Atro

AHFS DI® Essentials™ Page 1 of 27
Atropine (Systemic)
Introductory Information
Antimuscarinic; a naturally occurring tertiary amine.
Class: 12:08.08 Antimuscarinics/Antispasmodics; au350 (VA primary)
Brands*: AtroPen®, Sal-Tropine®
*also available generically
Generic Name: Atropine

CAS Number: 51-55-8
Synonym: d,l-Hyoscyamine
Boxed Warning
Pesticide and Chemical Warfare Agent Poisoning
• Primary protection against exposure to chemical nerve agents and insecticide poisoning is the wearing
of protective garments (e.g., specialized masks).105
• Do not rely solely on antidotes such as atropine and pralidoxime to provide complete protection from
chemical nerve agents and insecticide poisoning.105
• Seek immediate medical attention after injection with an atropine auto-injector.105
Uses
Surgery
To inhibit salivation and excessive secretions of the respiratory tract (antisialogogue).b, f However,
current surgical practice (e.g., using general anesthetics that do not stimulate salivary and
tracheobronchial secretions) has reduced the need to control excessive respiratory secretions during
surgery.b
To prevent other cholinergic effects during surgery (e.g., cardiac arrhythmias, hypotension, bradycardia)
secondary to visceral or ocular traction (resultant vagal stimulation), carotid sinus stimulation, or
concomitant drugs (e.g., succinylcholine).b, f
To block adverse muscarinic effects of anticholinesterase agents that are used after surgery to terminate
curarization.b, f
Ineffective for preventing acid-aspiration pneumonitis during surgery.b
CPR and Cardiac Arrhythmias
For its anticholinergic positive chronotropic effect in ACLS during CPR.b, 106, 108
Treatment of symptomatic sinus bradycardia (e.g., that accompanied by hemodynamic compromise or

by frequent ventricular ectopic beats).b, 106, 108 Reverses cholinergically mediated decreases in heart
mk:@MSITStore:D:\KULIAH\SEM%206\Pr.%20Farkin\Dafpus\AHFS%202011.chm::/nf... 5/21/2023
rate, systemic vascular resistance, and BP.b, 106, 108
Treatment of symptomatic bradycardia caused by AV block at the nodal level or by vagal stimulation
(e.g., induced by suctioning or endotracheal intubation).106, 108 Do not rely on atropine for AV block at
or below the His-Purkinje level (type II 2nd-degree AV block or 3rd-degree AV block, including 3rd-
degree AV block accompanied by new wide QRS complexes); do not delay pacing, these patients
require immediate pacing.106
In children, for treatment of bradycardia secondary to increased vagal activity or primary AV block,
however, only if manifestations of hemodynamic compromise persist despite support of adequate
oxygenation and ventilation and chest compressions (if indicated); bradycardia may respond to these
latter measures alone.b, 106, 108
In neonates, lack of evidence of usefulness in the acute phase of CPR; therefore, current guidelines for
ACLS no longer include recommendations for such use.b, 106, 108 Drugs rarely are needed during
resuscitation of neonates; establishing adequate ventilation is most important measure to correct
bradycardia.106, 108
Treatment of asystole;b, 106, 108 efficacy in children is unclear.b, 108
Treatment of pulseless electrical activity (PEA) if PEA rate is slow.b, 106, 108
Treatment of sustained bradycardia and hypotension associated with nitroglycerin use in MI and for
nausea and vomiting associated with morphine use in MI.b
Treatment of sudden-onset sinus node suppression complicated by hypotension or ventricular

irritability.b
Treatment of chronic symptomatic sinus node dysfunction when a permanent pacemaker is not
implanted.b
Cautiously in the presence of acute myocardial ischemia or MI because heart rate is a major determinant
of myocardial oxygen requirements.b, 106, 108
Cautiously and with appropriate monitoring following cardiac transplantation; may be ineffective due to
lack of vagal innervation in transplanted heart.106 Risk of paradoxical slowing of the heart rate and high-
degree AV block in patients receiving atropine after cardiac transplantation.106
VF and VT have occurred rarely following IV administration of atropine sulfate.b, 108
Diagnostic Uses in Cardiac Disorders
Diagnosis of sinus node dysfunction .b
Evaluation of CAD during atrial pacing .b
Diagnosis of MI in Wolff-Parkinson-White syndrome .b
Pesticide Poisoning
Concomitantly with a cholinesterase reactivator (pralidoxime chloride) to reverse muscarinic effects

associated with toxic exposure to organophosphate anticholinesterase pesticides.103, 105, b
Reversal of muscarinic effects associated with toxic exposure to carbamate anticholinesterase

pesticides.105, b, l Concomitant cholinesterase reactivator (pralidoxime chloride) therapy may not be
necessary.b, l
A challenge (test) dose of atropine may be useful in diagnosing cholinergic poisoning .l Failure of the
challenge dose to elicit typical antimuscarinic effects (e.g., mydriasis, tachycardia, dry mucous
membranes) strongly suggests the presence of organophosphate or carbamate poisoning.l
Chemical Warfare Agent Poisoning
Concomitantly with a cholinesterase reactivator (pralidoxime chloride) to reverse muscarinic effects

