weak spot [0.1:<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 additional 0.5-mg IM doses in rapid succession 10 minutes after the initial dose. 105 Children 7 18 kg who present with severe symptoms or are unconscious: Inject three 0.5-mg IM doses in rapid succession. 105 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 rapid succession. 105 Children 18 41 kg: Additional doses (i.e., >3) should only be administered 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 additional 2-mg IM doses in rapid succession 10 minutes after the initial dose. 105 Children >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in rapid succession. 105 Children >41 kg: Additional doses (i.e., >3) should only be administered under the supervision of trained medical personnel. 105 Endotracheal Children: 0.05 0.1 mg/kg every 5 10 minutes until muscarinic signs and symptoms disappear. 195 Dilute in 1 2 mL of 0.9% sodium chloride injection for endotracheal administration. 195 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. 105 197 (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. 197 Chemical Warfare Agent Poisoning Various doses and dosing intervals have been recommended; dosage requirements are based on severity of poisoning and individual patient response. 101 105 195 198 200 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 197 Give diazepam for seizure control. 101 Total atropine sulfate doses usually are much less than those required for organophosphate anticholinesterase pesticide poisoning. 197 IM Minimum dose in children is 0.1 mg. 197 Children 0 2 years of age with mild to moderate symptoms: Usual initial IM dose is 0.05 mg/kg. 101 Children 0 2 years of age with severe symptoms: Usual initial IM dose is 0.1 mg/kg. 101 Children 2 10 years of age with mild to moderate symptoms: Usual initial IM dose is 1 mg. 101 Children 2 10 years of age with severe symptoms: Usual initial IM dose is 2 mg. 101 Children older than 10 years of age with mild to moderate symptoms: Usual initial IM dose is 2 mg. 101 Children older than 10 years of age with severe symptoms: Usual initial IM dose is 4 mg. 101 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). 101 197 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 additional 0.5-mg IM doses in rapid succession 10 minutes after the initial dose. 105 Children 7 18 kg who present with severe symptoms or are unconscious: Inject three 0.5-mg IM doses in rapid succession. 105 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 rapid succession. 105 Children 18 41 kg: Additional doses (i.e., >3) may be given every 5 10 minutes 197 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 additional 2-mg IM doses in rapid succession 10 minutes after the initial dose. 105 Children >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in rapid succession. 105 Children >41 kg: Additional doses (i.e., >3) may be given every 5 10 minutes 197 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 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. 197 Adults Surgery Preoperatively for Antisialagogue or Antivagal Effects IV, IM, or Sub-Q 0.5 1 mg administered 30 60 minutes prior to surgery. 195 200 May repeat in 1 2 hours. 200 Muscarinic Blockade during Anticholinesterase Reversal of Neuromuscular Blocking Agents 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. b If bradycardia is present, administer before the anticholinesterase agent to increase pulse to 80 bpm. b ACLS and Bradyarrhythmias Bradycardia IV For symptomatic bradycardia, AHA recommends initial dose of 0.5 mg; may repeat every 3 5 minutes up to 3 mg. 401 Doses <0.5 mg may cause paradoxical slowing of heart rate. 401 Asystole or PEA IV or IO In previous ACLS guidelines, 1 mg every 3 5 minutes up to 3 doses recommended. 106 Endotracheal Optimum dose not established; typical doses 2 2.5 times usual IV doses. 401 One manufacturer recommends a dose of 1 2 mg (diluted in no more than 10 mL with sterile water or 0.9% sodium chloride injection). 200 Pesticide Poisoning Various doses and dosing intervals have been recommended; dosage requirements are based on severity of poisoning and individual patient response. 105 195 198 200 Organophosphate Anticholinesterase Pesticides Preferably should be administered IV, especially the initial dose. b A cholinesterase reactivator (pralidoxime chloride) is administered concomitantly. b 197 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. 197 IV or IM Usual initial dose 1 2 mg IV (preferable) or IM; some clinicians recommend that additional 2-mg doses may be administered every 5 60 minutes until muscarinic symptoms disappear. b For severe cases, 2 6 mg may be given initially, repeating doses every 5 60 minutes. 195 200 b Alternatively, infuse IV at an initial rate of 0.5 1 mg/hour, adjusting rate according to response. 197 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. 