Doses Of Atropine Research Articles

Glycemic status as a predictor for the outcomes in patients with acute organophosphorus pesticides poisoning

Acute organophosphate (OP) toxicity is a major health problem in different populations. Nearly three million cases are affected annually all over the world. The most common clinical presentations include muscarinic, nicotinic and central nervous system manifestations resulting from cholinergic overload. Nevertheless, endocrine toxicity and affection of glucose homeostasis are reported. The current study aimed to study random blood sugar (RBS) as a simple, inexpensive tool to predict mortality and major outcome events in acute organophosphate poisonings. Ninety adult patients with acute organophosphate poisoning were included in the study. Patients already known to be diabetic before exposure and those with mixed intoxication were excluded. RBS was done to all included patients on admission before receiving any medications. Patients were categorized into euglycemics (62.2%), hyperglycemic (28.9%) and hypoglycemics (8.9%). The severity of organophosphorus poisoning symptoms and signs was graded into; Mild (32.2%), Moderate (38.9%) and Severe (28.9%) grades with a statistically significant association between RBS and poisoning severity at the time of admission. In addition, RBS showed a statistically significant association with each of serum cholinesterase levels, the delay time before hospital admission, the need for intubation, mechanical ventilation and death. Meanwhile, RBS had no statistically significant association with either doses of atropine & toxogonine nor the duration of hospital stay.

THORACIC COMBINED SPINAL EPIDURAL ANESTHESIA FOR LAPAROSCOPIC CHOLECYSTECTOMY

Background and Aims: The use of regional anesthesia for laparoscopic cholecystectomy has been reserved for patients who are at high-risk under general anesthesia (GA). The aim of this study was to assess whether thoracic combined spinal epidural (CSE) anesthesia is a feasible option for American Society of Anesthesiologists (ASA) physical status I and II patients undergoing elective laparoscopic cholecystectomy. Material and Methods: Thirty ASA physical status I and II patients undergoing elective laparoscopic cholecystectomy received thoracic CSE anesthesia at T9-T10 or T10-T11 interspinous space using the midline approach. Two ml of isobaric levobupivacaine 0.5% with 25 μg of fentanyl was given intrathecally. Surgery was conducted successfully in all except Results: one patient. Thoracic CSE was performed at T9-T10 interspace in 25 patients and T10-T11 interspace in ve patients. Paresthesia occurred in two patients (6.6%) transiently on Whitacre needle insertion that disappeared spontaneously. Dural puncture on epidural needle insertion occurred in one patient, and intrathecal placement of epidural catheter occurred in one. Ten patients (33%) complained of shoulder pain. Conversion to GA was done in one patient due to severe shoulder pain and anxiety. Hypotension occurred in 11 patients (36%) and all responded to single dose of mephenteramine 6 mg and uid bolus. Bradycardia occurred in six patients (20%) which was managed in all with a single dose of atropine. Thoracic CSE anesthesia can be used Conclusion: effectively for ASA I and II patients undergoing laparoscopic cholecystectomy with signicant postoperative benets

Comparative Study of Effect of Spinal Anesthesia in Sitting and Lateral Positions on the Onset Time of Sensory Block and Hemodynamic Condition in Cesarean Section: A Randomized Clinical Trial.

BackgroundSpinal anesthesia is the method of choice for the cesarean section. Hypotension is a common complication of this method.ObjectivesThis study aimed to compare the effect of spinal anesthesia in the sitting and lateral positions on the onset time of sensory block and hemodynamic condition in cesarean sections.MethodsIn this clinical trial, 106 elective cesarean section candidates under spinal anesthesia were selected and randomly divided into two groups: spinal anesthesia in the sitting position (group S) and the lateral position (group L). The onset time of the sensory block, quality of sensory and motor block, hemodynamic condition, frequency of hypotension, nausea, and vomiting, and the doses of ephedrine and atropine were compared between both groups. Data were analyzed with SPSS version 16 software at a 95% confidence level.ResultsThere was no statistically significant difference between the two groups in terms of age. The frequency of hypotension in L and S groups was 24.5% and 57.7%, respectively (P = 0.001), in minute 6 after spinal anesthesia and 5.7% and 36.5%, respectively (P < 0.001), in minute 8 after spinal anesthesia. The mean time to reach the sensory level of T6 was 1.30 ± 0.43 min versus 4.54 ± 2.12 min (P < 0.001), motor block score in minute 5 was 2.98 ± 0.14 versus 2.82 (P = 0.044), and ephedrine dose was 11.5 mg and 16.92 mg in the L and S groups, respectively (P = 0.010). The maximum sensory-motor block and satisfaction of women with spinal anesthesia were significantly higher in the lateral position than in the sitting position (P < 0.05).ConclusionsCesarean sections under spinal anesthesia in the lateral position than in the sitting position lead to a more rapid sensory and motor block, reduced ephedrine consumption, and enhanced satisfaction of women.