associated with toxic exposure to organophosphate anticholinesterase nerve agents (e.g., sarin, soman,
tabun, VX [methylphosphonothioic acid]) in the context of chemical warfare or terrorism.b, 101, 102, 103,
104, 105
Initial management of nerve agent poisoning includes aggressive airway control and ventilation
(administration of nebulized β-adrenergic agonist [e.g., albuterol] and antimuscarinics [e.g., ipratropium
bromide] may be necessary), and administration of atropine and pralidoxime chloride;101, 102, 103
diazepam may be needed for seizure control.101
Mushroom Poisoning
Treatment of muscarinic effects associated with toxic ingestion of mushrooms containing muscarinef, l
(e.g., certain members of the Clitocybe and Inocybe genera).l However, substantial toxicity is
uncommon, and supportive symptomatic care (e.g., atropine) rarely is necessary.l
Although certain members of the Amanita genus also contain muscarine, the amount is limited.l
Radiographic Uses
Facilitation of hypotonic duodenographye by reducing motility and spasm; however, glucagon appears
to be more effective and generally is preferred.b
Facilitation of hypotonic contrast examination of the colone by reducing motility and spasm; however,
glucagon appears to be more effective and generally is preferred in these examinations.b
Has been used to increase visualization of the urinary tract in excretion urography.b, e
Bronchospasm
Has been used by oral inhalation as a quick-relief bronchodilator for the short-term symptomatic
treatment of acute symptoms and exacerbations of reversible bronchospasm associated with bronchial
asthma, bronchitis, and COPD; however, a solution of the drug for oral inhalation no longer is
commercially available in the US.b Ipratropium bromide currently is the anticholinergic of choice when
such therapy is indicated.h, i
Has been used in a combined regimen of oral inhalation and IM injection to prevent bronchospasm.b, c
GI Disorders
Has been used as an adjunct in the treatment of peptic ulcer disease;b, c however, no conclusive data that
it aids in the healing, decreases the rate of recurrence, or prevents complications of peptic ulcers.b
With the advent of more effective therapies for the treatment of peptic ulcer disease, antimuscarinics
have only limited usefulness in this condition.b
Has been used in the treatment of functional disturbances of GI motility such as irritable bowel
syndrome;b, g however, efficacy is limited.b Use only if other measures (e.g., diet, sedation, counseling,
amelioration of environmental factors) have been of little or no benefit.b
GU Disorders
Adjunctive therapy in the management of hypermotility disorders of the lower urinary tract.b May
provide symptomatic relief, but the underlying cause should be determined and specifically treated.b
With the exception of uninhibited or reflex neurogenic bladder, there is generally little evidence to
support the use of antimuscarinics in the treatment of various GU disorders.c
Biliary Disorders
Do not rely on for relief of biliary tract disorders (e.g., combined with opiates for biliary colic) because
of weak biliary antispasmodic action.b
Pancreatitis
Has been used to decrease gastric and pancreatic secretions in acute pancreatitis, but little evidence of
benefit.b
Dosage and Administration
Administration
Administer by sub-Q, IM, or IV injection.105, 106, 108, b, e, f, g
For ACLS during CPR, may be administered via an endotracheal tubeb, 106, 108, f or by intraosseous
infusion b, 106, 108 when IV injection is not possible. Although endotracheal administration is possible,
IV or intraosseous drug administration is preferred because of more predictable drug delivery and
pharmacologic effect.106
For bronchodilation, has been administered via oral inhalation, via nebulization, or by injection.b
IV Injection
CPR: When a vein has not been cannulated prior to the arrest, a peripheral vein is preferred because
central venous access requires interruption of chest compressions.b, 106
If a central venous catheter is already in place at the time of arrest, it can be used because of more rapid
onset (in adults), more secure access to circulation, and avoidance of tissue infiltration.b, 106, 108 Central
venous line placement should be avoided in patients who are candidates for pharmacologic reperfusion
(e.g., with thrombolytic therapy).b, 106, 108
Because peak drug concentrations are lower and circulation times are increased with peripheral vein
administration compared with central venous injection, inject rapidly IV during resuscitative efforts and
follow by a 20-mL flush of IV fluid.b, 106
If injected IV in an extremity, elevate the extremity for 10-20 seconds; when injected peripherally, 1-2
minutes generally are required for a drug to reach central circulation.b, 106
Rate of Administration
Preferably give IV rapidly because slow injection may cause a paradoxical slowing of the heart rate.b
IV Infusion
Occasionally, infused IV for the management of muscarinic poisoning (e.g., organophosphate
pesticides).l
Rate of Administration
Children: Has been infused IV at a rate of 0.025 mg/kg per hour for muscarinic poisoning.l
Adults: Has been infused IV at an initial rate of 0.5-1 mg/hour for muscarinic poisoning, increasing as
needed according to response and tolerance.l
IM Injection
For self-medication, instruct patients and their caregivers carefully in proper administration techniques
using the auto-injector provided by the manufacturer.105
Inject the weight-appropriate dose IM only into the anterolateral aspect of the thigh.105
In very thin patients and small children, bunch up the thigh prior to injection to provide a thicker
injection area.105
AtroPen® 0.5, 1, or 2 mg: Grasp the prefilled auto-injector with the green tip pointed downward; the
yellow activation (safety) cap should be removed.105 Point the green tip toward the outer thigh, swing
and jab it firmly into the outer thigh so that the auto-injector is perpendicular (90° angle) to the thigh,
and hold firmly in the thigh for at least 10 seconds until the dose is delivered.105
AtroPen® 0.25 mg: Grasp the prefilled auto-injector with the black tip pointed downward; the grey
activation (safety) cap should be removed.105 Point the black tip toward the outer thigh and jab it firmly
into the outer thigh so that the auto-injector is perpendicular (90° angle) to the thigh, and hold firmly in
the thigh for at least 10 seconds until the dose is delivered.105
Administer through clothing if necessary.105
Massage injection area for several seconds.105
If the needle is not exposed, check that the safety cap was removed and repeat administration but press
harder.105
Do not remove the activation cap until ready to use.105
The auto-injector cannot be refilled nor can the exposed needle be retracted.105
After use, bend the needle back against a hard surface and dispose of properly.105
Endotracheal Administration
When IV or intraosseous access cannot be established, may administer by the endotracheal route.106
Dilution
Adults: Dilute dose in 5-10 mL of 0.9% sodium chloride injection or sterile water.106
Intraosseous Administration
When IV administration is not possible, may be given by intraosseous administration for CPR.106
Oral Inhalation
Has been administered via oral inhalation using a nebulizer, but a solution for oral inhalation no longer
is commercially available in the US.b
Dilution
For administration via a nebulizer, the dose as a 0.2 or 0.5% solution has been diluted with 3-5 mL of
0.45 or 0.9% sodium chloride solution.b
Dosage
Higher than recommended dosage sometimes has been required for therapeutic effect.b Dosage should
be titrated until therapeutic effect is achieved or adverse effects become intolerable (using the lowest
possible effective dosage).b
Pediatric Patients
Usual Dosage
Oral: Usual oral dosage is 0.01 mg/kgf or 0.3 mg/m2, but generally not exceeding 0.4 mg, every 4-6
hours.b
>IV, IM, or Sub-Q

Usual IV, IM, or sub-Q dose is 0.01 mg/kgf or 0.3 mg/m2, but generally not exceeding 0.4 mgb; if
necessary, this dose may be repeated every 4-6 hours.b, k
Surgery
>Preoperatively to Decrease Secretions and Block Cardiac Vagal Reflexes
IV, IM, or Sub-Q: Children weighing >20 kg: 0.4 mg given 30-60 minutes before anesthesia.PDH, b
Higher doses (e.g., 0.5-0.6 mg) occasionally have been used in larger children (e.g., 32-41 kg).e, j
Children weighing <20 kg: 0.1 mg for 3 kg, 0.2 mg for 7-9 kg, or 0.3 mg for 12-16 kg given 30-60
minutes before anesthesia.PDH, b
>Muscarinic Blockade during Anticholinesterase Reversal of Curariform Neuromuscular Blockade

Administer concurrently with (but in a separate syringe) or a few minutes before the anticholinesterase
agent.b
If bradycardia is present, administer before the anticholinesterase agent to increase pulse to about 80
bpm.b
IV: Neonates and infants: 0.02-mg/kg dose of atropine sulfate concomitantly with each 0.04-mg/kg dose
of neostigmine methylsulfate.b
Children: 0.01- to 0.04-mg/kg dose of atropine sulfate concomitantly with each 0.025- to 0.08-mg/kg
dose of neostigmine methylsulfate.k

>Bradycardia and Pediatric Advanced Life Support
Current guidelines for ACLS no longer include recommendations for use in neonates.b, 106 (See CPR
and Cardiac Arrhythmias under Uses.)
Bradycardia may respond to adequate oxygenation and ventilation alone.106
IV or Intraosseous : Children and adolescents: 0.02 mg/kg, repeat once if needed; minimum pediatric
dose is 0.1 mg and maximum single dose is 0.5 mg in children and 1 mg in adolescents.106
Endotracheal: Children and adolescents: 0.03 mg/kg; repeat once if needed.106

