Key points
- We recommend to consult your poison centre with the use of this antidote.
- In the event of intoxication with organophosphorus, atropine will not reverse nicotinic effects, such as muscle weakness and fasciculations.
- Tachycardia is not a contraindication to the use of atropine in the context of organophosphorus (including insecticides and nerve agent, such as sarin, VX, etc.) or with carbamates poisoning.
- Other antidote to consider: Pralidoxime, benzodiazepines
+ Synonyms and other terms
- Atropine sulfate
+ Indications
- To reverse muscarinic effects, primarily bronchorrhea, following intoxication with an organophosphorus (including insecticides and nerve agent, such as sarin, VX, etc.) or with carbamates.
- To treat asystole, bradycardia and AV conduction disorders following intoxication with cardiotoxic agents.
+ Dosage
+ Pediatric Dose
Intoxication with organophosphorus or carbamates :
- 0.02 mg/kg by direct IV (maximum 2 mg). This dose can be doubled every 5 min, until atropinization is achieved, defined as:
- Resolution of bronchorrhea, and;
- Resolution of bradycardia, and;
- Resolution of hypotention, and;
- Dry axillae
- To maintain atropinization, a continuous IV infusion may be started at 10% to 20% of the total loading dose every hour (maximum initial rate of 3mg/h).
- Infusion rate should be titrated up and down depending on signs of under or over atropinization.
- There is no maximum cumulative dose of atropine in the treatment of organophosphorus or carbamate toxicity.
Treating bradycardia and AV conduction disorders following intoxication with cardiotoxic agents :
- 0.02 mg/kg by direct IV or 0.03 mg/kg by endotracheal route. Repeat once as needed. (minimum dose 0.1mg and maximum single dose 0.5mg)
+ Adult Dose
Intoxication with organophosphorus or carbamates :
- 1 to 2 mg by direct IV. This dose can be doubled every 5 min, until atropinization is achieved, defined as:
- Resolution of bronchorrhea, and;
- Resolution of bradycardia, and;
- Resolution of hypotension, and;
- Dry axillae
- To maintain atropinization, a continuous IV infusion may be started at 10% to 20% of the total loading dose every hour (maximum initial rate of 3mg/h).
- Infusion rate should be titrated up and down depending on signs of under or over atropinization.
- There is no maximum cumulative dose of atropine in treatment of organophosphorus or carbamate insecticide toxicity.
Treating bradycardia and AV conduction disorders following intoxication with cardio-toxic agents :
- Symptomatic bradycardia: 1 mg direct IV. Repeat as needed, up to a total of 3 mg.
+ Renal Impairment
No data suggests that the dose should be modified for short-term use.
+ Hepatic Impairment
No data suggests that the dose should be modified for short-term use.
+ Hemodialysis Patient
No data suggests that the dose should be modified for short-term use.
+ Pregnancy
- Safe as a single dose.
- The safety of repeated doses of atropine has not been demonstrated. However, do not hesitate to use it during pregnancy if the anticipated toxic effects pose a major risk of morbidity or mortality.
- No data suggests that the dose should be modified for short-term use.
+ Obese or Overweight Patient
No data suggests that the dose should be modified for short-term use.
+ Adverse effects
- Anticholinergic effects: visual hallucinations, hyperthermia, ileus, mydriasis, tachycardia, urinary retention.
+ Monitoring
- Vital signs
- EKG
- Signs of atropine toxicity: dry, hot skin, dry mouth, delirium.
+ End of treatment
Intoxication with organophosphorus or carbamates:
- No relapse of cholinergic or muscarinic signs after having stopped atropine for a few hours.
- Onset of anticholinergic syndrome (dry secretions, urinary retention, visual hallucinations, ileus)
Treating bradycardia and AV conduction disorders following intoxication with cardiotoxic agents:
- No relapse of cardiac conduction impairment.
- Onset of anticholinergic syndrome (urinary retention, visual hallucinations, hyperthermia, ileus)
+ Special Notes on Administration
Intravenous Route (IV)
- Direct IV :
- Administer injectable solution by direct IV over 1 to 2 minutes.
- Continuous IV Infusion :
- To maintain atropinization, dilute dose in a compatible solution to achieve a final concentration of 0.1 mg/ml, administer using a volumetric pump.
- Examples using syringes with a concentration of 0.1 mg/ml
- Transfer contents into an empty bag or syringe that can adapt to a syringe pump or volumetric pump.
- Final concentration: 0.1 mg/ml.
- Examples using an ampoule with a concentration of 0.4 mg/ml
- 5 mg (12.5 ml in 37.5 ml of NS Final volume: 50 ml. Final concentration: 0.1 mg/ml
- 10 mg (25 ml) in 75 ml of NS Final volume: 100 ml. Final concentration: 0.1 mg/ml
- Examples using an ampoule with a concentration of 0.6 mg/ml:
- 5 mg (8.3 ml) in 41.7 ml of NS. Final volume: 50 ml. Final concentration: 0.1 mg/ml
- 10 mg (16.7 ml) in 83.3 ml of NS. Final volume: 100 ml. Final concentration: 0.1 mg/ml
Subcutaneous Route (SC)
- Possible alternative to IV route.
Intramuscular Route (IM)
- Possible alternative to IV route, but slower onset of action.
Intraosseous Route (IO)
- Possible alternative to IV route.