197 For severe poisoning, 5-mg doses may be repeated every 2 3 minutes for stabilization. 197 Cumulative doses up to 1 g in 24 hours or 11 g over a course of treatment have been used. 197 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 Adults> 41 kg: Inject 2 mg IM initially for mild symptoms. 105 If severe symptoms develop, inject 2 additional 2-mg IM doses in rapid succession 10 minutes after the initial dose. 105 Adults >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in rapid succession. 105 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.) 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. 105 197 (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. 197 Chemical Warfare Agent Poisoning Various doses and dosing intervals have been recommended; dosage requirements are based on severity of poisoning and individual patient response. 105 195 198 200 Organophosphate Anticholinesterase Nerve Agents Administered IM in out-of-hospital setting or emergency department. 101 105 b A cholinesterase reactivator (pralidoxime chloride) is administered concomitantly. 197 b Give diazepam for seizure control. 101 Total atropine sulfate doses usually are much less than those required for organophosphate anticholinesterase pesticide poisoning. 197 IM Mild to moderate symptoms: Usual initial IM dose is 2 4 mg. 101 197 Severe symptoms: 5 6 mg. 101 197 Frail geriatric patients with mild to moderate symptoms: 1 mg. 101 Frail geriatric patients with severe symptoms: 2 4 mg. 101 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). 101 197 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. 197 In a report of sarin poisoning,> <20% of moderately symptomatic patients required more than 2 mg. 197 Pralidoxime chloride is administered concomitantly with atropine. 101 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 Adults> 41 kg: Inject 2 mg IM initially for mild symptoms. 105 If severe symptoms develop, inject 2 additional 2-mg IM doses in rapid succession 10 minutes after the initial dose. 105 Adults >41 kg who present with severe symptoms or are unconscious: Inject three 2-mg IM doses in rapid succession. 105 Additional doses (i.e., >3) may be given every 5 10 minutes 197 but only under the supervision of trained medical personnel. 105 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. 197 Radiographic Uses Hypotonic Radiograph of the GI Tract IM Usual dose is 1 mg. b Prescribing Limits Pediatric Patients PALS and Bradyarrhythmias Bradycardia IV, IO , or Endotracheal Infants and children: AHA recommends maximum single dose of 0.5 mg. 403 Adults ACLS and Bradyarrhythmias Asystole, PEA, and Bradycardia IV Maximum total dose of 3 mg recommended. 106 401 Special Populations Hepatic Impairment No specific hepatic dosage recommendations. 105 198 200 Renal Impairment No specific renal dosage recommendations. 105 198 200 Geriatric Patients Similar response between geriatric and younger patients. 200 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. 101 200 Cautions for AtroPen Contraindications No absolute contraindications to use in life-threatening conditions (e.g., poisoning by organophosphate nerve agents and pesticides). 105 200 Relative contraindications include: known hypersensitivity to atropine or any ingredient in the formulation 105 b angle-closure glaucoma 105 b c obstructive uropathy (e.g., bladder neck obstruction secondary to prostatic hypertrophy) c obstructive GI disease (e.g., pyloroduodenal stenosis, achalasia) c paralytic ileus c intestinal atony (especially in geriatric and debilitated patients) c severe ulcerative colitis c toxic megacolon c tachycardia secondary to cardiac insufficiency or thyrotoxicosis acute hemorrhage when cardiovascular status is unstable c 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. 198 Pediatric patients are particularly susceptible to overdosage. 198 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 Hypersensitivity reactions may occasionally occur; usually skin rashes that may progress to exfoliation. 105 200 Major Toxicities Cardiovascular Effects Caution in patients with cardiac disease. 105 200 Because heart rate is a major determinant of myocardial oxygen requirements, excessive rate acceleration in patients with acute myocardial ischemia or infarction may worsen ischemia or increase extent of infarction. b 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]). 