APPENDIX A: ATROPINE/SCOPOLAMINE PROTOCOL

Items Needed for One Casualty

(2) Vials 0.4mg/mL Scopolamine

(1) 3mL syringe

(1) 18ga hard needle

(1)250 mL Bag of NS.

(3) Vials 8mg/20mL Atropine

(1) Micro drip dial-a-flow.

(1) Pressure Infuser

(1) FAST One IO device w/ Flush or IV access kit

Preparation

If anticipating Nerve/Organophosphate/Carbamate exposed patients:

Prep Scopolamine as follows:

  1. Draw 0.8mg (2mL) of scopolamine from the 0.4 mg vials into one 3mL syringe.
  2. Leave syringe complete with a capped 18 ga needle so that it is ready for rapid administration.
  3. Label syringe conspicuously with “SCOPE 0.8mg/2mL”

Prep Atropine drip bag as follows:

  1. Add 50 mL of 8mg/20mL Atropine to 250 mL bag of NS.
  2. Bag is now 20 mg/300mL. Ensure no air is in the bag as the extra 50 mL may barely fit.
  3. Conspicuously mark bag w/ “ATROPINE 20mg/300mL approx. 1mg/3min”

Administration

After the administration of 3 ATNAA and 1 CANA IM assess patient and if not improved, administer scopolomine (preferred) OR atropine per the following protocols:

  • If inadequate response to 3 ATNAA and 1 CANA, administer 0.8mg Scopolamine hydrobromide via IV/IO and flush. IM as a secondary.

OR

  • Give bolus dose atropine in escalating doses every 3-5 minutes. Start with 2mg followed by 4mg, 8mg, 16mg. 
  • Once symptom control is achieved, start an atropine drip prepared as outlined above with a dose rate at 10% of the bolus dose (including the 6mg of atropine in the 3 initial ATNAAs) per hour.
  • If a rebolus is required to control recurrent symptoms, then increase the drip to 20% of the initial response dose.
  • Scopolamine 0.8mg is approximate to Atropine 10mg when calculating the initial response dose.
  • A drip rate to 300 mL/hr this will administer approximately 1mg of atropine every 3 min.

Note: This protocol is intended to use as a starting point for providers who do not routinely use these medications.  The protocol should be reviewed by physicians supervising non-licensed providers. This protocol does not supersede the clinical judgement of the responsible provider.

Sequence of actions in nerve agent exposure should be as follows:

  • 3xATNAA
  • 1xCANA
  • IO access
  • 2gTXA (if concomitant trauma)
  • 500mg 2PAM IO/IV push (15-20 min improvement)
  • 0.8mg scopolamine IO/IV
  • Atropine 2mg IO/IV followed by doubling escalating doses q3-5min
  • (if no change in mental status even if dry/atropinized) Midazolam 10mg for subclinical seizures
  • 2 PAM drip IV

Naloxone:

  • Initial dose of 2-4mg followed by doubling escalating doses (4mg, 8mg, 16mg)
  • Narcan drip at 2/3 response rate