Peds IM Doses for Atropine and Sux

[soorg]

What IM doses are folks around these parts using? I've never had to, but have heard 20 ug/kg for Atropine and 2-4mg/kg for sux.

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[IlDestriero]

Sounds good. You'll end up using it. Those little bastards love to get URIs and laryngospasm on you. Parents lie like a rug as well.

 

[RussianJoo]

are these im or iv doses?

 

[IlDestriero]

are these im or iv doses?

IM. Though 99% of the time I give atropine IV if needed. I would really only give it IM in a really little guy w/ IM Sux. In training we had an IM needle on a 3cc syringe with 2cc Sux and 1cc atropine for emergencies.
Now the scenario usually goes like this:
Laryngospasm during mask Induction (rarely emergence, and most of them have IVs already 😉 )
Me: "Shiite!". (Gets everyone's attention.)
IM sux after repositioning +/- OPA and PPV without success.
IV be me or OR nurse depending on if I am alone or not.
IV atropine. (usually not needed)
Once in a great while chest compressions and IV epi.
Tube.

 

[sevoflurane]

Love peds. Wish I did more little ones (< 3-4 mo).

Hey IlD. Do you have a minimum dose of atropine for the little guys? You know... The paradoxical bradycardia thing.

What if it was a 500 gram neonate?

 

[IlDestriero]

Love peds. Wish I did more little ones (< 3-4 mo).

Hey IlD. Do you have a minimum dose of atropine for the little guys? You know... The paradoxical bradycardia thing.

What if it was a 500 gram neonate?

The myth of a minimum dose of Atropine is just that, a myth.
I give 20 mcg/kg, practically limited to 40 mcg/dose. If it doesn't give me the desired effect, I double the dose.
For micro preemies, I mix some custom unit doses of atropine and epi, etc. in case the stool hits the fan.
There was just an article in the April 11 issue of Pediatrics about this topic. The science behind this dosing is ancient and weak.
Hugely overdosing neonates is a crime and the fact that a minimum dose of 100 mcg is in PALS and every other reference chart in the world is even worse. Some very smart people still teach this today at big name Children's Hospitals. I wonder if they would try to testify against me in court citing this weak, dated evidence and a fantasy guesstimated minimum dosing?

 

[soorg]

For the doses mentioned, what are the onset times for these IM injections? I've been told about 10 seconds.

 

[IlDestriero]

For the doses mentioned, what are the onset times for these IM injections? I've been told about 10 seconds.

IM dosing time of Sux and atropine is 2-4 min when given at the deltoid, but remember, you don't need much blockade to break laryngospasm. Laryngospasm usually breaks with profound hypoxia as well.😉
It is a bit faster when given sublingual. I worry about causing airway bleeding, so deltoid it is.

 

[proman]

The Myth of a Minimum Dose for Atropine
Pediatrics. 2011 Apr;127(4):783-4. Epub 2011 Mar 7.
1. Keith J. Barrington, MB, ChB

The highlight:

In the latest edition of PALS, the reference is a 1971 article written by Dauchot and Gravenstein.5 This interesting physiologic study demonstrated that very low doses of atropine, dosed on a per-kilogram basis, of 0.0036 mg/kg (3.6 &#956;g/kg) or less may cause a mild slowing of heart rate. It should be noted that there were no premature infants included in the study; the youngest studied infants were between 6 weeks and 3 months of age, and in these infants the cardiac slowing effect was not statistically significant. The most markedly affected children were the 7- to 12-year-olds who had an average decrease in heart rate from 79 to 70 beats per minute; above this dosage, heart rate was increased by atropine. This effect was later demonstrated to be a result of blockade of M1 muscarinic receptors, whereas the familiar tachycardic response is a result of blockade of the M2 and M3 receptors.6

snip

It seems that the strict, universal, often-repeated, minimum absolute dose of atropine is derived from an unsupported and irrational statement in the discussion of the aforementioned article in which the authors stated, "we therefore give a minimum dose of 0.1 mg of atropine to our patients." This minimum total dose is completely out of keeping with the results of the careful physiologic investigation that they performed but has developed a scriptural correctness.

 

[Arch Guillotti]

IM dosing time of Sux and atropine is 2-4 min when given at the deltoid, but remember, you don't need much blockade to break laryngospasm. Laryngospasm usually breaks with profound hypoxia as well.😉
It is a bit faster when given sublingual. I worry about causing airway bleeding, so deltoid it is.