An Analytical Study about Serum Creatine Phosphokinase as Predictor and Marker of Severity in Organophosphorus Poisoning

Introduction: Organophosphorus (OP) toxicity is an important global health problem, especially in many developing countries because of their widespread use and easy accessibility. The objectives of our study were to measure serial serum creatine phosphokinase (CPK) levels, to correlate CPK levels with severity of poisoning, and to record the total dose of atropine required. Methods: This was a retrospective and analytical study. One hundred patients of either sex, having age &gt;14 years, presented within 12 h of ingestion or inhalation of OP. It was observed that confirmation of OP poisoning was done by seeing the packet/container with clinical presentation. Clinical severity was categorized according to Peradeniya organophosphorus poisoning (POP) scale. Results: The severity of the poisoning increased in respect to POP score, the serum CPK levels, and total dose of atropine required for treatment also increased. The difference in serial CPK levels in patients without intermediate syndrome (IMS) and with IMS, it was observed that the difference in CPK between these patients was highly significant at baseline and 48 h. There was an increase in CPK levels at admission and 48 h, but reduced by 96 h. A weak positive correlation was observed between POP score and CPK levels, as well as CPK, and atropine dose. A negative correlation was observed between butyrylcholinesterase and CPK levels. Conclusion: In our opinion, these observations suggest that there is a direct relation between serum CPK levels and IMS. Hence, it is necessary for estimating CPK levels, especially after 48 h, in moderate-to-severe poisoning patients so that IMS can be recognized at the earliest and patients can be referred to higher centers for immediate management of respiratory failure, reducing morbidity and mortality.

Factors associated with time to successful weaning in mechanically ventilated organophosphate poisoned patients

We designed this study to identify the factors associated with time to successful weaning in mechanically ventilated organophosphate (OP)-poisoned patients as the primary outcomes while duration of mechanical ventilation (MV) support, intensive care unit (ICU), and hospital length of stay (LOS) and in-hospital mortality as the secondary outcomes. We conducted a retrospective study of mechanically ventilated OP-poisoned patients admitted to the ICU of Poison Control Center of Ain Shams, Cairo, Egypt, starting from January 2019 to December 2019. Weaning was considered successful if the patient succeeded in the first spontaneous breathing trial of weaning and did not need reinstitution of MV. We used Cox proportional hazards regression models to identify factors associated with time to successful weaning in the studied patients. A total of 55 patients were enrolled in the study. Thirty-eight patients were weaned successfully. Lower initial red cell distribution width (RDW) levels [adjusted hazard ratio (HR), 0.299, 95% confidence interval (CI) (0.184–0.486)] and lower initial doses of atropine [adjusted HR, 0.97, 95% CI (0.935–0.999)] were independently associated with shorter time to achieve successful weaning. Successfully weaned patients had significantly longer hospital LOS (p = 0.019) and no reported in-hospital mortality (p < 0.001) compared with patients who failed to wean. We concluded that initial RDW and initial doses of atropine were found to be the strongest factors associated with time to successful weaning in mechanically ventilated OP-poisoned patients. RDW and atropine can be used as simple risk assessment tools in OP poisoning.

