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Name /bks_53161_deglins_md_disk/atropine 02/20/2014 01:39PM Plate # 0-Composite pg 1 # 1 1 Contraindications/Precautions Contraindicated in: Hypersensitivity; Angle-closure glaucoma; Acute hemor- atropine (at-ro-peen) rhage; Tachycardia secondary to cardiac insufficiency or thyrotoxicosis; Obstructive disease of the GI tract. Use Cautiously in: Intra-abdominal infections; Prostatic hyperplasia; Chronic renal, hepatic, pulmonary, or cardiac disease; OB, Lactation: Safety not established; IV administration may produce fetal tachycardia; Pedi: Infants with Down syndrome have increased sensitivity to cardiac effects and mydriasis. Children may have increased susceptibility to adverse reactions. Exercise care when prescribing to children with spastic paralysis or brain damage; Geri: Increased susceptibility to adverse reactions. Atro-Pen Classification Therapeutic: antiarrhythmics Pharmacologic: anticholinergics, antimuscarinics Pregnancy Category C Indications IM: Given preoperatively to decrease oral and respiratory secretions. IV: Treatment of sinus bradycardia and heart block. IV: Reversal of adverse muscarinic effects of anticholinesterase agents (neostigmine, physostigmine, or pyridostigmine). IM, IV: Treatment of anticholinesterase (organophosphate pesticide) poisoning. Inhaln: Treatment of exercise-induced bronchospasm. Action Inhibits the action of acetylcholine at postganglionic sites located in: Smooth muscle, Secretory glands, CNS (antimuscarinic activity). Low doses decrease: Sweating, Salivation, Respiratory secretions. Intermediate doses result in: Mydriasis (pupillary dilation), Cycloplegia (loss of visual accommodation), Increased heart rate. GI and GU tract motility are decreased at larger doses. Therapeutic Effects: Increased heart rate. Decreased GI and respiratory secretions. Reversal of muscarinic effects. May have a spasmolytic action on the biliary and genitourinary tracts. Pharmacokinetics Absorption: Well absorbed following subcut or IM administration. Distribution: Readily crosses the blood-brain barrier. Crosses the placenta and enters breast milk. Metabolism and Excretion: Mostly metabolized by the liver; 30– 50% excreted unchanged by the kidneys. Half-life: Children ⬍2 yr: 4– 10 hr; Children ⬎2 yr: 1.5– 3.5 hr; Adults: 4– 5 hr. TIME/ACTION PROFILE (inhibition of salivation) ROUTE ONSET PEAK DURATION IM, subcut IV rapid immediate 15–50 min 2–4 min 4–6 hr 4–6 hr ⫽ Canadian drug name. ⫽ Genetic Implication. Adverse Reactions/Side Effects CNS: drowsiness, confusion, hyperpyrexia. EENT: blurred vision, cycloplegia, photophobia, dry eyes, mydriasis. CV: tachycardia, palpitations, arrhythmias. GI: dry mouth, constipation, impaired GI motility. GU: urinary hesitancy, retention, impotency. Resp: tachypnea, pulmonary edema. Misc: flushing, decreased sweating. Interactions Drug-Drug:qanticholinergic effects with other anticholinergics, including antihistamines, tricyclic antidepressants, quinidine, and disopyramide. Anticholinergics may alter the absorption of other orally administered drugs by slowing motility of the GI tract. Antacidspabsorption of anticholinergics. MayqGI mucosal lesions in patients taking oral potassium chloride tablets. May alter response to beta-blockers. Route/Dosage Preanesthesia (To Decrease Salivation/Secretions) IM, IV, Subcut (Adults): 0.4– 0.6 mg 30– 60 min pre-op. IM, IV, Subcut (Children ⬎ 5 kg): 0.01– 0.02 mg/kg/dose 30– 60 min preop to a maximum of 0.4 mg/dose; minimum: 0.1 mg/dose. IM, IV, Subcut (Children ⬍ 5 kg): 0.02 mg/kg/dose 30– 60 min preop then q 4– 6 hr as needed. Bradycardia IV (Adults): 0.5– 1 mg; may repeat as needed q 5 min, not to exceed a total of 2 mg (q 3– 5 min in Advanced Cardiac Life Support guidelines) or 0.04 mg/kg (total vagolytic dose). CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued. PDF Page #1 Name /bks_53161_deglins_md_disk/atropine 02/20/2014 01:39PM 2 IV (Children): 0.02 mg/kg (maximum single dose is 0.5 mg in children and 1 mg in adolescents); may repeat q 5 min up to a total dose of 1 mg in children (2 mg in adolescents). Endotracheal (Children): use the IV dose and dilute before administration. Reversal of Adverse Muscarinic Effects of Anticholinesterases IV (Adults): 0.6– 12 mg for each 0.5– 2.5 mg of neostigmine methylsulfate or 10– 20 mg of pyridostigmine bromide concurrently with anticholinesterase. Organophosphate Poisoning IM (Adults): 2 mg initially, then 2 mg q 10 min as needed up to 3 times total. IV (Adults): 1– 2 mg/dose q 10– 20 min until atropinic effects observed then q 1– 4 hr for 24 hr; up to 50 mg in first 24 hr and 2 g over several days may be given