atropine for brady

[JPINFV]

Naturally, correct me please if I am wrong!! Just my ever so often two cents worth.... 8)

Well, to be completely pedantically nitpicky, if the hypoxia is caused by a shunt, then increasing the FIO2 won't help any. Also the efficacy of supplemented FIO2 decreases as a V/Q mismatch gets worse.

[Laura Anne]

Block as in BBB..... but yes, I see what you're saying. If the patient has a poor V/Q ratio due to PMHx of any COPD or other resp illness/injury, increasing the supplemental O2 won't make much of a difference in the long run. Then again, when it comes to this medication, I can only go off of what I learned in class back in the day (which wasn't much if you knew my program :oops: ) and what I learn from my near and dear friend GOOGLE. :wink: Oh yes, and this site, too. thnx!

My old instructors all 'edge-ewma-katid' me on the simple fact that when giving Atropine, always start on the lower dose due to the O2 demand on the heart, but never explained as to why this happens. Over time, I got out of my monkey suit and decided if I want to be an appropriate EMS provider, I should maybe take things one at a time and educate myself. As you can see, I am STILL learning.

[MedicEllis]

Yeah, our protocol for symptomatic bradycardia reads 0.5 - 1.0 mg atropine q 5 min to a max. dose of 3 mg. If no change begin pacing. OR dopamine 5mcg/kg/min. while awaiting pacing or ineffective pacing.

Yikes! q5 for a symptomatic bradycardia (that is 15 min at 1mg dosing and 30 min for .5mg dosing)

that doesn't seem right and not anywhere what ACLS teaches. If you have a symptomatic pt, atropine should be/can be tried while TCP is readied. But I know of not a single protocol where should you wait 15 mins let alone 30 before you start TCP.

[ccmedoc]

..

that doesn't seem right and not anywhere what ACLS teaches. If you have a symptomatic pt, atropine should be/can be tried while TCP is readied. But I know of not a single protocol where should you wait 15 mins let alone 30 before you start TCP.

Most protocols would undoubtedly leave it up to the medic. Assessment and presentation (not necessarily in that order) is key. If the patient presented extremely unstable, then pacing sooner than later would be recommended. I am not against the trial of the 3mg of Atropine before pacing, given that the patient was, in my mind, able to withstand the time allowance. Pacing pads should definitely be applied as ASAP.

The ACLS2000 protocols recommended the 0.5-1.0 q 3-5 min then proceed to TCP. There too, if ASSESSMENT showed the patient very unstable, or the paramedic felt that the Atropine was not going to be effective, pace.

Symptomatic is a bit of a relative term. To say that anyones protocols would be rigid in this sense is a bit presumptuous. Someone that presents with postural hypotension is most definitely symptomatic, but do they need to be paced?...Kinda depends, huh?

IMHO, 15-30min is acceptable in most instances of bradycardia, presuming no deterioration in status...

[JakeEMTP]

Most protocols would undoubtedly leave it up to the medic. Assessment and presentation (not necessarily in that order) is key. If the patient presented extremely unstable, then pacing sooner than later would be recommended. I am not against the trial of the 3mg of Atropine before pacing, given that the patient was, in my mind, able to withstand the time allowance. Pacing pads should definitely be applied as ASAP.

Exactly. Just because we can administer up to 3mg Atropine, doesn't mean we have to. And yes, I always apply the pacing pads first.

[Novisen]

http://www.resus.org.uk/pages/periarst.pdf

[Doczilla]

One thing to keep in mind is that bradycardia or heart block from dig toxicity specifically is parasympathetically mediated, and may respond better to atropine than other types of bradycardia and AV block. TCP in these patients is more likely than other to lead to a serious ventricular arrhythmia. This is why I correct ACLS instructors who say not to give atropine in high degree AVB.

Atropine is a *fairly* benign drug overall, so I usually give it a shot to begin with anyway.

'zilla

[firedoc5]

Atropine is a *fairly* benign drug overall, so I usually give it a shot to begin with anyway.

'zilla

When I first took ACLS that is what was said. Give it anyway, it won't hurt. But I've heard the argument(s) that differ.

A rule of thumb we went by also then was if the patient was brady but not full arrest, 0.5mg. IV. If full arrest 1.0mg IV and repeat at 5 mins. total of 2.0mg. If not effective at that total dose then it's considered not working. Then they did change it to a total of 3.0mg. But about nine months later they went back to 2.0mg. It made us feel like "I'm not as think as you confused I am :banghead: :dontknow: ". I know things have changed even more since I've been out of the field.

[saboats]

It's not that it won't work, it can actually make the block worse. The Parasympathetic NS dosen't inervate into the ventricals so if you give a parasympatholitic medicication eg atopine to a pt in a 2nd degree type 2 or complete block, you will speed up the atrial rate, but won't have effect on the ventricular rate, meaning the SA node will fire at 120 beats a minute while the Ventricals are at 40... you will decrease any atrial kick effect even more, decrease minute volume, decrease BP and make the patient worse. Yes most protocols say you can consider giving 0.5mg while "preparing for pacing" but it could make things worse. Follow your local protocols, but I would have the pads ready if you try it...

yes according to ACLS protocols you can repeat atropine to a max of 3mg. they also state that if pacing is ineffective and the patient has poor perfusion you consider an epinephrine or dopamine infusion at 2-10 mcg/min. Atropine will most likely not work on a high degree block i.e 3rd degree or 2nd degree type II. Its more imperative that you get the pads on the patient.

[saboats]

One thing to keep in mind is that bradycardia or heart block from dig toxicity specifically is parasympathetically mediated, and may respond better to atropine than other types of bradycardia and AV block. TCP in these patients is more likely than other to lead to a serious ventricular arrhythmia. This is why I correct ACLS instructors who say not to give atropine in high degree AVB.

Atropine is a *fairly* benign drug overall, so I usually give it a shot to begin with anyway.

'zilla

I like the fact that you are bringing this point up, as long as it is clear that it is specifically for dig toxicity, not all high degree AV Blocks... Good point!