CASE STUDY: ORGANOPHOSPHATE POISONING – ATROPINE-INDUCED PSYCHOSIS IN INTENSIVE CARE UNIT PATIENT

Organophosphate compounds are used as commercial insecticides and applied as aerosols or dust. Consuming these compounds intentionally or unintentionally lead to dangerous conditions even to fatality. The most common obstacle in treating organophosphorus poisoning is the availability of sufficient medical care, equipment to provide proper emergency care observed in rural areas where there is a lot of gap between intensive care and acute care. Atropine use is as an antidote in organophosphorus poisoning. The dose of atropine mainly depends on the organophosphorus toxic doses. Atropine is a competitive antagonist of acetylcholine at the muscarinic postsynaptic membrane. Atropine blocks all the muscarinic effects in the body. This study presents a case of organophosphorus poisoning treated with atropine leading to atropine psychosis. Patient’s conditions, outcomes, and improvements are studied.

Database analysis of oral atropine treatment of infantile hypertrophic pyloric stenosis. A ten-year single center experience

Background/Aim. Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of surgery in newborns and young infants. Conservative treatment of IHPS is of great importance because it spares the newborn from stress caused by surgery and general anesthesia. The aim of this study was to evaluate the impact of various oral administration regimens of atropine on its efficacy in treating IHPS. Methods. The study included 45 patients with IHPS, conservatively treated by atropine sulfate in the period from 2006 to 2016. Clinical examination, laboratory analysis, and ultrasonography were performed on all patients on admission. The efficacy of treatment with different oral dosage regimens was analyzed and potential predictive factors of the negative outcome were defined. The evaluation of the success of the treatment was statistically analyzed by the method of the multivariate logistic regression model. Results. Out of 45 patients, 36 (80%) were successfully cured (p = 0.0008, without the need for surgery and without any complications. Gender prevalence, age, birth weight, body weight on admission, duration of symptoms, pyloric muscle thickness, and length had no statistically significant individual effect on the success of the atropine treatment. Patients who received a progressively increased dose of atropine had an 18 times higher risk of surgery, patients with hypochloremic alkalosis (HCA) had a 15 times higher risk, while others, with more than 5 vomitings within the first three days of the therapy, were 9 times more likely to be surgically treated. Conclusion. High success rate and no side effects represent an orally administered atropine treatment as a valid alternative choice for non-operative management of IHPS. Administration of initially high doses was shown to be more effective in relation to gradually increased oral doses of atropine sulfate. HCA and continued vomiting are considered as potential predictive factors of negative outcomes of the atropine treatment.

Comparative effects of dexmedetomidine and fentanyl as adjuvants to hyperbaric bupivacaine in elective caesarean sections: an observational study at tertiary care centre

Aim: The aim of the present study to compare the effects of Dexmedetomidine and fentanyl as adjuvants to hyperbaric bupivacaine in elective ceasearen sections. Methods: This prospective study was done in the Department of anaesthesiology, LD hospital an associated hospital of GMC, Srinagar, India from December 2019 to November 2020. The participants included 130 parturient with gestational age ≥37 weeks and ASA I and II candidates for elective caesarean section under spinal anesthesia were included in this study. All 130 patients were randomly and equally divided into the following two groups: Group B-D received 10 mg hyperbaric bupivacaine 0.5%+10 μg dexmedetomidine. Group B-F received 10 mg hyperbaric bupivacaine 0.5%+25 μg fentanyl. Hemodynamic monitoring including SBP and DBP, mean arterial pressure (MAP), heart rate (HR) and peripheral oxygen saturation level (SpO2) were recorded. Patient’s pain score was assessed using visual analogue scale (VAS); scored from 0–10 (where 0=no pain and 10=the worst pain imaginable) during the recovery room (T0) and at one, three, and six hours (T1, T3, and T6) in the postoperative period. If the VAS score was more than 3, a rescue dose of tramadol (100 mg) was administered intravenously. Results: The mean dose of mephentermine in the B-D and B-F groups were 5.45±6.74 and 6.79±5.69mg, respectively. The Mann–Whitney test showed that there was no significant difference between the two groups (P=0.78). With respect to the bradycardia, the mean dose of atropine in the B-D and B-F groups were 0.12±0.28 and 0.06±0.15 mg, respectively. According to the Mann–Whitney test, in this regard, no significant difference was seen between the two groups. (P=0.32). The results of the Mann–Whitney U-test indicated that the onset of block in the B-D group (97.88±32.78 seconds) was significantly faster than in the B-F group (112.03±36.68 seconds) (P=0.041). Considering the level of sensory block, T4 level was shown in 81 (62.31%) patients, from whom 47 (58.02%) and 34 (41.98%) patients were in the B-D and B-F groups, respectively. Moreover, T6 level was observed in 49 (37.69%) patients, from whom 19 (38.78%) and 30 (61.22%) patients were in the B-D and B-F groups, respectively. Chi-squared test revealed that there was no statistically significant difference between the two groups (P=0.13). Conclusion: Compared with fentanyl, it seems that adding 10μg dexmedetomidine to bupivacaine has a better effect on postoperative pain management in cesarean section under spinal anesthesia.