Follow each dose with a 5-mL flush of 0.9% sodium chloride injection; thereafter, apply 5 manual
ventilations to promote absorption.106
Pesticide Poisoning
>Organophosphate Anticholinesterase Pesticides
Preferably should be administered IV, especially the initial dose.b
A cholinesterase reactivator (pralidoxime) is administered concomitantly.b, l, m
Some degree of atropinism should be maintained for at least 48 hours; prolonged therapy (e.g., for
several weeks) may be necessary in severe cases.l, m
IV or IM: Children: 0.05 mg/kg IV (preferable) or IM up to an adult dose, repeated every 2-30 minutes
until muscarinic signs and symptoms disappear.b, l
Alternatively, infuse IV at a rate of 0.025 mg/kg per hour; continuous infusions have been maintained
for up to several weeks in severe cases.l
Adolescents: 1-2 mg IV (preferable) or IM, repeated every 2-60 minutes until muscarinic symptoms
disappear.b, e, f, l
For severe cases, 2-6 mg may be given initially, repeating doses every 2-60 minutes.b, e, f, l
IM Self-administration: For self-administration using a prefilled auto-injector (e.g., AtroPen®), dose is

based on body weight and symptom severity.105
Mild symptoms include miosis, blurred vision, tearing, runny nose, hypersalivation, drooling, wheezing,
muscle fasciculations, nausea/vomiting.105
Severe symptoms include behavioral changes, severe breathing difficulty, severe respiratory secretions,
severe muscle twitching, involuntary defecation or urination, seizures, unconsciousness.105
Children <7 kg: Inject 0.25 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
additional 0.25-mg IM doses in rapid succession 10 minutes after the initial dose.105
Children <7 kg who present with severe symptoms or are unconscious: Inject three 0.25-mg IM doses in
rapid succession.105
Children <7 kg: Additional doses (i.e., >3) should only be administered under the supervision of trained
medical personnel.105
Children 7-18 kg: Inject 0.5 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Children 7-18 kg who present with severe symptoms or are unconscious: Inject three 0.5-mg IM doses in
Children 7-18 kg: Additional doses (i.e., >3) should only be administered under the supervision of
trained medical personnel.105
Children 18-41 kg: Inject 1 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
additional 1-mg IM doses in rapid succession 10 minutes after the initial dose.105
Children 18-41 kg who present with severe symptoms or are unconscious: Inject three 1-mg IM doses in
Children >41 kg: Inject 2 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Children >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in
Children >41 kg: Additional doses (i.e., >3) should only be administered under the supervision of
>Carbamate Anticholinesterase Pesticides

Carbamate poisoning is treated with the same doses of atropine sulfate as for organophosphate poisoning
and IM self-administration can be employed when necessary.105, l (See Organophosphate
Anticholinesterase Pesticides under Dosage.)
Concomitant cholinesterase reactivator (pralidoxime chloride) therapy may not be necessary and
atropine therapy generally is less prolonged (e.g., only 1 or 2 days) and symptoms usually do not recur
once asymptomatic.l

>Organophosphate Anticholinesterase Nerve Agents
Administer IM in out-of-hospital setting or emergency department.101, 105, b
A cholinesterase reactivator (pralidoxime chloride) is administered concomitantly.b, l, m
Give diazepam for seizure control.101
Total atropine sulfate doses usually are much less than those required for organophosphate
anticholinesterase pesticide poisoning.l
IM: Minimum dose in children is 0.1 mg.l

Children 0-2 years of age with mild to moderate symptoms: Usual initial IM dose is 0.05 mg/kg.101, b
Children 0-2 years of age with severe symptoms: Usual initial IM dose is 0.1 mg/kg.101, b
Children 2-10 years of age with mild to moderate symptoms: Usual initial IM dose is 1 mg.101, b
Children 2-10 years of age with severe symptoms: Usual initial IM dose is 2 mg.101, b
Children older than 10 years of age with mild to moderate symptoms: Usual initial IM dose is 2 mg.101,
b
Children older than 10 years of age with severe symptoms: Usual initial IM dose is 4 mg.101, b
Repeat doses every 2-10 minutes as needed until muscarinic toxicity resolves (e.g., secretions have
diminished and breathing is comfortable or airway resistance has returned to near normal).101, b, l

Children <7 kg: Inject 0.25 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Children <7 kg who present with severe symptoms or are unconscious: Inject three 0.25-mg IM doses in
Children <7 kg: Additional doses (i.e., >3) should only be administered under the supervision of trained
Children 7-18 kg: Inject 0.5 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Children 7-18 kg who present with severe symptoms or are unconscious: Inject three 0.5-mg IM doses in
Children 18-41 kg: Inject 1 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Children 18-41 kg who present with severe symptoms or are unconscious: Inject three 1-mg IM doses in
Children 18-41 kg: Additional doses (i.e., >3) may be given every 5-10 minutesl but only under the
supervision of trained medical personnel.105
Children >41 kg: Inject 2 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Children >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in
Children >41 kg: Additional doses (i.e., >3) may be given every 5-10 minutesl but only under the
supervision of trained medical personnel.105
IV: Children 0-2 years of age with mild, moderate, or severe symptoms: May receive 0.02 mg/kg IV, if
treated in an emergency department.101, b
Mushroom Poisoning
>Muscarine-containing Clitocybes and Inocybes
IV: If needed for severe symptoms, 0.02 mg/kg IV (minimum of 0.1 mg), repeated and titrated as needed
according to response.l
Bronchospasm
>Treatment of Acute Exacerbations of Asthma
Oral Inhalation: Children: 0.05 mg/kg 3 or 4 times daily via nebulization;b individual dose may be
based on the patient's weight as suggested in the following table, and may be adjusted according to the
patient's response and tolerance.b
Weight Pediatric Dose

15-25.8 kg 1 mg
25.9-37.6 kg 1.5 mg
37.7-63.2 kg 2.5 mg
Adults
Usual Dosage
Oral: Usual oral dosage is 0.4-0.6 mg (range: 0.1-1.2 mg) every 4-6 hours.b
>IV, IM, or Sub-Q

Usual IV, IM, or sub-Q dose is 0.4-0.6 mg (range: 0.3-1.2 mg); if necessary, this dose may be repeated
every 4-6 hours.b
Surgery
>Preoperatively to Decrease Secretions and Block Cardiac Vagal Reflexes
IV, IM, or Sub-Q: 0.4 mg (range: 0.2-1 mg) given 30-60 minutes before anesthesia.b, e, f
>Muscarinic Blockade during Anticholinesterase Reversal of Curariform Neuromuscular Blockade

IV: 0.6-1.2 mg for each 0.5-2.5 mg of neostigmine methylsulfate or 10-20 mg of pyridostigmine
bromide given.b
Administer concurrently with (but in a separate syringe) or a few minutes before the anticholinesterase
agent.
If bradycardia is present, administer before the anticholinesterase agent to increase pulse to 80 bpm.b