105 200 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 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 More susceptible than adults to toxic effects; deaths at doses as low as 10 mg. c 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 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 Frequent effects include xerostomia (dry mouth), dry skin, blurred vision, cycloplegia, mydriasis, photophobia, anhidrosis, urinary hesitancy and retention, tachycardia, palpitation, xerophthalmia, and constipation, 105 200 c which may appear at therapeutic or subtherapeutic doses. c In many patients, 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), 105 200 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 for AtroPen 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 Amantadine Increased anticholinergic effects c Inform patient and monitor carefully c Antacids Decreased GI absorption of atropine c Administer oral atropine at least 1 hour before antacids c Anticholinergic drugs Increased anticholinergic effects c Inform patient and monitor carefully c Antihistamines (anticholinergic) Increased anticholinergic effects c Inform patient and monitor carefully c Antiparkinsonian (antimuscarinic) agents Increased anticholinergic effects c Inform patient and monitor carefully c Corticosteroids Increased IOP c Caution; monitor IOP c Digoxin (slow dissolving) Increased serum digoxin c Use digoxin oral solution (elixir) or rapidly dissolving tablets (e.g., Lanoxin ) c Disopyramide Increased anticholinergic effects c Inform patient and monitor carefully c Ketoconazole Increased gastric pH decreases ketoconazole absorption c Administer atropine at least 2 hours after ketoconazole c Levodopa Increased GI metabolism of levodopa & decreased systemic concentrations c Adjust levodopa dosage if atropine is started or discontinued c Meperidine Increased anticholinergic effects c Inform patient and monitor carefully c Mexiletine Decreased GI absorption rate of mexiletine; no effect on bioavailability 200 Muscle (anticholinergic) relaxants Increased anticholinergic effects c Inform patient and monitor carefully c Phenothiazines Increased anticholinergic effects c Inform patient and monitor carefully c Potassium chloride Slowed GI transit potentiates adverse GI effects of oral potassium chloride (especially wax-matrix tablets) c Caution if used concomitantly; monitor for possible GI mucosal lesions c Procainamide Increased anticholinergic effects c Inform patient and monitor carefully c Pralidoxime Increased rate of atropinization c Tricyclic antidepressants Increased anticholinergic effects c Inform patient and monitor carefully c AtroPen 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. 200 Well absorbed following endotracheal administration. b Dilution with sterile water versus 0.9% sodium chloride injection may increase endotracheal absorption. 401 Onset Inhibition of salivation occurs within 30 minutes and peaks within 1 1.6 hours after IM administration. b Increase in heart rate occurs within 2 4 minutes after IV injection. b Increase in heart rate occurs within 5 40 minutes and peaks within 20 60 minutes after IM administration. b Duration Inhibition of salivation persists for up to 4 hours. b Plasma Concentrations Following IM administration, peak plasma concentrations are reached within 30 minutes. b Distribution Extent Rapidly and well distributed throughout the body, including the CNS. 105 b Traces are found in various secretions, including milk. 200 Crosses the placental barrier and enters fetal circulation but is not found in amniotic fluid. 200 Plasma Protein Binding Low binding (about 18%) to serum albumin. b 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 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 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. 200 No gender effect on pharmacokinetics and pharmacodynamics. 200 Stability Storage Parenteral Injection 25 C (may be exposed to 15 30 C). 105 Protect from freezing and light. 105 Compatibility For information on systemic interactions resulting from concomitant use, see Interactions. Parenteral Solution Compatibility HID Compatible Sodium chloride 0.9% Drug Compatibility Admixture CompatibilityHID Compatible Dobutamine HCl Furosemide Meropenem Sodium bicarbonate Verapamil HCl Y-Site CompatibilityHID Compatible Abciximab Amiodarone HCl Argatroban Bivalirudin Dexmedetomidine HCl Doripenem Etomidate Famotidine Fenoldopam mesylate Fentanyl citrate Heparin sodium Hydrocortisone sodium succinate Hydromorphone HCl Meropenem Methadone HCl Morphine sulfate Nafcillin sodium Palonosetron HCI Potassium chloride Tirofiban HCl Variable Propofol Compatibility in SyringeHID Compatible Buprenorphine HCl Butorphanol tartrate Chlorpromazine HCl Dimenhydrinate Diphenhydramine HCl Droperidol Fentanyl citrate Glycopyrrolate Heparin sodium Hydromorphone HCl Hydroxyzine HCl Meperidine HCl Metoclopramide HCl Midazolam HCl Milrinone lactate Morphine sulfate Nalbuphine HCl Ondansetron HCl Pentazocine lactate Prochlorperazine edisylate Promethazine HCl Ranitidine HCl Scopolamine HBr Incompatible Pantoprazole sodium 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 that dry mouth may occur. 105 b 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 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; cons for lavatory
to straightforward AtroPen are expecting
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