Study of organophosphorus compound poisoning in a tertiary care hospital and the role of Peradeniya Organophosphorus Poisoning scale as a prognostic marker of the outcome

Introduction:Organophosphate compounds (OPC) cause most self-poisoning deaths in India due to their easy availability and lack of stringent laws.Aim:To evaluate the clinical profile and outcome of the patients presenting with OPC poisoning and to study the prognostic value of Peradeniya Organophosphorus Poisoning Scale (POPS) in predicting the clinical outcomes.Methods and Materials:This was a prospective study involving 100 patients of OPC poisoning admitted to Tata Main Hospital from June 2018 to May 2020 based on the inclusion criteria. Demographic profile, clinical features, treatment details, and need for ventilatory support were noted. POPS was applied on admission, and the patients were followed up for the outcome in terms of morbidity and mortality.Observations:Of the 100 patients, most patients were between 20 and 29 years with male to female ratio being 1.2:1. Vomiting (94%), followed by excessive secretions (84%) were the most common symptoms. Overall mortality was 22%. On grading of severity as per the POP scale, 27% of the patients had mild poisoning, 37% patients had moderate, whereas 36% had severe poisoning. Only 11.11% of the patients with POPS 0–3 required ventilator support, whereas 16.2% of the patients with POPS 4–7, and 100% of patients with POPS 8–11 required ventilator assistance (P < 0.0001). Similarly, the total dose of atropine required (P < 0.0001), length of intensive care unit (ICU) stay, complications, and mortality (P < 0.0001) were significantly associated with higher POPS.Conclusion:POPS at admission, correlated well with the need for ventilator support, the total dose of atropine required, length of stay in the ICU, complications, and mortality. It can thus be used for prognostication and risk stratification of patients with OPC poisoning.

Pharmacological Myopia Control Influence on Quality of Life and Psyche among Adolescents.

Myopia is a global problem affecting all aspects of patients’ lives. Objectives: The aim of the study was to evaluate the influence of low dose atropine (LDA) myopia control on the quality of life in patients with myopia. Material and Methods: A self-constructed questionnaire, including eight questions, was distributed among 40 patients. The questionnaire was divided into two subsections: (1) influence of LDA on visual functions and (2) influence of LDA on self-esteem. Answers were collected separately for boys (18 patients) and girls (22 patients) and compared considering spherical equivalent (SE) and myopia progression rate. Results: Girls reported more issues with near activities and pupil size. Boys and girls complained similarly, regarding the sun glare. We found a high level of certainty about the efficacy of LDA therapy among both examined groups and a little improvement in self-esteem. Girls recommended LDA therapy more often than boys, especially when the progression rate was low. There was no statistically significant difference in answer scores between groups with different myopia progression rates for boys. Girls with lower progression rates reported more issues with near work and sun glare and less trust in LDA therapy’s effectiveness than girls with a higher progression rate. There was no statistically significant correlation between SE and the total answer score for both genders. Conclusions: Findings concerning childrens’ and adolescents’ psyche are a new aspect of myopia control. We prove that patients during pharmacological myopia control did not report significant problems caused by LDA therapy and they were convinced about its efficacy, had greater self-esteem, and recommended it to peers.

