IM Atropine dose for peds emergency

kids · May 21, 2006

Good question, I'm interested in the answer, PALS only lists IV/IO or tracheal routes.

MmacFN · May 21, 2006

Hey there

As a PALS and ACLS Regional Faculty, there is no IM dose for atropine in regards to unstable kiddies. Really, atropine is a second line med for peds bradycardia as it is often not a vagal mechanism. Atropine is only used in peds for bradycardia as a first line drug during intubation, no other time.

If a child is in extemis there should be no IV attempts but an IO insertion and epi pushed. IM medications have no place in acute peds, or adult care.

Why did the question come up sand? From reading your other posts this information wouldnt seem to be anything new to you.

Hope that helps

Editorial Team / Admin · May 21, 2006

Straight from the PALS Support Drugs and Electrical Therapy 2002 guidelines:

Atropine given IV/IO/Endotrachael

IV/IO administration:

0.02 mg/kg

Minimum single dose: 0.1 mg

Maximum child single dose: 0.5 mg

Mazimum adolescent single dose: 1.0 mg

May double for second IV/IO dose

Maximim child total dose: 1.0 mg

Maximum adolescent total dose: 2.0 mg

Tracheal Administration:

0.02 mg/kg (absorption may be unreliable)

Larger dose than IV dose may be required

sandman1 · May 21, 2006

Thanks for your reply. I just wonder because at most facilities that I have been to, most anesthesia providers want you to draw up an IV AND IM dose of Succs and atropine for pediatric cases. The Succs is obviously to break laryngospasm in the unfortunate case of having no IV (during PE tubes, etc). The atropine to counteract the Succs adverse effects or to use in an extreme situation not corrected with a little O2, I guess. Nothing happened. It's just confusing when you have people(not just one person) telling you to draw up Succs and ATropine with the IM dose being double the IV for both drugs yet I can only confirm the IM dose of Succs in the texts. All I can find regarding Atropine is .02mg/kg IM which is the same as IV.

heartICU · May 21, 2006

Thanks for your reply. I just wonder because at most facilities that I have been to, most anesthesia providers want you to draw up an IV AND IM dose of Succs and atropine for pediatric cases. The Succs is obviously to break laryngospasm in the unfortunate case of having no IV (during PE tubes, etc). The atropine to counteract the Succs adverse effects or to use in an extreme situation not corrected with a little O2, I guess. Nothing happened. It's just confusing when you have people(not just one person) telling you to draw up Succs and ATropine with the IM dose being double the IV for both drugs yet I can only confirm the IM dose of Succs in the texts. All I can find regarding Atropine is .02mg/kg IM which is the same as IV.

Hmmm, I haven't seen that. I am doing my peds rotation now, and we always have a 10cc syringe with an atropine/succ mixture in it (16mg/cc succ, 0.07mg/cc atropine) as well as a 1cc syringe with 0.4mg/cc atropine.

So you don't typically place an IV in kids getting tubes? We always do - we don't run fluid through it, but always place a peripheral IV with just a cap on it - I would hate to have to recover a kid with no access.

MmacFN · May 21, 2006

Ahh

Well that is unusual. IM atropine wont be helpful to the kid 15 min post injection if they are hypoxic and bradycardic from a vagal episode secondary to laryngoscopy. I wonder why they would ask for that? I cant think of a single use for IM atropine in any situation at all.

Did you ask them directly?

I asked an anesthesiologist friend of mine and he said he had never heard of such a thing. He also said the use of IM succs would be odd as well.

Now i have given IM succs to patients who have threatened to crash the helicopter and had pulled their IVs. I can tell you, it works in about 5 minutes to paralyze them

Thanks for your reply. I just wonder because at most facilities that I have been to, most anesthesia providers want you to draw up an IV AND IM dose of Succs and atropine for pediatric cases. The Succs is obviously to break laryngospasm in the unfortunate case of having no IV (during PE tubes, etc). The atropine to counteract the Succs adverse effects or to use in an extreme situation not corrected with a little O2, I guess. Nothing happened. It's just confusing when you have people(not just one person) telling you to draw up Succs and ATropine with the IM dose being double the IV for both drugs yet I can only confirm the IM dose of Succs in the texts. All I can find regarding Atropine is .02mg/kg IM which is the same as IV.

jwk · May 21, 2006

Hmmm, I haven't seen that. I am doing my peds rotation now, and we always have a 10cc syringe with an atropine/succ mixture in it (16mg/cc succ, 0.07mg/cc atropine) as well as a 1cc syringe with 0.4mg/cc atropine.
So you don't typically place an IV in kids getting tubes? We always do - we don't run fluid through it, but always place a peripheral IV with just a cap on it - I would hate to have to recover a kid with no access.

