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Three Part Question

In [paediatric patients undergoing rapid sequence intubation] does [pre-treatment with atropine] reduce the [incidence of clinically significant reflex bradycardia]?

Clinical Scenario

An 8 month old child presents to the Emergency Department in status epilepticus and is given so much benzodiazepines during treatment that he can no longer protect his airway. His vital signs are all stable and a non-rebreather mask is helping him to maintain his oxygen saturations. As you prepare to intubate him using RSI, you wonder if atropine is really necessary or helpful in preventing the bradycardia reported during endotracheal intubation.

Search Strategy

Using the OVID interface Medline 1950 to February Week 3 2007
Embase 1980 to 2007 Week 08
The Cochrane Library Issue 1 2007
Medline:[(exp intubation, intratracheal OR intubation.mp OR intubate$.mp) AND (exp atropine/ or atropine.mp) AND (exp bradycardia/ or bradycardia.mp)]. LIMIT to human AND English AND "all child (0 to 18 years)."
Embase:[(exp intubation, intratracheal OR intubation.mp OR intubate$.mp) AND (exp atropine/ or atropine.mp) AND (exp bradycardia/ or bradycardia.mp)]. LIMIT to human AND English AND to (child or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>)
Cochrane:atropine (kw) AND bradycardia (kw) 59 articles of which 0 were relevant. Subject groups of premeds and outpatients were deemed inappropriate

Search Outcome

112 unique papers of which 2 were relevant and are included in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fastle, RK and Roback MG, 2004, USA	143 paediatric patients ranging in age from newborn to 19 years who underwent RSI from 1997 to March 2001 in a level 1 paediatric hospital. The study used ACEP recommendations to determine those patients who should receive atropine and those who should not 68 in the atropine group and 75 in the no-atropine group.	Retrospective cohort study	Bradycardia ( two standard deviations below the mean for age or a 30% decrease from baseline HR on presentation).	3 in the atropine group and 3 in the no-atropine group.	The study is of insufficient power and design. This was a retrospective study and all medical data was abstracted from the medical record. The principle investigator was not blinded to the results. Most patients in this study received rocuronium and reflex bradycardia was seen only 4% of the time regardless of whether atropine was given or not. 16 of the 143 patients received succinylcholine and none of these experienced any bradycardic events.
McAuliffe et al, 1995, Canada	41 ASA class I or II children aged 1 to 12 undergoing elective surgery Those with a history of neuromuscular disease, medications known to affect neuromuscular function, or malignant hyperthermia were excluded. Atropine (20 ug/kg) and succinylcholine (1.5 mg/kg) vs succinylcholine alone	Randomized single blinded control study	Episodes of bradycardia	1 vs 0	It was assumed prior to the study that succinylcholine induced bradycardia occurs 50% of the time so that is what figure was used for the power calculation. However, there were no bradycardic events during the study making the power insufficient to show there is a difference between succinylcholine-induced bradycardia with and without atropine. This study was done in the operating room in a controlled setting which is a different environment to the ED.
			Dysrhythmias	7 vs 3
			Increase in heart rate	Statistically significant rise (p= < 0.05) in the atropine group

Comment(s)

The evidence from these two studies would indicate that the incidence of reflex bradycardia in children during rapid sequence intubation (RSI) is much lower than previously thought. Furthermore, it does not appear the paralysing agent used significantly contributes to incidences of bradycardia. It appears that hypoxia, not foregoing pre-treatment with atropine, is a stronger predictor of patients who will develop reflex bradycardia following RSI.

Clinical Bottom Line

There is evidence that the use of atropine is unnecessary when performing RSI in paediatric patients in the Emergency Department. However, this evidence lacks statistical power and further studies are needed.

References

1. Fastle, RK and Roback MG. Pediatric Rapid Sequence Intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatric Emergency Care 2004;20;651-5.
2. McAuliffe G, Bissonnette B, Boutin C. Should the routine use of atropine before succinylcholine in children be reconsidered? Canadian Journal of Anaesthesia 1995:42;724-9.