Efficacy and safety of atropine to control myopia progression: a systematic review and meta-analysis

BackgroundThe effect and safety of atropine on delaying the progression of myopia has been extensively studied, but its optimal dose is still unclear. Therefore, the purpose of this meta-analysis is to systematically evaluate the safety and effectiveness of atropine in controlling the progression of myopia, and to explore the relationship between the dose of atropine and the effectiveness of controlling the progression of myopia.MethodsThis work was done through the data searched from PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. The Cochrane Handbook was also used to evaluate the quality of the included studies. In addition, a meta-analysis was performed using Revman5.3 software.ResultsA total of 10 randomized controlled trials (RCTs) were included. Myopia progression was mitigated greater in the atropine treatment group than that in the control group, with MD = − 0.80, 95% CI (− 0.94, − 0.66) during the whole observation period. There was a statistical difference among 0.05, 0.5, and 1.0% atropine (P = 0.004). In addition, less axial elongation was shown, with MD = − 0.26, 95% CI (− 0.33, − 0.18) during the whole observation period.ConclusionThe effectiveness of atropine in controlling the progression of myopia was dose related. A 0.05% atropine was likely to be the optimal dose.

A STROBE-compliant case–control study

Topical atropine has become a mainstream treatment of myopia throughout East and Southeast Asia, but it is uncertain whether long-term topical atropine therapy induces intraocular pressure (IOP) elevation and subsequent development of glaucoma. We then prospectively examined the effects of long-term atropine treatment on IOP.Our case series collected 186 myopic children who were younger than 16 years of age. Complete ocular examination data, IOP and refractive status measurements beginning in 2008 were collected for all participants. Participants were divided into two groups: 121 children who received atropine therapy at various concentrations were classified as the treated group, whereas 65 children who did not receive atropine therapy were classified as the untreated (reference) group. In the treated group, clinicians prescribed different concentrations of atropine eye drops according to their discretion with regard to the severity of myopia on each visit of the patient. We then calculated the cumulative dose of atropine therapy from 2008 to the patients’ last follow-up in 2009. Furthermore, the treated group was then further divided into low- and high-refractive-error groups of nearly equal size for further analysis.There were no significant differences for the baseline refractive errors and IOPs between the treated and untreated groups. Both the low- and high-cumulative atropine dosage subgroups showed significantly lower myopic progression than the untreated group, but there was no significant difference between the two subgroups in terms of different cumulative dosages. All groups, including the untreated group, showed an increase of mean IOP at the last follow-up, but both low- and high-cumulative atropine dosage subgroups experienced a smaller increase of IOP. The mean IOP of all atropine-treated groups showed no significant increase in either low- or high-refractive-error eyes.This study revealed that topical atropine eye drops do not induce ocular hypertension and are effective for slowing the progression of myopia. The treatment effects are not correlated with the cumulative atropine dosages.

Novel pyridinium oximes enhance 24-h survivability against a lethal dose of nerve agent surrogate in adult female rats

Our laboratory has developed novel substituted phenoxyalkyl pyridinium oximes (US Patent 9,227,937) designed to more efficiently penetrate the central nervous system to enhance survivability and attenuate seizure-like signs and neuropathology. Previous studies with male Sprague-Dawley rats indicated that survivability was enhanced against the nerve agent (sarin) surrogate, 4-nitrophenyl isopropyl methylphosphonate (NIMP). In this study, female adult Sprague-Dawley rats, tested specifically in diestrus, were challenged subcutaneously with lethal concentrations of NIMP (0.6 mg/kg). After development of seizure-like behavior and other signs of cholinergic toxicity, human equivalent dosages of atropine (0.65 mg/kg) and one of four oximes (2-PAM, or novel oxime 15, 20, or 55; 0.146 mmol/kg) or Multisol vehicle was administered alone or in binary oxime combinations intramuscularly. Animals were closely monitored for signs of cholinergic toxicity and 24 h survivability. Percentages of animals surviving the 24 h NIMP challenge dose were 35 % for 2-PAM and 55 %, 70 %, and 25 % for novel oximes 15, 20, and 55, respectively. Improvements in survival were also observed over 2-PAM alone with binary combinations of 2-PAM and either oxime 15 or oxime 20. Additionally, administration of novel oximes decreased the duration of seizure-like behavior as compared to 2-PAM suggesting that these oximes better penetrate the blood-brain barrier to mitigate central nervous system hypercholinergic activity. Efficacies were similar between females and previously reported males. These data indicate that the novel pyridinium oximes enhance survivability against lethal OP toxicity as compared to 2-PAM in adult female rats.

Adrenaline is effective in reversing the inadequate heart rate response in atropine treated organophosphorus and carbamate poisoning

Background In acute organophosphorus (OP) or carbamate poisoning, some patients require high dose atropine to counteract the effects on heart rate (HR) and blood pressure (BP). This study describes the factors associated with high dose atropine therapy and the use of adrenaline to reverse the inadequate HR response to atropine. Methods Consecutive patients admitted to the intensive care unit (ICU) were prospectively recruited. Demographic data, treatment and outcomes of patients who failed to achieve target HR (100/min) or systolic BP >90 mm Hg with either a cumulative atropine dose of 100-mg within 6-h following admission or an infusion of 30 mg/h for at least 3-h were compared with patients who achieved the targets. Factors associated with high dose atropine therapy were explored using logistic regression analysis and expressed as odds ratio (OR) with 95% confidence intervals (CIs). Results Of the 181 patients admitted with OP or carbamate poisoning, 155 patients fulfilled inclusion criteria. The mean (SD) age was 35.7 (15.8) years; admission APACHE-II score was 14.6 (7.5). Heart rate and/or BP target was not achieved in 13.6%. In these patients, target HR was achieved after adding adrenaline infusion at 2–4 μg/min. Ventilation duration (11.6 ± 6.3 vs. 8.4 ± 6.9 days, p = 0.05) and ICU stay (12.3 ± 5.8 vs. 8.9 ± 5.8 days, p = 0.01) were longer in patients requiring high dose atropine when compared with others. On multivariate logistic regression analysis, shorter time to presentation to hospital (p = 0.04) was associated with need for high dose atropine. Overall mortality was 9% and similar in both groups (p = 0.41). Conclusions High dose atropine therapy is required in a subset of patients with OP and carbamate poisoning and was associated with longer ventilation duration and ICU stay. Adrenaline infusion improved hemodynamics in these patients.

Transthoracic Echocardiographic Hemodynamic Assessment in Patients under Spinal Anesthesia in Lower Limb Surgery

Background: Spinal anesthesia is often associated with significant hypotension due to a sympathetic blockand can increase the risk of perioperative cardiac complications. Transthoracic echocardiography (TTE) is widely used throughout medicine as a clinical, diagnostic and research tool. Portability, accuracy, ease of use and a variety of training courses have encouraged its use. Aim: The present study was designed to evaluate the hemodynamic changes of spinal anesthesia by Transthoracic Echocardiography and test its efficacy as a monitoring tool in lower limb surgery. Methods: The study included50 patients, who were scheduled for lower limb surgery under spinal anesthesia. Two serial TTE studies were performed. One immediately before spinal anesthesia after giving the preload, then at 10 mins after spinal anesthesia. Changes of heart rate (HR), mean arterial blood pressure (MAP), the total doses of ephedrine and atropine, and data regarding highest sensory level and bromage scale were recorded. Results: Echocardiographic monitoring the heart variables have showed marked decrease when MAP was < 70% of basal values. Conclusion: Transthoracic echocardiography has proved its efficacy as a monitoring tool in assessment and guiding the management of hemodynamic changes after spinal anesthesia.

Atropine Refractoriness in Acute Organophosphorus and Carbamate Poisoning

Background: In acute Organophosphorus (OP) or Carbamate poisoning, some patients require high dose atropine to achieve atropinisation targets. This study evaluated the incidence and factors associated with atropine refractoriness. Methods: Consecutive patients, admitted to the intensive care unit (ICU) with OP and Carbamate, were prospectively recruited. Atropine refractoriness was defined as failure to achieve target heart rate (100/min) or systolic BP >90 mm Hg with either a cumulative atropine dose of 100-mg within 6-h following admission or an infusion of 30 mg/h for at least 3-h. Demographic data, treatment and outcomes were recorded. Factors associated with atropine refractoriness were explored using logistic regression analysis and expressed as Odds ratio (OR) with 95% Confidence Intervals (CI). Findings: Of the 181 patients admitted with OP or Carbamate poisoning, 155 patients fulfilled inclusion criteria. The mean (SD) age was 35·7 (15·8) years; admission APACHE-II score was 14·6 (7·5). Atropine refractoriness occurred in 13·6%. In these patients, target heart rate was achieved after adding adrenaline infusion at 2-4 mcg/min. Ventilation duration (11·6±6·3 vs. 8·4±6·9 days, P=0·05) and ICU stay (12.3±5·8 vs. 8·9±5·8 days, P=0·01) were longer in atropine refractory patients when compared with non-refractory patients. On multivariate logistic regression analysis, shorter time to presentation to hospital (p=0·04) was associated with atropine refractoriness. Overall mortality was 9% and similar in refractory and non-refractory patients (P=0·41). Interpretation: Atropine refractoriness is not uncommon in OP and Carbamate poisoning and is associated with longer ventilation duration and ICU stay. Adrenaline infusion improves hemodynamics in these patients. Funding Statement: None. Declaration of Interests: There is no conflict of interest or any financial disclosures for all the authors listed in the submission. Ethics Approval Statement: The study was approved by the institutional review board (IRB) and ethics committees of the institution (IRB Min. No. 10100, dated 10.06.2016).

Treatments of Calcium Channel Blocker Overdose

Pharmaceutical agents are the most common causes of poisoning in Korea. Calcium channel blockers (CCBs) are commonly used in Korea for the management of hypertension and other cardiovascular diseases, but are associated with a risk of mortality due to overdose. Due to the frequent fatalities associated with CCB overdose, it is essential that the emergency physician is capable of identifying CCB intoxication, and has the knowledge to manage CCB overdose. This article reviews the existing clinical guidelines, retrospective studies, and systematic reviews on the emergency management of CCB overdose. The following are the varied treatments of CCB overdose currently administered. 1) For asymptomatic patients: observation with enough time and decontamination, if indicated. 2) For symptomatic patients: infusion of calcium salt, high dose insulin therapy, and vasopressor (norepinephrine) or atropine for bradycardia. 3) For patients refractory to the first line therapy or with refractory shock or impending arrest: lipid emulsion therapy and extracorporeal membrane oxygenation. 4) As adjunct therapy: phosphodiesterase inhibitors, glucagon, methylene blue, pacemaker for AV block. Small CCB ingestion is known to be fatal for pediatric patients. Hence, close observation for sufficient time is required.

Safety and efficacy of atropine treatment for slowing myopia progression in children: a 5-year review

Aim: To report the efficacy and safety of atropine treatment (0.01% and 0.125%) in slowing myopia progression in children. Methods: This is a retrospective non-interventional case series. All patients aged <18 years who received topical atropine for myopia control from 2011 to 2016 in the Hong Kong Sanatorium & Hospital were included for analysis. Myopia progression, atropine treatment, and other factors affecting treatment outcomes were analyzed. We also reported any adverse effects associated with atropine use. Results: A total of 346 patients were recruited, with mean a follow-up period of 2.26±0.82 years. The patients had a mean reduction of myopia progression of 68.4% after atropine treatment (p<0.001). The mean myopia progression rate (in spherical equivalent) was -0.38±0.36 D/year, and the mean axial length elongation rate was 0.23±0.19 mm/year. More reduction of myopia progression was associated with baseline myopia progression of <-1 D/year (p<0.001) and initial atropine dosage of 0.125% (p<0.001). Reduction of myopiaprogression was associated with starting age (p=0.041) and baseline myopia progression (p=0.004). Patients aged <6 years who received atropine treatment (n=17) showed reduction of myopia progression by 71.1%. Only mild adverse effects such as photophobia were reported. Conclusion: Topical atropine is an efficacious and safe treatment for slowing myopia progression.