Selection of dosing interval (3-5 minutes) requires the clinician's judgment about the severity of the
patient's symptoms; the shorter dosing intervals should be used in the more distressed patients (e.g.,
those with ventricular asystole).108, b, f
>Endotracheal
Can administer via an endotracheal tube when atropine cannot be administered IV for bradycardia or
ACLS during CPR.b, 106, j
Optimum dose for bradycardia and ACLS not established.106 Doses 2-2.5 times usual IV doses have
been recommended.b, 106

One manufacturer recommends a dose of 1-2 mg.f
>Intraosseous
Can administer by intraosseous infusion when atropine cannot be administered IV for ACLS during
CPR.b, 106
Intraosseous doses usually have been the same as those administered IV, although some evidence
suggests that intraosseous doses should be higher than those administered IV.b
>Asystole
IV: Usually, 1 mg; the dose may be repeated in 3-5 minutes if asystole persists up to a total of 3 doses
(or up to 3 mg).106
>Slow Pulseless Electrical Activity

IV: Usually, 1 mg; the dose may be repeated in 3-5 minutes if necessary up to a total of 3 doses (or up to
3 mg).106
>Bradycardia
IV: 0.5 mg; may repeat dose at 3- to 5-minute intervals up to a total dose of 3 mg.106
Pesticide Poisoning
Preferably should be administered IV, especially the initial dose.b
Some degree of atropinism should be maintained for at least 48 hours; prolonged therapy (e.g., for
several weeks) may be necessary in severe cases.l, m
IV or IM: 1-2 mg IV (preferable) or IM, repeated every 2-60 minutes until muscarinic symptoms
disappear.b, e, f, l For severe cases, 2-6 mg may be given initially, repeating doses every 2-60 minutes.b,
e, f, l
Alternatively, infuse IV at an initial rate of 0.5-1 mg/hour, adjusting rate according to response.l
Mildly symptomatic poisoning may respond to 1-2 mg for reversal of muscarinic toxicity whereas
moderate poisoning commonly requires total doses up to 40 mg.l
For severe poisoning, 5-mg doses may be repeated every 2-3 minutes for stabilization.l
Cumulative doses up to 1 g in 24 hours or 11 g over a course of treatment have been used.l

Adults >41 kg: Inject 2 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Adults >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in
Additional doses (i.e., >3) should only be administered under the supervision of trained medical
personnel.105
Adults <41 kg: Pediatric doses can be used.105 (See Pediatric Patients: Pesticide Poisoning, under
Dosage.)
Oral: Oral therapy can replace parenteral therapy for maintenance as needed.b
0.5-1 mg may be administered orally at intervals of several hours as maintenance therapy until signs and
symptoms completely subside.b
>Carbamate Anticholinesterase Pesticides

Carbamate poisoning is treated with the same doses of atropine sulfate as for organophosphate poisoning
and IM self-administration can be employed when necessary.105, l (See Organophosphate
Anticholinesterase Pesticides under Dosage.)
Concomitant cholinesterase reactivator (pralidoxime chloride) therapy may not be necessary and
atropine therapy generally is less prolonged (e.g., only 1 or 2 days) and symptoms usually do not recur
once asymptomatic.l

Administered IM in out-of-hospital setting or emergency department.101, 105, b
Give diazepam for seizure control.101
Total atropine sulfate doses usually are much less than those required for organophosphate
IM or IV: Mild to moderate symptoms: Usual initial IM dose is 2-4 mg.101, b, l

Severe symptoms: 5-6 mg.101, b, l
Frail geriatric patients with mild to moderate symptoms: 1 mg.101, b
Frail geriatric patients with severe symptoms: 2-4 mg.101, b
Repeat doses every 2-10 minutes as needed until muscarinic toxicity resolves (e.g., secretions have
diminished and breathing is comfortable or airway resistance has returned to near normal).101, b, l
Up to 15-20 mg may be required within the first 3 hours,104 but most patients respond to <20 mg usually
during the initial 24 hours.l In a report of sarin poisoning, <20% of moderately symptomatic patients
required more than 2 mg.l Pralidoxime chloride is administered concomitantly with atropine.101

Adults >41 kg: Inject 2 mg IM initially for mild symptoms.105 If severe symptoms develop, inject 2
Adults >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in
Additional doses (i.e., >3) may be given every 5-10 minutesl but only under the supervision of trained
Adults <41 kg: Pediatric doses can be used.105 (See Pediatric Patients: Pesticide Poisoning, under
Dosage.)
Mushroom Poisoning
>Muscarine-containing Clitocybes and Inocybes
IV: If needed for severe symptoms, 1-2 mg IV (minimum of 0.1 mg), repeated and titrated as needed
according to response.l
Radiographic Uses
>Hypotonic Radiograph of the GI Tract
IM: 1 mg IM.b, e
Bronchospasm
Oral Inhalation: 0.025 mg/kg (usually up to 2.5 mg) 3 or 4 times daily via nebulization;b individual
dose may be based on the patient's weight as suggested in the following table, and may be adjusted
according to the patient's response and tolerance.b
Adult Weight Adult Dose

30.5-50.8 kg 1 mg
50.9-75.8 kg 1.5 mg
75.9-126.4 kg 2.5 mg
Prescribing Limits
Pediatric Patients
>Bradycardia and Pediatric Advanced Life Support
IV or Intraosseous : Children: Maximum single dose is 0.5 mg; maximum total dose is 1 mg.b, 106
Adolescents: Maximum single dose is 1 mg; maximum total dose is 2 mg.b, 106
>Other Uses
Oral: Generally, not exceeding 0.4 mg.b
IV: Generally, not exceeding 0.4 mg.b
IM: Generally, not exceeding 0.4 mg.b
Adults
>Asystole, Slow Pulseless Electrical Activity, and Bradycardia
IV: Total dose usually should not exceed 3 mg (0.04 mg/kg) in asystole, slow pulseless electrical
activity, or bradycardia because complete vagal blockade (total vagolytic dose) generally occurs.b, f, 106
Pesticide Poisoning

Maximum up to 1 g in 24 hours (with a cholinesterase activator [pralidoxime chloride]), depending on
muscarinic severity.l
Total cumulative doses up to 11 g (with a cholinesterase activator [pralidoxime chloride]) during a
course of treatment, depending on muscarinic severity.l

IM or IV: Total atropine sulfate doses usually are much less than those required for organophosphate
Up to 15-20 mg may be required within the first 3 hours,104 but most patients respond to <20 mg during
the initial 24 hours.l
Bronchospasm
Oral Inhalation: Usually, up to 2.5 mg per dose via nebulization;b minimally increased efficacy but
increased adverse effects with higher doses.b
Special Populations
Hepatic Impairment
No specific hepatic dosage recommendations.105, e, g
Renal Impairment
No specific renal dosage recommendations.105, e, g
Geriatric Patients
Similar response between geriatric and younger patients.f In general, dose selection for an elderly patient
should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency
of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.101, f
Cautions
Contraindications
• No absolute contraindications to use in life-threatening conditions (e.g., poisoning by organophosphate

nerve agents and pesticides).105
• Relative contraindications include:
• known hypersensitivity to atropine or any ingredient in the formulation105, b