We rarely start IV's on very minor peds cases such as ear tubes.

Also, I usually wouldn't have a 10cc syringe of ANYTHING drawn up when doing most peds cases, except perhaps propofol on bigger kids. Laying out larger full syringes with adult-sized doses (such as the sux/atropine mix you describe) for peds cases is not a great idea. Better to use smaller syringes, closer to unit-dose size.

heartICU · May 21, 2006

We rarely start IV's on very minor peds cases such as ear tubes.
Also, I usually wouldn't have a 10cc syringe of ANYTHING drawn up when doing most peds cases, except perhaps propofol on bigger kids. Laying out larger full syringes with adult-sized doses (such as the sux/atropine mix you describe) for peds cases is not a great idea. Better to use smaller syringes, closer to unit-dose size.

It's not a full 10cc syringe - I should have clarified. We draw up 5cc of succs, 1cc of atropine, the final concentration is as I said above (total of 6cc in the syringe). This is also at a strictly peds hospital, and it's done in each OR - so every anesthetist knows the concentration and where to reach for the emergency meds. When they have a tiny kid, of course they always mix up the more dilute meds so as not to overdose.

maturner · May 23, 2006

Ahh
Well that is unusual. IM atropine wont be helpful to the kid 15 min post injection if they are hypoxic and bradycardic from a vagal episode secondary to laryngoscopy. I wonder why they would ask for that? I cant think of a single use for IM atropine in any situation at all.
Did you ask them directly?
I asked an anesthesiologist friend of mine and he said he had never heard of such a thing. He also said the use of IM succs would be odd as well.
Now i have given IM succs to patients who have threatened to crash the helicopter and had pulled their IVs. I can tell you, it works in about 5 minutes to paralyze them

IM Sux/atropine (a.k.a sux/atropine DART) in peds is for the purpose of breaking a laryngospasm in a patient without an IV. Which is frequently the case during mask inductions or short procedures such a PE tubes.

The atropine is to off set the bradycardia frequently associated with sux administration in this population. Peds particularly small ones are PNS (vagal) dominant as their SNS system is immature.

The dose per Nagelhoudt is sux 4mg/kg and atropine 0.03mg/kg.

The sux/atropine dart is pretty much standard in the 10+ hospitals through which I have rotated in SoCal and HI.

MmacFN · May 23, 2006

Hey mat

Everything i have read suggests that IM atropine is both unpredictable in HR change and duration and often dosent begin to take effect for > 15 minutes. How is it helpful?

As for breaking spasm, i use PPV then if that dosent work i was taught to shoot 5 cc's of lidocaine without epi on the cords directly to break the spasm. Have you ever tried this?

Interesting stuff!

IM Sux/atropine (a.k.a sux/atropine DART) in peds is for the purpose of breaking a laryngospasm in a patient without an IV. Which is frequently the case during mask inductions or short procedures such a PE tubes.
The atropine is to off set the bradycardia frequently associated with sux administration in this population. Peds particularly small ones are PNS (vagal) dominant as their SNS system is immature.
The dose per Nagelhoudt is sux 4mg/kg and atropine 0.03mg/kg.
The sux/atropine dart is pretty much standard in the 10+ hospitals through which I have rotated in SoCal and HI.

maturner · May 23, 2006

Hey mat
Everything i have read suggests that IM atropine is both unpredictable in HR change and duration and often dosent begin to take effect for > 15 minutes. How is it helpful?
As for breaking spasm, i use PPV then if that dosent work i was taught to shoot 5 cc's of lidocaine without epi on the cords directly to break the spasm. Have you ever tried this?
Interesting stuff!

Is it better to give a drug to prevent or attenuate a bradycardic response or stand there like Gomer Pyle?

PPV is always the first like offense to break a laryngospasm

The first line defense is don't muck with the cords during stage II of anesthetic depth

I have not used lidocaine directly on the cords (nor have I had to use the DART) PPV has worked thus far... knock on wood...

I vaguely remember reading something somewhere about lidocaine on the cords to break a spasm but most texts discuss sux as the primary back up following PPV. M&M has a vignette about a pressure point behind the ear that can break a spasm but again I don't remember the details.

Mike