Atropine + Pralidoxime

Organophosphate Poisoning

Organophosphate Poisoning Indicated for treatment of poisoning by organophosphorus nerve agents as well as organophosphorus insecticides in adults and pediatric patients weighing >41 kg (90 pounds) 2.1 mg atropine/0.7 mL + 600 mg pralidoxime/2 mL IM Maximum dose: Not to exceed 3 injections unless medical care support available 3 autoinjectors should be available for use in each patient (including healthcare providers) at risk for organophosphorus poisoning; use 1 for mild symptoms plus 2 more for severe symptoms Mild symptoms >2 mild symptoms: 1 injection IM; if after 10-15 min there are no severe symptoms experienced, no further injections are necessary Additional doses: If, at any time following the first injection, the patient develops any of the severe symptoms, administer 2 additional IM injections in rapid succession Mild symptoms: Bradycardia, chest tightness, breathing difficulties, blurred vision, increased salivation (eg, sudden drooling), miosis, nausea or vomiting, runny nose, stomach cramps (acute onset), salivation, teary eyes, wheezing/coughing, tremors/muscular twitching, airway secretions increased Severe symptoms Any severe symptom listed below: 3 injections IM in rapid succession Severe symptoms: Confused/strange behavior, involuntary urination/defecation, muscular twitching/generalized weakness (severe), severe breathing difficulties or copious secretion from lung or airway, convulsions, unconsciousness

Organophosphate Poisoning Indicated for treatment of poisoning by organophosphorus nerve agents as well as organophosphorus insecticides in adults and pediatric patients weighing >41 kg (90 pounds) <41 kg: Safety and efficacy not established >41 kg: 2.1 mg atropine/0.7 mL + 600 mg pralidoxime/2 mL IM Maximum dose: Not to exceed 3 injections unless medical care support available 3 autoinjectors should be available for use in each patient (including healthcare providers) at risk for organophosphorus poisoning; use 1 for mild symptoms plus 2 more for severe symptoms Mild symptoms >2 mild symptoms: 1 injection IM; if after 10-15 min there are no severe symptoms experienced, no further injections are necessary Additional doses: If, at any time following the first injection, the patient develops any of the severe symptoms, administer 2 additional IM injections in rapid succession Mild symptoms: Bradycardia, chest tightness, breathing difficulties, blurred vision, increased salivation (eg, sudden drooling), miosis, nausea or vomiting, runny nose, stomach cramps (acute onset), salivation, teary eyes, wheezing/coughing, tremors/muscular twitching, airway secretions increased Severe symptoms Any severe symptom listed below: 3 injections IM in rapid succession Severe symptoms: Confused/strange behavior, involuntary urination/defecation, muscular twitching/generalized weakness (severe), severe breathing difficulties or copious secretion from lung or airway, convulsions, unconsciousness

Renal impairment Pralidoxime can cause decreased renal function Patients with severe renal impairment may require less frequent doses after initial dose

Older individuals may be more susceptible to atropine effects

Hepatic impairment Patients with severe hepatic impairment may require less frequent doses after the initial dose

IM Administration Administer IM in the lateral thigh muscle or buttocks

Cardiovascular (CV) Risks: Tachycardia, palpitations, premature ventricular contractions, flutter, fibrillation, etc. Use caution in individuals with known CV disease or conduction problems. Heat Injury: May inhibit sweating and lead to hyperthermia; avoid excessive exercising and heat exposure. Acute Glaucoma: May precipitate in susceptible individuals. Urinary Retention: Administer with caution in individuals with bladder outflow obstruction. Pyloric Stenosis: May convert into complete obstruction. Exacerbation of Chronic Lung Disease: Atropine may cause inspiration of bronchial secretions and formation of dangerous viscid plugs in individuals with chronic lung disease; monitor respiratory status.

Not Classi Pregnancy Atropine readily crosses the placental barrier and enters fetal circulation; there are no adequate data on developmental risk associated with use of atropine, pralidoxime, or combination in pregnant women Lactation Atropine has been reported to be excreted in human milk; unknown whether pralidoxime is excreted in human milk

Succinylcholine and Mivacurium: Accelerated reversal of neuromuscular blocking effects may occur; monitor with concomitant administration. Contraindicated (0) Serious - Use Alternative (10) eluxadoline glucagon glucagon intranasal glycopyrronium tosylate topical macimorelin pramlintide revefenacin secretin sofpironium topical umeclidinium bromide/vilanterol inhaled

Frequency Not Defined Injection site reaction (muscle tightness, pain) Atropine Dry mouth Blurred vision Dry eyes Photophobia Confusion Headache Dizziness Pralidoxime Vision changes Dizziness, headache Drowsiness Nausea Tachycardia Increased blood pressure Muscular weakness Dry mouth Emesis Rash Dry skin Hyperventilation Decreased renal function Manic behavior Transient elevation of LFTs

Atropine: Competitively blocks the effects of acetylcholine, including excess acetylcholine due to organophosphorus poisoning, at muscarinic cholinergic receptors on smooth muscle, cardiac muscle, secretory gland cells, and in peripheral autonomic ganglia and the central nervous system Pralidoxime: Reactivates acetylcholinesterase which has been inactivated by phosphorylation due to an organophosphorous nerve agent or insecticide; reactivated acetylcholinesterase hydrolyzes excess acetylcholine, which is clinically important because only a small proportion of active acetylcholinesterase is needed to maintain vital functions