2-4 minutes seems long to me. Every time I have ever given sux IM it kicked in pretty quick.

 

[IlDestriero]

I should have been more specific. The atropine takes that long for the expected effect per an A&A article looking at SL vs delt vs quad IM injections The Sux usually works well enough to break the laryngospasm quickly, but it's quite variable. Sometimes I think just the stimulation of the injection is enough.

 

[sevoflurane]

The myth of a minimum dose of Atropine is just that, a myth.
I give 20 mcg/kg, practically limited to 40 mcg/dose. If it doesn't give me the desired effect, I double the dose.
For micro preemies, I mix some custom unit doses of atropine and epi, etc. in case the stool hits the fan.
There was just an article in the April 11 issue of Pediatrics about this topic. The science behind this dosing is ancient and weak.
Hugely overdosing neonates is a crime and the fact that a minimum dose of 100 mcg is in PALS and every other reference chart in the world is even worse. Some very smart people still teach this today at big name Children's Hospitals. I wonder if they would try to testify against me in court citing this weak, dated evidence and a fantasy guesstimated minimum dosing?

Thx. This is what I was after. Always thought 100 mcgs sounded like a lot when dealing with little tiny guys (or for those under 5kg). Dogma.


👍

 

[Arch Guillotti]

I should have been more specific. The atropine takes that long for the expected effect per an A&A article looking at SL vs delt vs quad IM injections The Sux usually works well enough to break the laryngospasm quickly, but it's quite variable. Sometimes I think just the stimulation of the injection is enough.

I can only recall giving atropine once recently in a former preemie, seemed like it took 30-60 seconds in the delt to kick in.

For me sux has enough of an effect in 30-60 seconds or so to break the spasm (although by this time the kid is in extremis).

 

[IlDestriero]

With Brady on induction of a downs kid, or from hypoxia, the HR will usually increase when you decrease the Sevo or restore oxygen. The IM atropine doesn't work very quickly. That's why I immediately place an IV if things are headed south, or tell the OR nurse to place it while I give the IM Sux. I'd much rather give it IV where it will have very rapid effect.

Anesth Analg. 1997 Jan;84(1):54-8.
Intramuscular atropine sulfate in children: comparison of injection sites.
Sullivan KJ, Berman LS, Koska J, Goodwin SR, Setzer N, White SE, Graves SA, Nall AV.
Source
Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA.
Abstract
In children undergoing inhaled induction of anesthesia with halothane who suffer bradycardia, submental glossal injection of atropine may result in more rapid onset of vagolysis than traditional intramuscular sites. We compared the intervals between injection and onset of heart rate acceleration (tHR increases) after intramuscular injection of atropine into the deltoid, vastus lateralis, and glossa in children between 1 mo and 10 yr of age scheduled for elective surgery. The tHR increases was determined by measuring the interval between atropine injection and the time point at which the slope of the heart rate curve initially became positive. To ensure that the drug had taken effect before surgical stimulation, heart rate observation was continued until it increased at least 5% above baseline with evidence of continuing acceleration. Anesthesia was induced in all subjects by mask with nitrous oxide and halothane. After tracheal intubation, constant inspired concentrations of the anesthetics were administered for 3 min. While heart rate was monitored, atropine (0.02 mg/kg) was injected into one of the three sites. Each patient's end-tidal anesthetic concentrations were recorded, and minimum alveolar anesthetic concentrations (MAC) were subsequently calculated and adjusted for age. The tHR increases was recorded and averaged for each group. The study groups did not differ by age, weight, end-tidal anesthetic concentrations, age-adjusted MAC, or heart rate at the time atropine was administered. After submental glossal injection (n = 11), tHR increases increase was fastest (3.0 +/- 1.1 min) and was significantly faster than that found with deltoid injection (n = 16; 4.4 +/- 1.1 min) or vastus lateralis injection (n = 8; 6.4 +/- 2.4 min) (P < 0.05 compared with both). The tHR increases also differed significantly between the deltoid and the vastus lateralis (P < 0.05). We conclude that submental glossal injection of atropine results in a more rapid onset of vagolysis than injection at traditional intramuscular sites.