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Should We Use Atropine to Prevent Bradycardia in Pediatric Airways?

March 16, 2022

Written by Clay Smith

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Atropine pretreatment was not associated with a reduction in the incidence of bradycardia in this tiny, single center study of pediatric intubations.

Why does this matter?
PALS guidelines from 2015 state, “The available evidence does not support the routine use of atropine preintubation of critically ill infants and children. It may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia (eg, when giving succinylcholine as a neuromuscular blocker to facilitate intubation).” So, should we give it or not?

How slow can you go?
This was a small, single-center retrospective study with 62 children undergoing endotracheal intubation. Just 3 patients (4.8%) had bradycardia (according to age-based norms) at the time of RSI or within 5 minutes. Pre-treatment with atropine was up to the physician, and 15 (24.2%) were pretreated. There was no difference in the incidence of bradycardia in the treatment vs non-treatment cohorts: 6.6% vs 4.3%, respectively. Bradycardia was rare in this study. Patients treated with atropine were younger than those who did not, and there were undoubtedly other differences that physicians may have seen in the moment that could have confounded these results. Personally, I use atropine for intubations in children <12 months. I don’t see much downside risk and would like to think this could prevent conversion of a peri-arrest child to full arrest requiring compressions if the heart rate drops. Maybe atropine isn’t doing any good. But this study is so small, it’s really hard to tell. A large database or RCT would be helpful to clarify.

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department. Pediatr Emerg Care. 2022 Feb 1;38(2):e540-e543. doi: 10.1097/PEC.0000000000002382.

What are your thoughts?