• angle-closure glaucoma105, b, c, e, f, g
• obstructive uropathy (e.g., bladder neck obstruction secondary to prostatic hypertrophy)c
• obstructive GI disease (e.g., pyloroduodenal stenosis, achalasia)c
• paralytic ileusc
• intestinal atony (especially in geriatric and debilitated patients)c
• severe ulcerative colitisc
• toxic megacolonc
• tachycardia secondary to cardiac insufficiency or thyrotoxicosis

• acute hemorrhage when cardiovascular status is unstablec
• myasthenia gravis (unless used to reduce adverse muscarinic effects of an anticholinesterase agent
such as neostigmine)c
Warnings/Precautions
Warnings
Overdosage
Avoid overdosage, especially with IV administration.f
Pediatric patients are particularly susceptible to overdosage.f
Pesticide and Chemical Warfare Agent Poisoning

Use in patients with a history of anaphylactic reaction to atropine and mildly symptomatic
organophosphate pesticide or nerve agent poisoning only when there is adequate medical supervision.105
Severe breathing difficulty requires artificial respiration because atropine alone is not dependable in
reversing respiratory muscle weakness or paralysis.105
Administer with extreme caution when the symptoms of nerve agent poisoning are less severe in
patients with disorders of heart rhythm (e.g., atrial flutter), substantial renal insufficiency, or a recent
MI.105
No more than 3 doses should be self-administered IM; additional doses require medical supervision.105
Sensitivity Reactions
Parabens present in multiple-dose preparations may cause hypersensitivity reactions.c
Anaphylaxis, urticaria, rash (e.g., scarlatiniform) that may progress to exfoliation, delayed
hypersensitivity reactions, and various dermal manifestations.c, 105, e
Major Toxicities
Cardiovascular Effects
Caution in tachyarrhythmias, CHF, or CAD because antimuscarinics block vagal inhibition of the SA
nodal pacemaker.c
CNS Disturbances
Large or toxic doses or usual doses in patients with excess susceptibility may produce marked CNS
disturbances (e.g., ranging from marked excitement, ataxia, hallucination, depression, and/or
disorientation to active delirium to coma to death [secondary to respiratory failure]).105, f, g
Marked somnolence in susceptible patients.c
Mental confusion and/or excitement, especially in geriatric patients.c
GI Disturbances
Extreme caution in known or suspected GI infections because of decreased GI motility and retention of
causative organism and/or toxins.c
Extreme caution in mild to moderate ulcerative colitis because of suppressed intestinal motility and
resultant paralytic ileus and toxic megacolon.c
Extreme caution in diarrhea (especially in patients with ileostomy or colostomy) because it may be an
early sign of intestinal obstruction.c
Caution in gastric ulcer because of delayed gastric emptying and possible antral stasis.c
Caution in esophageal reflux and hiatal hernia because of decreased gastric motility and lower
esophageal sphincter pressure leading to gastric retention and reflux aggravation.c
GU Disturbances
Extreme caution in patients with partial obstructive uropathy because of decreased tone and amplitude
of contractions of ureters and bladder and resultant urinary retention.c (See Contraindications under
Cautions)
Respiratory Effects
Caution with systemically administered atropine in debilitated patients with chronic pulmonary disease
because a reduction in bronchial secretions may lead to inspissation and formation of bronchial plugs;
however, has been used effectively as bronchodilator when administered via oral inhalation.
Thermoregulatory Effects
Exposure to high environmental temperatures may result in heat prostration due to decreased sweating.c
Increased risk of hyperthermia in patients who are febrile.c
General Precautions
Neuropathy
Extreme caution in patients with autonomic neuropathy.c
Down's Syndrome, Spastic Paralysis, and Brain Damage

Increased sensitivity to antimuscarinic effects (e.g., mydriasis, positive chronotropic effect).c
Hypertension
Caution in hypertensive patients.c
Hyperthyroidism
Caution in hyperthyroid patients.c
Seizure Management in Anticholinesterase Poisoning

Use barbiturates cautiously to manage seizures because the drugs are potentiated by
anticholinesterases.105 Diazepam is preferred for seizure control.101
Specific Populations
Pregnancy
Category C.105, c, f, g
Lactation
Atropine is found in human milk in trace amounts; use caution when administered to a nursing
woman.105
Pediatric Use
Safety and efficacy in the setting of organophosphate pesticide poisoning established in children of all
ages.105
Increased susceptibility to the effects of atropine.105, c, f More susceptible than adults to toxic effects;
deaths at doses as low as 10 mg.c
May produce fever through inhibition of heat loss by evaporation.e, g
Infants, patients with Down's syndrome (mongolism), and children with spastic paralysis or brain
damage may be hypersensitive to antimuscarinic effects (e.g., mydriasis, positive chronotropic effect).c
Geriatric Use
Increased susceptibility to the effects of atropine.105, c Mental confusion and/or excitement are
especially likely in geriatric patients.c
Use with caution in all patients >40 years of age.f
Monitor closely for urine retentionPDH, e in elderly men with BPH.c, PDH
Constipation and difficulty in micturition in elderly patients.f
Hepatic Impairment
Use with caution in hepatic disease.c
Renal Impairment
Use with caution in renal disease.c
Common Adverse Effects
Most adverse effects are manifestations of pharmacologic effects at muscarinic-cholinergic receptors

and usually are reversible when therapy is discontinued.c
Severity and frequency of adverse effects are dose related and individual intolerance varies greatly;
adverse effects occasionally may be obviated by a reduction in dosage but this also may eliminate
potential therapeutic effects.c, e
Frequent effects include xerostomia (dry mouth), dry skin, blurred vision, cycloplegia, mydriasis,
photophobia, anhidrosis, urinary hesitancy and retention, tachycardia, palpitation, xerophthalmia, and
constipation,105, c, e, f, g which may appear at therapeutic or subtherapeutic doses.c Xerostomia is the
dose-limiting effect.c
Other common effects include increased ocular tension (especially in patients with angle-closure
glaucoma), loss of taste, headache, nervousness, restlessness, drowsiness, weakness, dizziness, flushing,
insomnia, nausea, vomiting, bloated feeling, anhidrosis (especially in hot environments),105, e, f fever,e
mild to moderate pain at the injection site,105, c loss of libido, and erectile dysfunction (via block of
cholinergically mediated vasodilation).105, c
Interactions
Drugs with Anticholinergic Effects
Additive adverse effects resulting from cholinergic blockade (e.g., xerostomia, blurred vision,
constipation).c Advise of possibility of increased anticholinergic effects and monitor carefully.c
Effects on GI Absorption of Drugs
By inhibiting the motility of the GI tract and prolonging GI transit time, antimuscarinics have the
potential to alter GI absorption of various drugs.c
Specific Drugs
Drug Interaction Comments

