Pronunciation:

(A troe peen)

U.S. Brand Names:

Synonyms:

Generic Available:

Canadian Brand Names:

Use:

Injection: Preoperative medication to inhibit salivation and secretions; treatment of symptomatic sinus bradycardia; AV block (nodal level); ventricular asystole; antidote for organophosphate pesticide poisoning

Ophthalmic: Produce mydriasis and cycloplegia for examination of the retina and optic disc and accurate measurement of refractive errors; uveitis

Oral: Inhibit salivation and secretions

Use - Unlabeled/Investigational:

Restrictions:

Pregnancy Risk Factor:

Pregnancy Implications:

Lactation:

Contraindications:

Warnings/Precautions:

AtroPen®: There are no absolute contraindications for the use of atropine in organophosphate poisonings, however, use caution in those patients where the use of atropine would be otherwise contraindicated. Formulation for use by trained personnel only.

Adverse Reactions:

Cardiovascular: Arrhythmia, flushing, hypotension, palpitation, tachycardia

Central nervous system: Ataxia, coma, delirium, disorientation, dizziness, drowsiness, excitement, fever, hallucinations, headache, insomnia, nervousness

Dermatologic: Anhidrosis, urticaria, rash, scarlatiniform rash

Gastrointestinal: Bloating, constipation, delayed gastric emptying, loss of taste, nausea, paralytic ileus, vomiting, xerostomia

Genitourinary: Urinary hesitancy, urinary retention

Neuromuscular & skeletal: Weakness

Ocular: Angle-closure glaucoma, blurred vision, cycloplegia, dry eyes, mydriasis, ocular tension increased

Respiratory: Dyspnea, laryngospasm, pulmonary edema

Miscellaneous: Anaphylaxis

Overdosage/Toxicology:

Drug Interactions:

Drugs with anticholinergic activity (including phenothiazines and TCAs) may increase anticholinergic effects when used concurrently.

Sympathomimetic amines may cause tachyarrhythmias; avoid concurrent use.

Stability:

Compatibility:

Y-site administration: Compatible: Etomidate, famotidine, heparin, hydrocortisone sodium succinate, inamrinone, meropenem, nafcillin, potassium chloride, propofol, sufentanil, vitamin B complex with C. Incompatible: Thiopental

Compatibility in syringe: Compatible: Butorphanol, chlorpromazine, cimetidine, dimenhydrinate, diphenhydramine, droperidol, fentanyl, glycopyrrolate, heparin, hydromorphone, hydroxyzine, hydroxyzine with meperidine, meperidine, meperidine with promethazine, metoclopramide, midazolam, milrinone, morphine, nalbuphine, ondansetron, pentazocine, perphenazine, prochlorperazine, promazine, promethazine, propiomazine, ranitidine, scopolamine, sufentanil. Incompatible: Cimetidine with pentobarbital. Variable (consult detailed reference): Pentobarbital

Compatibility when admixed: Compatible: Dobutamine, furosemide, meropenem, sodium bicarbonate, verapamil. Incompatible: Floxacillin, metaraminol, methohexital, norepinephrine

Mechanism of Action:

Pharmacodynamics/Kinetics:

Onset of action: I.V.: Rapid

Absorption: Complete

Distribution: Widely throughout the body; crosses placenta; trace amounts enter breast milk; crosses blood-brain barrier

Metabolism: Hepatic

Half-life elimination: 2-3 hours

Excretion: Urine (30% to 50% as unchanged drug and metabolites)

Dosage:

Neonates, Infants, and Children: Doses <0.1 mg have been associated with paradoxical bradycardia.

Inhibit salivation and secretions (preanesthesia): Oral, I.M., I.V., SubQ:

<5 kg: 0.02 mg/kg/dose 30-60 minutes preop then every 4-6 hours as needed. Use of a minimum dosage of 0.1 mg in neonates <5 kg will result in dosages >0.02 mg/kg. There is no documented minimum dosage in this age group.

>5 kg: 0.01-0.02 mg/kg/dose to a maximum 0.4 mg/dose 30-60 minutes preop; minimum dose: 0.1 mg

Alternate dosing:

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

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

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

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

>30 kg (>65 lb): 0.4 mg

Bradycardia: I.V., intratracheal: 0.02 mg/kg, minimum dose 0.1 mg, maximum single dose: 0.5 mg in children and 1 mg in adolescents; may repeat in 5-minute intervals to a maximum total dose of 1 mg in children or 2 mg in adolescents. (Note: For intratracheal administration, the dosage must be diluted with normal saline to a total volume of 1-5 mL). When treating bradycardia in neonates, reserve use for those patients unresponsive to improved oxygenation and epinephrine.

Infants and Children: Nerve agent toxicity management (unlabeled use): See "Note" in Adults dosing.

Prehospital ("in the field"): I.M.:

Birth to <2 years: Mild-to-moderate symptoms: 0.05 mg/kg; severe symptoms: 0.1 mg/kg

2-10 years: Mild-to-moderate symptoms: 1 mg; severe symptoms: 2 mg

>10 years: Mild-to-moderate symptoms: 2 mg; severe symptoms: 4 mg

Hospital/emergency department: I.M.:

Birth to <2 years: Mild-to-moderate symptoms: 0.05 mg/kg I.M. or 0.02 mg/kg I.V.; severe symptoms: 0.1 mg/kg I.M. or 0.02 mg/kg I.V.