SAT-507 Myxedema Coma: A Fatal Diagnosis in a Patient with No Known History of Hypothyroidism

Myxedema coma is a rare yet commonly missed diagnosis. Early detection is key to management as this diagnosis carries a high mortality rate.We report a case of a 108-year-old female with a past medical history of CKD stage 3, hypertension, CHF, and atrial fibrillation who was brought to the emergency department (ED) by her grandson for seizures. The patient has no history of seizures, hypothyroidism (previous TSH 6 years back was 2.29 micro IU/mL), diabetes, or previous radiation exposure. The family noticed the first seizure 8 hours prior to admission with eyes rolling backward, shaking for 1 minute and slurred speech upon awakening. She had 2 other seizure episodes prior to arrival to the ED. Vitals in the ED showed a temperature of 31.7°C, BP of 85/50, HR of 35, RR of 8, and SpO2 was 83% on room air. Given the patient’s age, code status was changed to DNR/DNI. Blood work in the ED revealed a sodium of 146 mMol/L (136-145), anion gap of 25, Creatinine of 2.67 mg/dL (last creatinine prior to this admission was 1.65 mg/dL), and a troponin of 0.04 ng/mL (<0.04). Thyroid function testing was not done in the ED. Home medications included Lasix, digoxin, isosorbide mononitrate, and atenolol. The patient was admitted to the medical floor for workup of bradycardia and was being worked up for beta-blocker/digoxin toxicity but continued to be bradycardic despite atropine. She became hypoglycemic to 37 mg/dL. The patient was admitted to the CCU at night on day 1 of admission and was started on dopamine and glucagon drips. Sulfonylurea screen was negative, and the patient did not have further hypoglycemic episodes. While in the CCU, blood work showed a lactic acid of 10 mMol/L (0.4-2.0), TSH of 21.03 micro IU/mL (0.45-5.33), free T4 of 0.61 ng/dL (0.70-1.70), and total T3 71 ng/dL (87-178). Myxedema score was >130. Digoxin level came back elevated at 4.5 ng/ml (0.9-2.0). Cosyntropin stimulation testing was negative for adrenal insufficiency and thus the patient was not started on steroids. Urinalysis revealed pyuria with blood, but no urine cultures were done. Blood cultures were negative. The patient was given levothyroxine 200 mcg IV in the AM on Day 2 of admission and was started on antibiotics with azithromycin, cefepime, vancomycin, and metronidazole given concern for sepsis. Hypoglycemia resolved and glucagon was discontinued. In the evening of Day 2 of admission, despite being on a dopamine drip, the patient became increasingly bradycardic, hypotensive, and short of breath. She was initially stabilized after a dose of bicarb, atropine, and epinephrine. However, her BP and respiratory status continued to decline, and the patient passed away.In conclusion, myxedema coma should be suspected in patients presenting with typical symptoms and should be tested for on presentation even when no prior history of hypothyroidism exists.

Atropine 0.01% as a Potential Myopia Prevention in Children with Dosage Effectivity Comparison: a Literature Review

Myopia (long-sightedness) is one of the many problems of vision disorder occurring around the world and being 1 in 5 eye conditions that becoming a priority at the World Health Organization's Global Intitiative for the Elimination of Avoidable Blindness. Many methods of preventing myopia development have been sought. Atropine is an alkaloid derived herbal plant Atropa belladonna which acts as a muscarinic acetylcholine receptor antagonist that has a strong nonselective competitive affinity on the five types of muskarinic acetylcholine receptors (M1-M5) that weaken the muscles of the ciliary and iris and causes the reduction of accommodation and the occurrence of pupil dilation. Recent research found that with the use of low dose atropine (0.01%), in addition to the side effects inflicted more minimal, effectiveness in the long time period shows better results. Until now, the mechanism of atropine is still experiencing debate whether working on an accommodating or non-accommodating pathway. But recent research suggests the possibility of working mechanism of this drug is through a non-accommodating pathway i.e. on GABAergic, dopaminergic as well as involving nitric oxide (NO) role to help inhibit the progression of myopia. In research and advanced scientific studies, it can be researched regarding the pathways of atropine mechanism and its advantages and disadvantages at any dose of atropine given to myopia sufferers using the latest literature sources.