Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Will We Do With All of That Atropine

While epinephrine has not yet been removed from the AHA (American Heart Association) Guidelines, atropine is no longer considered the standard of care in the algorithm for asystole or PEA (Pulseless Electrical Activity).

Drug Therapy for PEA/Asystole

A vasopressor can be given as soon as feasible with the primary goal of increasing myocardial and cerebral blood flow during CPR and achieving ROSC (see “Vasopressors” below for dosing) (Class IIb, LOE A). Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb, LOE B). For this reason atropine has been removed from the cardiac arrest algorithm.[1]

What are we going to do with all of that left over atropine?

Theoretically, atropine might be helpful because it is an antagonist to vagal stimuli. In practice, these dead people tend not to have been vagally stimulated to death. While people do experience vaso-vagal syncope, this either does not appear to be lethal or it is not just a simple matter of giving an anti-vagal drug and making it all better.

The great dilemma now – what do we do with all of that atropine? Many medics will be pushing as much as they can before their protocols change. First they take our atropine, then they take our tubes!

A better approach might be for hospitals to try to stockpile a lot of this atropine that is no longer being used. How many hospitals have enough atropine on hand to deal with a significant organophosphate poisoning?

Atropine

Currently, data on hospital stocking of atropine are lacking. However, even one severe case of toxicity from an organophosphorus compound can require the amounts of atropine that would exceed the stores in most communities. [The highest reported dosage requirement was for 3,600 mg in a 24 hour period for a suicidal ingestion, with a total dose of 30,730 mg over the patient’s 35 days of treatment. (LeBlanc, Bensen et al. 1986)][2]

But what about the expiration date?

I’m not going to risk saving somebody’s life if I have to violate a sacred expiration date. That would be bad.

Properly stored, atropine only seems to become more potent as it ages.

OBJECTIVE: A massive nerve agent attack may rapidly deplete in-date supplies of atropine. The authors considered using atropine beyond its labeled shelf life. The objective was to determine the stability of premixed injectable atropine sulfate samples with different expiration dates.

RESULTS: All solutions were clear and colorless. Atropine concentrations were as follows: in date, 252 microg/mL; 2001 exp, 290 microg/mL; 1999 exp, 314 microg/mL; 1990 exp, 398 microg/mL; and WW II specimen, 1,475 microg/mL. Tropine was found in concentrations of <10 microg/mL in all study samples.

CONCLUSIONS: Significant amounts of atropine were found in all study samples. All samples remained clear and colorless, and no substantial amount of tropine was found in any study sample. Further testing is needed to determine clinical effect.[3]

Certainly worth considering, because even in the unlikely event that there is no terrorist attack using organophosphates, accidental poisonings can exhaust the supplies of a hospital, or even a community.

Footnotes:

[1] Drug Therapy for PEA/Asystole
Part 8: Adult Advanced Cardiovascular Life Support
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8.2: Management of Cardiac Arrest
Rhythm-Based Management of Cardiac Arrest
PEA/Asystole
Free Full Text Article with links to Free Full Text PDF download

[2] Antidote Stocking (Optional Reading)
Case Studies in Environmental Medicine (CSEM)
Cholinesterase Inhibitors
Including Insecticides and Chemical Warfare Nerve Agents
Part 4: The Cholinergic Toxidrome
Section 11: Management of the Cholinergic Toxidrome
Free Full Text

[3] Preparing for chemical terrorism: stability of injectable atropine sulfate.
Schier JG, Ravikumar PR, Nelson LS, Heller MB, Howland MA, Hoffman RS.
Acad Emerg Med. 2004 Apr;11(4):329-34.
PMID: 15064203 [PubMed – indexed for MEDLINE]

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Comments

  1. Nebulize it instead of ipratropium?

  2. We’re still using it for bradycardia, although I’m sure we will be seeing that analyzed with greater scrutiny as well

  3. ANOTHER ONE BITES THE DUST!

    You know, Rogue, if we were to be carrying a drug box today with all the drugs I used back then that have been scientifically proven to work, by your science, as advertised, I think I’d be left with:

    +1 Enough Morphine for me to kill myself (since nothing I had was any good!)
    -1 Enough Narcan to cheat the Grim Reaper (providing you’d be so kind as to help!)
    ___

    0 Ooops!

    • firetender,

      You know, Rogue, if we were to be carrying a drug box today with all the drugs I used back then that have been scientifically proven to work, by your science, as advertised

      Where have I ever stated that any drug for cardiac arrest was scientifically proven to work?

      You keep making this claim, but it is not true.

      Show me some evidence that any drug improves survival from cardiac arrest.

      Show me something that states that anyone claimed, without misrepresenting the science, that any drug improved survival from cardiac arrest.

      We need to do a better job of education in our schools, so that people understand science.

      The failure of people to understand science does not mean that science does not work.

      • Rogue, at no time am I stating that science doesn’t work.

        Somehow that’s what you’ve gotten in your head that I stand for.

        You also seems to associate what I’m “pushing” as Alternative Medicine…I’m not.

        So, in a few minutes, I’ll have something up, for fun.

        Blessings!

        • firetender,

          Rogue, at no time am I stating that science doesn’t work.

          You keep stating that science reverses itself. How do you claim that science will completely reverse itself, but that it still works. That appears contradictory to me. Please explain yourself.

          You also seems to associate what I’m “pushing” as Alternative Medicine…I’m not.

          You advocate against treatments that are consistently shown to work better than placebo.

          You advocate for treatments that consistently fail to work better than placebo.

          If it is science-based medicine, you criticize it.

          If it is based on some expert (shaman, witchdoctor, acupucturist, reiki master, or some other anti-science expert), you claim that the only evidence necessary is anecdote.

          This is what I continually am told by alternative medicine promoters. How are you not doing the same?

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  3. […] response to one of Rogue Medic’s posts, about the demise of Atropine, I sent him a comment entitled “Another one bites the dust” lamenting that everything I […]