 0.6 mg/min; give through Y-tube or 3-way stopcock; do not add to IV sol; may cause paradoxical bradycardia lasting 2 min

Contraindications

Generally contraindicated in patients with glaucoma, pyloric stenosis,

or prostatic hypertrophy, except in doses usually used for preanesthesia or when emergency exists (e.g., nerve agent poisoning or ACLS protocol)

Cautions: Autonomic neuropathy, paralytic ileus, intestinal atony, severe ulcerative colitis, toxic megacolon, renal/hepatic impairment, myocardial ischemia, hyperthyroidism, hypertension, tachyarrhythmias, HF, coronary artery disease, esophageal reflux or hiatal hernia associated with reflux esophagitis; infants, children with spastic paralysis or brain damage; elderly; biliary tract disease, chronic pulmonary disease

Interactions

Individual drugs

• Amantadine: increased anticholinergic effects

• Ketoconazole, levodopa: decreased absorption

• Potassium chloride (oral): increased mucosal lesions

Drug classifications

• Antacids: decreased absorption of atropine

• Antidepressants (tricyclic), antiparkinson

• agents: increased anticholinergic effect

Drug/laboratory tests

• None significant

Drugs/food

• None known

Herbal

• None significant

Side effects

• CNS: Agitation, amnesia, anxiety, ataxia, Babinski’s or Chaddock’s reflex, behavioral changes, CNS stimulation (at high doses), coma, confusion, decreased concentration, decreased tendon reflexes, delirium, dizziness, drowsiness, fever, hallucinations, headache, hyperreflexia, insomnia, lethargy, mania, mental disorders, nervousness, paranoia, restlessness, seizures, somnolence, stupor, syncope, vertigo, weakness

• CV: Arrhythmias, bradycardia (at low doses), cardiac dilation, chest pain, hypertension, hypotension, left ventricular failure, MI, palpitations, tachycardia (at high doses), weak or impalpable peripheral pulses

• EENT: Acute angle-closure glaucoma, altered taste, blepharitis, blindness, blurred vision, conjunctivitis, cyclophoria, cycloplegia, decreased visual acuity or accommodation, dry eyes or conjunctiva, dry mucous membranes, dry mouth, eye irritation, eyelid crusting, heterophoria, increased intraocular pressure, keratoconjunctivitis, lacrimation, laryngitis, laryngospasm, mydriasis, nasal congestion, oral lesions, photophobia, pupils poorly reactive to light, strabismus, tongue chewing

• GI: Abdominal distention, abdominal pain, bloating, constipation, decreased bowel sounds or food absorption, delayed gastric emptying, dysphagia, heartburn, ileus, nausea, vomiting

• GU: Bladder distention, enuresis, impotence, urinary hesitancy, urinary urgency, urine retention

• MS: Dysarthria, hypertonia, muscle twitching

• RESP: Bradypnea, dyspnea, inspiratory stridor, pulmonary edema, respiratory failure, shallow breathing, subcostal recession, tachypnea

• SKIN: Cold skin, cyanosis, decreased sweating, dermatitis, flushing, rash, urticaria

• Other: Anaphylaxis, dehydration, injection site reaction, polydipsia, sensations of warmth

 

Nursing considerations

Baseline assessment

• Determine if pt is sensitive to atropine, homatropine, scopolamine

Intervention/evaluation

• Monitor changes in B/P, pulse, temperature. Observe for tachycardia if pt has cardiac abnormalities

• Assess skin turgor, mucous membranes to evaluate hydration status (encourage adequate fluid intake unless NPO for surgery), bowel sounds for peristalsis. Be alert for fever (increased risk of hyperthermia)

• Monitor I&O, palpate bladder for urinary retention

• Monitor daily pattern of bowel activity, stool consistency

Equipment must be available for anaphylaxis

• Monitor I&O ratio; check for urinary retention and daily output in geriatric or postoperative patients

• Monitor ECG for ectopic ventricular beats, PVC, tachycardia in cardiac patients

• Monitor for bowel sounds; check for constipation; abdominal distention and constipation may occur

• Monitor respiratory status: rate, rhythm, cyanosis, wheezing, dyspnea, engorged neck veins

• Monitor cardiac rate: rhythm, character, B/P continuously

• Monitor allergic reaction: rash, urticaria Patient/family education

• Advise patient not to perform strenuous activity in high temperatures; heat stroke may result

• Instruct patient to take as prescribed; not to skip doses

• Instruct patient to report change in vision; blurring or loss of sight; trouble breathing; sweating; flushing, chest pain, allergic reactions, constipation, urinary retention, to use sunglasses to protect the eyes

• Caution patient not to operate machinery if drowsiness occurs

• Advise patient not to take OTC products without approval of physician

• Teach patient not to freeze or expose to light (Astropen)

Evaluation

Positive therapeutic result

• Decreased dysrhythmias

• Increased heart rate

• Decreased secretions, GI, GU spasms

• Bronchodilatation

Patient/family teaching

• Advise patient not to perform strenuous activity in high temperatures; heat stroke may result

• Instruct patient to take atropine sulfate 30 to 60 minutes before meals

• Instruct patient to take as prescribed; not to skip doses

• For patient prescribed an AtroPen to carry because of risk of nerve gas or insecticide exposure, explain when and how to selfadminister the drug

• Instruct patient to report change in vision; blurring or loss of sight; trouble breathing; sweating; flushing, chest pain, allergic reactions, constipation, urinary retention, to use sunglasses to protect the eyes

• Caution patient not to operate machinery if drowsiness occurs

• Advise patient not to take OTC products without approval of physician

• Advise patient to notify prescriber if he has persistent or severe diarrhea, constipation, or difficulty urinating

Treatment of Overdose:

O2, artificial ventilation, ECG; administer DOPamine for circulatory depression; administer diazepam or thiopental for seizure; assess need for antidysrhythmics