in severe intoxication. IM (Children ⬎10 yr ⬎90 lbs): 2 mg. IM (Children 4– 10 yr 40– 90 lbs): 1 mg. IM (Children 6 mo– 4 yr 15– 40 lbs): 0.5 mg. IV (Children): 0.02– 0.05 mg/kg q 10– 20 min until atropinic effects observed then q 1– 4 hr for 24 hr. Bronchospasm Inhaln (Adults): 0.025– 0.05 mg/kg/dose q 4– 6 hr as needed; maximum 2.5 mg/ dose. Inhaln (Children): 0.03– 0.05 mg/kg/dose 3– 4 times/day; maximum 2.5 mg/ dose. NURSING IMPLICATIONS Assessment ● Assess vital signs and ECG tracings frequently during IV drug therapy. Report any significant changes in heart rate or BP, or increased ventricular ectopy or angina to health care professional promptly. ● Monitor intake and output ratios in elderly or surgical patients because atropine may cause urinary retention. Plate # 0-Composite pg 2 # 2 ● Assess patients routinely for abdominal distention and auscultate for bowel sounds. If constipation becomes a problem, increasing fluids and adding bulk to the diet may help alleviate constipation. ● Toxicity and Overdose: If overdose occurs, physostigmine is the antidote. Potential Nursing Diagnoses Decreased cardiac output (Indications) Impaired oral mucous membrane (Side Effects) Constipation (Side Effects) Implementation ● IM: Intense flushing of the face and trunk may occur 15– 20 min following IM ad- ministration. In children, this response is called “atropine flush” and is not harmful. IV Administration ● Direct IV: Diluent: Administer undiluted. Rate: Administer over 1 min; more rapid administration may be used during cardiac resuscitation (follow with 20 mL saline flush). Slow administration (over ⬎1 min) may cause a paradoxical bradycardia (usually resolved in approximately 2 min). ● Y-Site Compatibility: abciximab, alfentanyl, amikacin, aminophylline, amiodarone, argatroban, ascorbic acid, azathioprine, aztreonem, benztropine, bivalirudin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, cefazolin, cefoperazone, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, clindamycin, cyanocobalamin, cyclosporine, dexamethasone, dexmedetomidine, digoxin, diphenhydramine, dobutamine, dopamine, doripenem, doxycycline, enalaprilat, ephedrine, epinephrine, epoetin alfa, eptifibatide, erythromycin, esmolol, etomidate, famotidine, fenoldopam, fentanyl, fluconazole, folic acid, furosemide, ganciclovir, gentamicin, glycopyrrolate, heparin, hydrocortisone sodium succinate, hydromorphone, imipenem/cilastatin, indomethacin, insulin, isoproterenol, ketamine, ketorolac, labetalol, lidocaine, magnesium sulfate, mannitol, meperidine, meropenem, methadone, methyldopate, methylprednisolone, metoclopramide, metoprolol, midazolam, morphine, multivitamins, nafcillin, nalbuphine, naloxone, nitroglycerin, nitroprusside, norepinephrine, ondansetron, oxacillin, oxytocin, palonosetron, papaverine, penicillin G, pentamidine, pentazocine, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, protamine, pyri䉷 2015 F.A. Davis Company CONTINUED PDF Page #2 Name /bks_53161_deglins_md_disk/atropine 02/20/2014 01:39PM Plate # 0-Composite pg 3 # 3 3 PDF Page #3 CONTINUED atropine doxime, ranitidine, sodium bicarbonate, streoptkinase, succinylcholine, sufentanil, theophylline, thiamine, ticarcillin/clavulanate, tirofiban, tobramycin, tolazoline, vancomycin, vasopressin, verapamil, vitamin B complex with C. ● Y-Site Incompatibility: amphotericin B colloidal, dantrolene, diazepam, diazoxide, pantoprazole, phenytoin, trimethoprim/sulfamethoxazole, thiopental. ● Endotracheal: Dilute with 5– 10 mL of 0.9% NaCl. ● Rate: Inject directly into the endotracheal tube followed by several positive pressure ventilations. Patient/Family Teaching ● May cause drowsiness. Caution patients to avoid driving or other activities requir- ing alertness until response to medication is known. ● Instruct patient that oral rinses, sugarless gum or candy, and frequent oral hygiene may help relieve dry mouth. ● Caution patients that atropine impairs heat regulation. Strenuous activity in a hot environment may cause heat stroke.Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications. ● Pedi: Instruct parents or caregivers that medication may cause fever and to notify health care professional before administering to a febrile child. ● Geri: Inform male patients with benign prostatic hyperplasia that atropine may cause urinary hesitancy and retention. Changes in urinary stream should be reported to health care professional. Evaluation/Desired Outcomes ● Increase in heart rate. ● Dryness of mouth. ● Reversal of muscarinic effects. Why was this drug prescribed for your patient? ⫽ Canadian drug name. ⫽ Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough ⫽ Discontinued.