2-10 years: Mild-to-moderate symptoms: 1 mg; severe symptoms: 2 mg

>10 years: Mild-to-moderate symptoms: 2 mg; severe symptoms: 4 mg

Children: Organophosphate or carbamate poisoning:

I.V.: 0.03-0.05 mg/kg every 10-20 minutes until atropine effect, then every 1-4 hours for at least 24 hours

I.M. (AtroPen®): Mild symptoms: Administer dose listed below as soon as exposure is known or suspected. If severe symptoms develop after first dose, 2 additional doses should be repeated in 10 minutes; do not administer more than 3 doses. Severe symptoms: Immediately administer 3 doses as follows:

<6.8 kg (15 lbs): Use of AtroPen® formulation not recommended; administer atropine 0.05 mg/kg

6.8-18 kg (15-40 lbs): 0.5 mg/dose

18-41 kg (40-90 lbs): 1 mg/dose

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

Adults (doses <0.5 mg have been associated with paradoxical bradycardia):

Asystole or pulseless electrical activity:

I.V.: 1 mg; repeat in 3-5 minutes if asystole persists; total dose of 0.04 mg/kg.

Intratracheal: Administer 2-2.5 times the recommended I.V. dose; dilute in 10 mL NS or distilled water. Note: Absorption is greater with distilled water, but causes more adverse effects on PaO2.

Inhibit salivation and secretions (preanesthesia):

I.M., I.V., SubQ: 0.4-0.6 mg 30-60 minutes preop and repeat every 4-6 hours as needed

Bradycardia: I.V.: 0.5-1 mg every 5 minutes, not to exceed a total of 3 mg or 0.04 mg/kg; may give intratracheally in 10 mL NS (intratracheal dose should be 2-2.5 times the I.V. dose)

Neuromuscular blockade reversal: I.V.: 25-30 mcg/kg 60 seconds before neostigmine or 7-10 mcg/kg in combination with edrophonium

Organophosphate or carbamate poisoning:

I.V.: 2 mg, followed by 2 mg every 5-60 minutes until adequate atropinization has occurred; initial doses of up to 6 mg may be used in life-threatening cases

I.M. (AtroPen®): Mild symptoms: Administer 2 mg as soon as exposure is known or suspected. If severe symptoms develop after first dose, 2 additional doses should be repeated in 10 minutes; do not administer more than 3 doses. Severe symptoms: Immediately administer three 2 mg doses.

Nerve agent toxicity management (unlabeled use): I.M.: See Note. Prehospital ("in the field") or hospital/emergency department: Mild-to-moderate symptoms: 2-4 mg; severe symptoms: 6 mg

Note: Pralidoxime is a component of the management of nerve agent toxicity; consult pralidoxime monograph for specific route and dose. For prehospital ("in the field") management, repeat atropine I.M. (children: 0.05-0.1 mg/kg; adults: 2 mg) at 5-10 minute intervals until secretions have diminished and breathing is comfortable or airway resistance has returned to near normal. For hospital management, repeat atropine I.M. (infants 1 mg; all others: 2 mg) at 5-10 minute intervals until secretions have diminished and breathing is comfortable or airway resistance has returned to near normal.

Mydriasis, cycloplegia (preprocedure): Ophthalmic (1% solution): Instill 1-2 drops 1 hour before procedure.

Uveitis: Ophthalmic:

1% solution: Instill 1-2 drops 4 times/day

Ointment: Apply a small amount in the conjunctival sac up to 3 times/day; compress the lacrimal sac by digital pressure for 1-3 minutes after instillation

Elderly, frail patients: Nerve agent toxicity management (unlabeled use): I.M.: See "Note" in Adults dosing.

Prehospital ("in the field"): Mild-to-moderate symptoms: 1 mg; severe symptoms: 2-4 mg

Hospital/emergency department: Mild-to-moderate symptoms: 1 mg; severe symptoms: 2 mg

Administration:

I.M.: AtroPen®: Administer to outer thigh. May be given through clothing as long as pockets at the injection site are empty. Hold auto-injector in place for 10 seconds following injection; massage the injection site.

I.V.: Administer undiluted by rapid I.V. injection; slow injection may result in paradoxical bradycardia.

Intratracheal: Dilute in NS or distilled water. Absorption is greater with distilled water, but causes more adverse effects on PaO2. Pass catheter beyond tip of tracheal tube, stop compressions, spray drug quickly down tube. Follow immediately with several quick insufflations and continue chest compressions.

Monitoring Parameters:

Patient Education:

Ophthalmic: Instill as often as recommended. Wash hands before using. Sit or lie down, open eye, look at ceiling, and instill prescribed amount of solution. Do not blink for 30 seconds, close eye and roll eye in all directions, and apply gentle pressure to inner corner of eye for 1-2 minutes. Do not let tip of applicator touch eye; do not contaminate tip of applicator (may cause eye infection, eye damage, or vision loss). Temporary stinging or blurred vision may occur.

Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.

Nursing Implications:

Anesthesia and Critical Care Concerns/Other Considerations:

Cardiovascular Considerations:

Dental Health: Effects on Dental Treatment:

Dental Health: Vasoconstrictor/Local Anesthetic Precautions:

Mental Health: Effects on Mental Status:

Mental Health: Effects on Psychiatric Treatment:

Dosage Forms:

Injection, solution, as sulfate: 0.05 mg/mL (5 mL); 0.1 mg/mL (5 mL, 10 mL); 0.4 mg/mL (0.5 mL, 1 mL, 20 mL); 0.5 mg/mL (1 mL); 1 mg/mL (1 mL)

AtroPen® [prefilled auto-injector]: 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)

Ointment, ophthalmic, as sulfate: 1% (3.5 g)

Solution, ophthalmic, as sulfate: 1% (5 mL, 15 mL)

Atropine-Care®: 1% (2 mL)

Isopto® Atropine: 1% (5 mL, 15 mL)

Tablet, as sulfate (Sal-Tropine™): 0.4 mg

International Brand Names: