# use of atropine and RSI



## Emt512 (Oct 5, 2011)

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?


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## MSDeltaFlt (Oct 5, 2011)

Emt512 said:


> 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?



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.


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## tssemt2010 (Oct 8, 2011)

MSDeltaFlt said:


> 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.



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


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## redcrossemt (Oct 13, 2011)

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.


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## systemet (Oct 13, 2011)

redcrossemt said:


> 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



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.




> 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.



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.


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## redcrossemt (Oct 13, 2011)

systemet said:


> 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.



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....


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## systemet (Oct 14, 2011)

redcrossemt said:


> 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....



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.


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