1. Tired of seeing ads? Are they too distracting? Click here to register today and the ads go away. Oh yeah, and it's FREE too!
  2. Can't find what you're looking for? Use the search bar in the upper right corner.

use of atropine and RSI

Discussion in 'ALS Discussion' started by Emt512, Oct 5, 2011.

  1. Emt512

    Emt512 New Member

    so going over RSI right now..and it states that the use of atropine can be used in regards to a bradycardiac patient and pediatrics...it also states its unproven and contreversial...what does your protocols say? experience?
  2. MSDeltaFlt

    MSDeltaFlt Lawn Dart

    Location:
    Cleveland, MS
    The smaller the kid the easier it'll be to stimulate the vagus nerve causing bradycardia. So yes, give a small dose to prevent bradycardia. Been my experience that the sicker cardiovascularly your pt is the more prone to bradycardia during RSI they "might" be. This is antecdotal only here. For these pts atropine would be a judgement call; still a very low dose.
  3. tssemt2010

    tssemt2010 New Member

    exactly what i was going to get too, that vagus nerve can be a real mofo, so atropine as a cautionary measure would absolutely be a good idea
  4. redcrossemt

    redcrossemt New Member

    Location:
    Michigan
    It might have been unproven or controversial many years ago, but a preliminary internet search returned several articles published recently that all indicate that bradycardia is a common problem with pediatric (<8-11 years old) intubations and that premedication with atropine is indicated.

    Here's one such article abstract:

    http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1996.tb03301.x/abstract

    I also found protocols supporting Atropine (with references) in Ron Wall's Manual of Emergency Airway Management and the EM text we have at our station.
  5. systemet

    systemet New Member

    The article you've linked to is a retrospective chart review, i.e. a case series, of pediatric intubations, from 1996. It reports data from 40 patients. They required atropine pre-medication for patients < 4 years old, and report 3 cases of bradycardia. It's not controlled, and hardly presents compelling evidence.

    Here's some articles that suggest current controversy exists with atropine premedication:


    * An RCT of propofol alone versus morphine/sux/atropine in neonatal intubation (n=63) [1]

    * Another retrospective review, this time of 163 patients, with an equal incidence of bradycardiac (a blistering 3 cases per group) in the atropine-treated and non-treated groups [4]

    * Review articles discussing the controversy from 2007 [2] and 2005 [3][5].

    It absolutely remains both unproven, and controversial. There's a real lack of evidence either supporting or arguing against the procedure.

    [1]Ghanta S, Abdel-Latif ME, Lui K, Ravindranathan H, Awad J, Oei J.
    Propofol compared with the morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: a randomized, controlled trial. Pediatrics. 2007 Jun;119(6):e1248-55. Epub 2007 May 7.

    [2] Bean A, Jones J. Atropine: re-evaluating its use during paediatric RSI.
    Emerg Med J. 2007 May;24(5):361-2. Free here: Atropine: re-evaluating its use during paediatric RSI. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658493/pdf/361a.pdf (free)

    [3] Fleming B, McCollough M, Henderson HO. Myth: Atropine should be administered before succinylcholine for neonatal and pediatric intubation. CJEM. 2005 Mar;7(2):114-7. http://www.cjem-online.ca/v7/n2/p114 (free)

    [4]Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2004 Oct;20(10):651-5.

    [5] Zelicof-Paul A, Smith-Lockridge A, Schnadower D, Tyler S, Levin S, Roskind C, Dayan P.Controversies in rapid sequence intubation in children. Curr Opin Pediatr. 2005 Jun;17(3):355-62.


    The point is that the recommendation for atropine usage in these protocols isn't clearly supported by available evidence. Wall's book is absolutely excellent, and I'm sure the EM text you have is too. But they're just repeating common practice that's based on historical usage more than proven efficacy, like many things in medicine.
  6. redcrossemt

    redcrossemt New Member

    Location:
    Michigan
    Systemet thanks for a thorough review of current literature. There doesn't seem to be good evidence for either premedication with atropine or withholding such....
  7. systemet

    systemet New Member

    That was what I took from it. It's a practice that seems intuitively reasonable but hasn't really been subjected to the rigors of evidence-based medicine to show a proven benefit.

    I should point out that I just checked pubmed very quickly, and looked at a few .pdfs. I have probably missed a number of studies. I was just trying to demonstrate that this is an area of controversy.

    My understanding, from the reading, was the atropine may well be used as a standard premedication in young pediatric patients in the US, but there are other countries where their approach varies greatly.

Share This Page