Inform patient and monitor
Amantadine Increased anticholinergic effectsc
carefullyc
Administer oral atropine at least 1
Antacids Decreased GI absorption of atropinec
hour before antacidsc
Anticholinergic drugs Increased anticholinergic effectsc
carefullyc
Antihistamines Inform patient and monitor
Increased anticholinergic effectsc
(anticholinergic) carefullyc
Antiparkinsonian c Inform patient and monitor
(antimuscarinic) agents Increased anticholinergic effects carefullyc
Corticosteroids Increased IOPc Caution; monitor IOPc
Use digoxin oral solution (elixir)
Digoxin (slow
dissolving) Increased serum digoxinc or rapidly dissolving tablets (e.g.,
Lanoxin®)c
Disopyramide Increased anticholinergic effectsc
carefullyc
Increased gastric pH decreases Administer atropine at least 2
Ketoconazole
ketoconazole absorptionc hours after ketoconazolec
Adjust levodopa dosage if
Increased GI metabolism of levodopa &
Levodopa atropine is started or
decreased systemic concentrationsc
discontinuedc
Meperidine Increased anticholinergic effectsc
carefullyc
Mexiletine
Decreased GI absorption rate of
mexiletine; no effect on bioavailabilityf

Muscle (anticholinergic) Inform patient and monitor
relaxants carefullyc
Phenothiazines Increased anticholinergic effectsc
carefullyc
Slowed GI transit potentiates adverse GI Caution if used concomitantly;
Potassium chloride effects of oral potassium chloride monitor for possible GI mucosal
(especially wax-matrix tablets)c lesionsc
Procainamide Increased anticholinergic effectsc
carefullyc
Pralidoxime Increased rate of atropinizationc
Tricyclic Inform patient and monitor
antidepressants carefullyc
Pharmacokinetics
Absorption
Bioavailability
Well absorbed (90%) from the GI tract, principally from upper small intestine.b
Rapidly and well absorbed after IM injection.b Physical exercise, either prior to or immediately
following IM injection, increases absorption due to muscle perfusion and decreases clearance.f
Well absorbed following endotracheal administration.c, 106, 108 Water dilution increases endotracheal
absorption106, 108 but adversely affects arterial oxygen pressure (PaO2) relative to sodium chloride
dilution.108
Well absorbed following oral inhalation,b but only small amounts reach systemic circulation.c
Onset
Inhibition of salivation occurs within 30 minutes or 30-60 minutes and peaks within 1-1.6 or 2 hours
after IM or oral administration, respectively.b
Increase in heart rate occurs within 2-4 minutes after IV injection.b
Increase in heart rate occurs within 5-40 minutes or 0.5-2 hours and peaks within 20-60 minutes or 1-2
hours after IM or oral administration, respectively.b
Ocular effects are delayed following systemic administration.b
Bronchodilation (as determined by forced expiratory volume in 1 second [FEV1]) occurs within 15
minutes and is maximal within 0.25-1.5 hours after oral inhalation.b
Duration
Inhibition of salivation persists for up to 4 hours.b
Plasma Concentrations
Peak plasma concentrations are reached within 1 hour following oral administration.b
Following IM administration, peak plasma concentrations are reached within 30 minutes.b
Following oral inhalation, appears in serum within 15 minutes and peaks within 1.5-4 hours.b
Distribution
Extent
Rapidly and well distributed throughout the body, including the CNS.105, b, c
Traces are found in various secretions, including milk.f
Crosses the placental barrier and enters fetal circulationb, f but is not found in amniotic fluid.f
Plasma Protein Binding

Binds poorly (about 44%); mainly to α1-acid glycoprotein.f
Elimination
Metabolism
Via the liver to several metabolites including tropic acid, atropine (or a chromatographically similar
compound), and, possibly, esters of tropic acid and glucuronide conjugates.b
Elimination Route
About 30-50% of a dose is excreted in urine unchanged.b
Excreted mainly through the kidneys;b, PDH however, small amounts may be excreted in the feces and
expired air.b
Half-life
2-3 hours.b
Biphasic following IM injection; 2-3-hours initially followed by a terminal half-life of 12.5 hours or
longer.b, PDH
Special Populations
Elimination half-life is more than doubled in children <2 years and the elderly (>65 years of age)
compared with other age groups.f
No gender effect on pharmacokinetics and pharmacodynamics.f
Stability
Storage
Effloresces on exposure to dry air and is slowly affected by light.b
Oral
Tablets
Well-closed containers.b
Parenteral
Injection
25°C (may be exposed to 15-30°C).105, e, f
Protect from freezing and light.105, b
Compatibility
For information on systemic interactions resulting from concomitant use, see Interactions.
Parenteral
Solution CompatibilityHID
Compatible
Sodium chloride 0.9%
Drug Compatibility
>Admixture CompatibilityHID
Compatible
Dobutamine HCl
Furosemide
Meropenem
Sodium bicarbonate
Verapamil HCl
Incompatible
Floxacillin sodium
>Y-Site CompatibilityHID
Compatible
Abciximab
Amiodarone HCl
Argatroban
Etomidate
Famotidine
Fenoldopam mesylate
Fentanyl citrate
Heparin sodium
Hydrocortisone sodium succinate
Hydromorphone HCl
Inamrinone lactate
Meropenem
Methadone HCl
Morphine sulfate
Nafcillin sodium
Potassium chloride
Sufentanil citrate
Tirofiban HCl
Vitamin B complex with C
Incompatible
Thiopental sodium
Variable
Propofol
>Compatibility in SyringeHID
Compatible
Butorphanol tartrate
Chlorpromazine HCl
Cimetidine HCl
Dimenhydrinate
Diphenhydramine HCl
Droperidol
Fentanyl citrate
Glycopyrrolate
Heparin sodium
Hydromorphone HCl
Hydroxyzine HCl
Hydroxyzine HCl with meperidine HCl
Meperidine HCl
Meperidine HCl with hydroxyzine HCl
Meperidine HCl with promethazine HCl
Metoclopramide HCl
Midazolam HCl
Milrinone lactate
Morphine HCl
Morphine sulfate
Nalbuphine HCl
Ondansetron HCl
Papaveretum
Pentazocine lactate
Perphenazine
Prochlorperazine edisylate
Promethazine HCl
Promethazine HCl with meperidine HCl
Ranitidine HCl
Scopolamine HBr
Sufentanil citrate
Incompatible
Cimetidine HCl with pentobarbital sodium
Pentobarbital sodium with cimetidine HCl
Variable
Pentobarbital sodium
Actions
• Competitively inhibits acetylcholine or other cholinergic stimuli at autonomic effectors innervated by