Endotracheal Route (ET)
- Possible alternative when IV or IO routes not accessible.
Compatibility
Partial list only. Consult the pharmacist on duty at your health care facility.
- Compatible solutions : NS, D5W, D5W - NS, D5W - ½NS.
- Y-site compatibility : aminophylline, amiodarone, atracurium, benztropine, bicarbonate (sodium), calcium (chlorine and gluconate), dexamethasone, digoxin, diphenhydramine, dobutamine, dopamine, ephedrine, esmolol, etomidate, famotidine, fentanyl, folic acid, furosemide, standard heparin, regular insulin, isoproterenol, ketamine, labetalol, lidocaine, magnesium (sulfate), mannitol, metoclopramide, metoprolol, midazolam, morphine, MVI, naloxone, nitroglycerin, sodium nitroprusside, norepinephrine, ondansetron, pentobarbital, phenobarbital, phentolamine, phenylephrine, phytonadione (vitamin K1), potassium (chloride), procainamide, prochlorperazine, propranolol, protamine, pyridoxine, ranitidine, succinylcholine, thiamine, vasopressin, verapamil.
- Y-site incompatibility : dantrolene, diazepam, pantoprazole, phenytoin, sulfamethoxazole - trimethoprim, thiopental.
Stability
- Ampoules and syringes of 0.4 and 0.6 mg/ml are intended for single use only and do not contain any preservatives. Discard any unused portion. Store at room temperature (15°C to 30°C).
- The 0.4 mg/ml multidose vial by Sandoz contains a preservative (0.5% chlorobutanol).
- No stability data for atropine diluted in any of the compatible solutions.
+ Available products
- Atropine injection BP, 0.4 mg/ml, Inj. Sol., 1 ml per ampoule, Alveda, DIN 02094681,
- Atropine injection BP, 0.6 mg/ml, Inj. Sol., 1 ml per ampoule, Alveda, DIN 02432196,
- Atropine sulfate injection USP, 0.1 mg/ml, Inj. Sol., 5 and 10 ml per syringe (Abboject or Lifeshield), Hospira, DIN 00328154,
- Atropine sulfate injection USP, 0.4 mg/ml, Inj. Sol., 1 ml per ampoule, Sandoz, DIN 0392782,
- Atropine sulfate injection USP, 0.6 mg/ml, Inj. Sol., 1 ml per ampoule, Sandoz, DIN 00392693,
+ Amount required to treat a person weighting 70kg during 24 hours
- At least 100 mg.
+ References
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Balali-Mood, Mahdi, and Hamidreza Saber. 2012a. “Recent Advances in the Treatment of Organophosphorous Poisonings.” Iranian Journal of Medical Sciences 37 (2):74–91.
Bhalla, Ashish, and Surjit Singh. n.d. “Why Do the Results of Studies on the Effectiveness of Pralidoxime for Treatment of Organophosphate Poisoning Vary?”
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Eddleston, Michael, Nick A. Buckley, Peter Eyer, and Andrew H. Dawson. 2008. “Management of Acute Organophosphorus Pesticide Poisoning.” The Lancet 371 (9612):597–607.
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Murray, Douglas B., Michael Eddleston, Simon Thomas, Robert D. Jefferson, Adrian Thompson, Mick Dunn, Daniel S. Vidler, R. Eddie Clutton, and Peter G. Blain. 2012. “Rapid and Complete Bioavailability of Antidotes for Organophosphorus Nerve Agent and Cyanide Poisoning in Minipigs after Intraosseous Administration.” Annals of Emergency Medicine 60 (4):424–30.
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Prete, Mark R., Charles J. Hannan, and t. Frederick M. Burkle. n.d. “Plasma Atropine Concentrations via Intravenous, Endotracheal, and intraosseous Administration.”
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Singh, S., D. Chaudhry, D. Behera, D. Gupta, and S. K. Jindal. 2001. “Aggressive Atropinization and Continuous Pralidoxime (2-PAM) Infusion in Patients with Severe Organophosphate Poisoning: Experience of a Northwest Indian Hospital.” Human & Experimental Toxicology 20 (1):15–18.
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St-Onge, Maude, Kurt Anseeuw, Frank Lee Cantrell, Ian C. Gilchrist, Philippe Hantson, Benoit Bailey, Valéry Lavergne, et al. 2017. “Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults.” Critical Care Medicine 45 (3):e306–15.
Thiermann, Horst, Dirk Steinritz, Franz Worek, Maria Radtke, Peter Eyer, Florian Eyer, Norbert Felgenhauer, and Thomas Zilker. 2011. “Atropine Maintenance Dosage in Patients with Severe Organophosphate Pesticide Poisoning.” Toxicology Letters 206 (1):77–83.
American Hearth Association, Advanced cardiac life support (ACLS) Guidelines, Oct 25th, 2020.
© Centre antipoison du Québec, CIUSSS de la Capitale-Nationale, 2017. The information contained in this site may be cited, provided the source is acknowledged. Any use for commercial or advertising purposes is strictly prohibited.
ISSN : 2292-230X
Authors: Bailey B, Blais R, Dubé PA, Friesen M, Gaudreault P, Gosselin S, Laliberté M, Larocque A, St-Onge M
Reviewers: Elliott A, Mackenzie C, Murphy N, Letarte A, Pursell R, Thompson M, Yarema M
