NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 5304

POLICIES AND PROCEDURES

Subject: Medical Direction

Associated Policies: 02/05/98

1. Class:

1. Parasympathetic blocker (anticholingeric). Blocks vagal effects.

2. Indications:

1. Sinus bradycardia when associated with symptomatic hypotension, chest pain, shortness of breath (SOB) or premature ventricular contractions (PVCs).
2. Second or Third degree atrioventricular (AV) block when associated with a rate less than 60/min and hypotension, chest pain, SOB, diminished level of consciousness, or PVCs.
3. Pulseless bradycardias.
4. Asystole.
5. Symptomatic organophosphate poisoning.

3. Therapeutic Effects:

1. Blocks parasympathetic action on the heart.
2. Enhances conduction through the AV junction.
3. Accelerates heart rate thereby improving cardiac output.
4. Suppresses hypercholinergic effects of organophosphate poisoning.

4. Contraindications:

1. Absolute:

1. Tachycardia.
2. Hypersensitivity.

1. Relative:

1. Narrow-angle glaucoma.

5. Adverse Effects:

1. Blurred vision.
2. Dryness of the mouth.
3. Flushing of the skin.
4. Urinary retention.
5. Headache.
6. Tachycardia.
7. Palpitations.

6. Administration and Dosage:

1. Bradycardia with pulses:

1. Adult: 0.5 mg IV (minimum single dose 0.5 mg) every 5 minutes to a maximum of 0.04 mg/ kg.
2. Pediatric: 0.02 mg/ kg (minimum single dose 0.1 mg and a maximum single dose 0.5 mg), which may be repeated every 5 minutes as needed to a maximum total dose of 1 mg in a child and 2.0 mg in an adolescent.

1. Pulseless bradycardias:

1. Adult: 1.0 mg IV repeat every 3-5 minutes up to maximum total dose of 0.04 mg/ kg. Double the dose to 2 mg for ET.
2. Pediatric: 0.02 mg/ kg IV or IO minimum single dose 0.1 mg. 0.04 mg/ kg ET administration and dilute to total volume of 3-5 ml with normal saline.

1. Asystole:

1. Adult: 1.0 mg. IV (2- 2.5 mg ET) repeat every 3-5 minutes up to maximum total dose of 0.04 mg/ kg.
2. Pediatric: 0.02 mg/ kg IV or IO, minimum single dose 0.1 mg. 0.04 mg/ kg ET and dilute to total volume of 3 - 5 mg with normal saline.

1. Organophosphate:

1. Adult: 2 mg IV or IM every 5 to 15 minutes as needed.
2. Pediatric: 0.05 mg/ kg, IV, IO or IM every 15 minutes as needed.

7. Special Information:

1. Doses smaller than 0.5 mg in an adult can cause paradoxical bradycardia.
2. Doses smaller than 0.1 mg in a child or infant can cause paradoxical bradycardia.
3. Rule out hypoglycemia before treating for organophosphate poisoning.
4. Need for atropine should be weighed against exacerbation of possible ischemic heart disease or AMI. Use with caution in the presence of chest pain.
5. Can cause ventricular fibrillation in the presence of hypoxia or acidosis.