postganglionic cholinergic nerves and, to a lesser extent, on smooth muscles that lack cholinergic
innervation.c At usual doses, principally antagonizes cholinergic stimuli at muscarinic receptors and
has little or no effect on cholinergic stimuli at nicotinic receptors.c
• Antimuscarinics also have been referred to as anticholinergics (cholinergic blocking agents), but this
term is appropriate only when it describes the antagonism of cholinergic stimuli at any cholinergic
receptor, whether muscarinic or nicotinic.c
• Also have been referred to as parasympatholytics because the antagonized functions principally are
under the parasympathetic division of the nervous system.c
• Receptors at various sites are not equally sensitive to inhibition of muscarinic effects.c Relative
sensitivity of physiologic functions (proceeding from the most sensitive) is as follows: secretions of
the salivary, bronchial, and sweat glands; pupillary dilation, ocular accommodation, and heart rate;
contraction of the detrusor muscle of the bladder and smooth muscle of the GI tract; and gastric
secretion and motility.c Doses used to decrease gastric secretions are likely to cause dryness of the
mouth (xerostomia) and interfere with visual accommodation, and possibly cause difficulty in
urinating.c
• Various antisecretory effects in the GI tract, including reduction of salivation (producing xerostomia)
and gastric secretions (only partial reduction in gastric acid secretion).c Prolonged inhibitory effects
on the motility of the esophagus, stomach, duodenum, jejunum, ileum, and colon.c
• Relaxes lower esophageal sphincter with a resultant decrease in lower esophageal sphincter pressure.c
• Decreases the tone and amplitude of contractions of the ureters and bladder.c May cause urinary
retention (e.g., in patients with urinary obstruction).c In patients with uninhibited or reflex neurogenic
bladder, the amplitude and frequency of uninhibited contractions are reduced and bladder capacity is
increased.c
• Positive chronotropic effect (increased SA node automaticity), accelerating sinus rate by direct
parasympathetic blockade.c Stimulates the AV functional pacemaker.c Facilitates AV nodal
conduction in a normal AV node.c

• Can reverse reflex vagal cardiac slowing or asystole such as that induced by inhalation of irritant
vapors or by vagal stimulation (e.g., carotid sinus stimulation, pressure on the eyeball).c
• May cause cutaneous vasodilation, especially at toxic doses (atropine flush).c
• Reduces secretions from the nose, mouth, pharynx, and bronchi.c Relaxes smooth muscles of the
bronchi and bronchioles with a resultant decrease in airway resistance.c Potent bronchodilation,
particularly in large bronchial airways; especially effective in reversing bronchoconstriction induced
by parasympathetic stimulation.c
• Stimulates the medulla and higher cerebral centers and exhibits CNS effects similar to those produced
by antimuscarinics used in the treatment of parkinsonian syndrome (e.g., trihexyphenidyl).c
• Blocks the responses of the sphincter muscle of the iris and the ciliary muscle of the lens to cholinergic
stimulation, producing mydriasis and cycloplegia and a resultant decrease in ocular accommodation.c
Little effect on IOP except with angle-closure glaucoma where IOP may increase.c
• Reduces the volume of perspiration by inhibiting sweat-gland secretions.c May suppress sweating
sufficiently to increase body temperature.c
Advice to Patients
• Seek immediate medical attention after injection with an atropine injection auto-injector.105
• Advise to report serious adverse reactions promptly.PDH
• Advise that dry mouth may occur.105, b, e, f, g
• Advise of risk of hyperthermia and heat prostration; avoid exposure to high environmental
temperatures and avoid use when febrile.c
• Advise patients receiving chronic therapy of possible blurred vision with the drug; activities that
require good, clear vision should be avoided.105, b, e, f, g
• Risk of dizziness or drowsiness; avoid driving or operating machinery until effects on individual are
known.c
• For IM self-administration in nerve gas and pesticide poisoning, proper techniques for storage,
attention to expiration dating (replacing before expiration), use, and disposal of the prefilled auto-
injector (e.g., AtroPen®) and for administration of the drug.105
• For IM self-administration in nerve gas and pesticide poisoning, importance of understanding the
indications for use and the symptoms of poisoning.105
• For IM self-administration in nerve gas and pesticide poisoning, importance of ensuring adequate
understanding of the recognition and treatment of such poisoning and when concomitant
cholinesterase reactivator (pralidoxime chloride) therapy may be necessary.105
• For IM self-administration in nerve gas and pesticide poisoning, importance of not exceeding 3 doses
unless under medical supervision.105
• For IM self-administration in nerve gas and pesticide poisoning, importance of seeking immediate
medical attention once the initial dose(s) is administered because respiratory and other supportive care
and prolonged atropinization may be needed.105
• For IM self-administration in nerve gas and pesticide poisoning, importance of recognizing that
inadvertent administration when such poisoning is not present could result in atropine toxicity and
temporary incapacitation (inability to walk properly, see clearly, or think clearly for several hours or
longer).105
• For self-administration in nerve gas and pesticide poisoning, importance of not contaminating other
individuals (e.g., medical and emergency personnel) by clothing exposure; aggressive and safe
decontamination by trained personnel is strongly suggested.105

• Importance of informing clinicians of existing or contemplated concomitant therapy, including
prescription and OTC drugs.105, b
• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-
feed.105
• Importance of informing patients of other important precautionary information.105, b (See Cautions.)
Preparations
Excipients in commercially available drug preparations may have clinically important effects in some
individuals; consult specific product labeling for details.
Atropine
Dosage
Routes Strengths Brand Names Manufacturer
Forms
Bulk Powder
Parenteral Injection
equivalent to Atropine Sulfate AtroPen® Auto-Injector ("green Meridian
0.5 mg/0.7 mL label")
equivalent to Atropine Sulfate 1 AtroPen®Auto-Injector ("dark
Meridian
mg/0.7 mL red label")
equivalent to Atropine Sulfate 2 AtroPen®Auto-Injector ("blue
Meridian
mg/0.7 mL label")
Atropine Sulfate
Routes Dosage Forms Strengths Brand Names Manufacturer
Bulk Powder*
Oral Tablets 0.4 mg Sal-Tropine® Hope
Parenteral Injection 0.05 mg/mL* Atropine Sulfate Injection
0.1 mg/mL* Atropine Sulfate Injection
0.4 mg/mL*
0.5 mg/mL* Atropine Sulfate Injection
1 mg/mL*
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary)
name
Comparative Pricing
This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing
information was updated 03/2011. For the most current and up-to-date pricing information, please visit
www.drugstore.com. Actual costs to patients will vary depending on the use of specific retail or mail-
order locations and health insurance copays.
Diphenoxylate-Atropine 2.5-0.025MG/5ML Liquid (ROXANE): 60/$20.6 or 180/$56.65
Diphenoxylate-Atropine 2.5-0.025MG Tablets (MYLAN): 30/$15.99 or 90/$45.97
Lomotil 2.5-0.025MG/5ML Liquid (PFIZER U.S.): 60/$35.99 or 180/$89.97
Lomotil 2.5-0.025MG Tablets (PFIZER U.S.): 30/$46.29 or 90/$111.1
Lonox 2.5-0.025MG Tablets (SANDOZ): 60/$27.99 or 120/$52.98
Use is not currently included in the labeling approved by the US Food and Drug Administration.
References
Only references cited for selected revisions after 1984 are available electronically.
101. Agency for Toxic Substances and Disease Registry. Nerve agents: tabun (GA) CAS 77-81-6;
sarin (GB) CAS 107-44-8; soman (GD) CAS 96-64-0; and VX CAS 50782-69-9. From the CDC
website. Accessed Nov 12, 2001. [Web]
102. DeLorenzo RA. Exposed: signs, symptoms & EMS management of nerve-agent poisoning. J
Emerg Med Serv JEMS. 2001; 26:48-57. [PubMed 11409202]
103. In Ellenhorn MJ, Schonwald S, Ordog G, Wasserberger J, eds. Ellenhorn's medical toxicology:
diagnosis and treatment of human poisoning. 2nd ed. Baltimore: Williams & Wilkins; 1997:1267-
90.
104. Anon. Prevention and treatment of nerve gas poisoning. Med Lett Drugs Ther. 1990; 32:103-5.
[PubMed 2233511]
105. Meridian Medical Technologies. AtroPen® (atropine injection) prescribing information.

Columbia, MD; 2004 Aug.
106. The American Heart Association. Guidelines 2005 for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation. 2005; 112(Suppl I): IV1-IV211.
107. Brown AFT. Anaphylaxis gets adrenaline going. Emerg Med J. 2004; 21:128-9. [PubMed
14988331] [Free Fulltext PMC]
108. The American Heart Association in Collaboration with the International Liaison Committee on
Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation. 2000; 102(Suppl I) I-121,I-151-1, I-153, I-308, I-312-4.
109. Eigel B. (American Heart Association, Dallas, TX): Personal communication; 2006 Aug 17.
PDH. Schilling McCann JA, Publisher. Pharmacists drug handbook. 2nd ed. Philadelphia, PA:
Lippincott Williams and Wilkins and American Society of Health-System Pharmacists; 2003.
b. AHFS Drug Information 2004. McEvoy, GK, ed. Atropine. Bethesda, MD: American Society of
Health-System Pharmacists; 2004:1206-1209.
c. AHFS Drug Information 2004. McEvoy, GK, ed. Antimuscarinics/Antispasmodics General

Statement. Bethesda, MD: American Society of Health-System Pharmacists; 2004:1199-1206.
e. American Pharmaceutical Partners, Inc. Atropine sulfate injection, USP prescribing information.
Schaumburg, IL; 2002 Jan.
f. Abbott Laboratories. Atropine sulfate injection, USP prescribing information. North Chicago, IL;
2001 Feb.
g. Hope Pharmaceuticals. Atropine sulfate, USP prescribing information. Scottsdale, AZ; 1998 Nov.
h. National Asthma Education and Prevention Program. Expert panel report II: guidelines for the
diagnosis and management of asthma. Bethesda, MD: National Institutes of Health National Heart
Lung, and Blood Institute. (NIH publication No. 97-4051) 1997 Jul.
i. National Asthma Education and Prevention Program. Expert panel report: guidelines for the
diagnosis and management of asthma. Update on selected topics 2002. Bethesda, MD: National
Institutes of Health National Heart Lung, and Blood Institute. (NIH publication No. 02-5074) 2003
Jun.
j. Shirkey HC. Pediatric dosage handbook. Philadelphia, PA: American Pharmaceutical Association;
1980:19,295.
k. The Harriet Lane handbook: a manual for pediatric house officers. 16th ed. Gunn VL, Nechyba C,
eds. Baltimore, MD: Mosby; 2002:600-1,772.
l. Goldfrank's toxicologic emergencies. 7th ed. Goldfrank LR, Howland MA, Flomenbaum NE et al,
eds. New York: McGraw-Hill; 2002:1353-6.
m. AHFS Drug Information 2004. McEvoy, GK, ed. Pralidoxime chloride. Bethesda, MD: American
Society of Health-System Pharmacists; 2004:3541-3.
n. The United States pharmacopeia, 27th rev, and The national formulary, 22nd ed. Rockville, MD:
The United States Pharmacopeial Convention, Inc; 2004:190-2.
HID. Trissel LA. Handbook on injectable drugs. 14th ed. Bethesda, MD: American Society of Health-
System Pharmacists; 2007:182-8.

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AHFS DI® Essentials™ Page 1 of 27

Antimuscarinic; a naturally occurring tertiary amine.

Class: 12:08.08 Antimuscarinics/Antispasmodics; au350 (VA primary)

Brands*: AtroPen®, Sal-Tropine®

*also available generically

Generic Name: Atropine

Ineffective for preventing acid-aspiration pneumonitis during surgery.b

CPR and Cardiac Arrhythmias

Treatment of symptomatic sinus bradycardia (e.g., that accompanied by hemodynamic compromise or

rate, systemic vascular resistance, and BP.b, 106, 108

Treatment of asystole;b, 106, 108 efficacy in children is unclear.b, 108

Treatment of sudden-onset sinus node suppression complicated by hypotension or ventricular

VF and VT have occurred rarely following IV administration of atropine sulfate.b, 108

Diagnostic Uses in Cardiac Disorders

Diagnosis of sinus node dysfunction .b

Evaluation of CAD during atrial pacing .b

Diagnosis of MI in Wolff-Parkinson-White syndrome .b

Concomitantly with a cholinesterase reactivator (pralidoxime chloride) to reverse muscarinic effects

Reversal of muscarinic effects associated with toxic exposure to carbamate anticholinesterase

Chemical Warfare Agent Poisoning

Concomitantly with a cholinesterase reactivator (pralidoxime chloride) to reverse muscarinic effects

Dosage and Administration

Administer by sub-Q, IM, or IV injection.105, 106, 108, b, e, f, g

Administer through clothing if necessary.105

Massage injection area for several seconds.105

Do not remove the activation cap until ready to use.105

>IV, IM, or Sub-Q

necessary, this dose may be repeated every 4-6 hours.b, k

>Muscarinic Blockade during Anticholinesterase Reversal of Curariform Neuromuscular Blockade

CPR and Cardiac Arrhythmias

Endotracheal: Children and adolescents: 0.03 mg/kg; repeat once if needed.106

IM Self-administration: For self-administration using a prefilled auto-injector (e.g., AtroPen®), dose is

>Carbamate Anticholinesterase Pesticides

Chemical Warfare Agent Poisoning

anticholinesterase pesticide poisoning.l

IM: Minimum dose in children is 0.1 mg.l

IM Self-administration: For self-administration using a prefilled auto-injector (e.g., AtroPen®), dose is

Weight Pediatric Dose

>IV, IM, or Sub-Q

>Muscarinic Blockade during Anticholinesterase Reversal of Curariform Neuromuscular Blockade

CPR and Cardiac Arrhythmias

been recommended.b, 106

>Slow Pulseless Electrical Activity

IM Self-administration: For self-administration using a prefilled auto-injector (e.g., AtroPen®), dose is

>Carbamate Anticholinesterase Pesticides

Chemical Warfare Agent Poisoning

IM or IV: Mild to moderate symptoms: Usual initial IM dose is 2-4 mg.101, b, l

IM Self-administration: For self-administration using a prefilled auto-injector (e.g., AtroPen®), dose is

Adult Weight Adult Dose

IV: Generally, not exceeding 0.4 mg.b

IM: Generally, not exceeding 0.4 mg.b

>Organophosphate Anticholinesterase Pesticides

Chemical Warfare Agent Poisoning

• No absolute contraindications to use in life-threatening conditions (e.g., poisoning by organophosphate

• known hypersensitivity to atropine or any ingredient in the formulation105, b

• tachycardia secondary to cardiac insufficiency or thyrotoxicosis

Pediatric patients are particularly susceptible to overdosage.f

Pesticide and Chemical Warfare Agent Poisoning

Marked somnolence in susceptible patients.c