How should a patient with hypotension, previously treated with atropine for bradycardia, be managed?

From the Guidelines

A patient with hypotension who was previously treated with atropine for bradycardia should be managed with fluid resuscitation and vasopressors if needed, with norepinephrine as the first-line vasopressor agent, as recommended by the most recent guidelines 1. The management plan should include:

• Rapid administration of crystalloid fluids (normal saline or lactated Ringer's) at 500-1000 mL boluses, reassessing after each bolus
• Initiation of vasopressor therapy with norepinephrine (starting at 0.05-0.1 mcg/kg/min, titrating to maintain mean arterial pressure ≥65 mmHg) if hypotension persists despite adequate fluid resuscitation
• Consideration of adding vasopressin (0.03-0.04 units/min) or epinephrine (0.05-0.5 mcg/kg/min) for patients with refractory hypotension
• Continuous cardiac monitoring to identify and treat the underlying cause of hypotension
• Consideration of transcutaneous or transvenous pacing if bradycardia persists or recurs despite atropine

The SOAP note should include:

• Subjective: Patient reports dizziness and lightheadedness
• Objective: Blood pressure 80/50 mmHg, heart rate 50 bpm
• Assessment: Hypotension with bradycardia, possibly indicating cardiogenic or distributive shock
• Plan: Fluid resuscitation with crystalloid fluids, initiation of norepinephrine as first-line vasopressor, and consideration of additional vasopressors or pacing as needed.

It is essential to prioritize the patient's hemodynamic stability and tissue perfusion, and to continuously monitor their condition to adjust the management plan as needed, based on the most recent and highest quality evidence available 1.

From the FDA Drug Label

Atropine Sulfate Injection, USP in clinical doses counteracts the peripheral dilatation and abrupt decrease in blood pressure produced by choline esters However, when given by itself, atropine does not exert a striking or uniform effect on blood vessels or blood pressure. Systemic doses slightly raise systolic and lower diastolic pressures and can produce significant postural hypotension. Such doses also slightly increase cardiac output and decrease central venous pressure

The patient with hypotension, previously treated with atropine for bradycardia, should be managed with Noradrenaline as it is specifically mentioned that hypotension needs Noradrenaline.

• Atropine was used to treat bradycardia, which it successfully responded to.
• Noradrenaline is required for hypotension management in this scenario. 2

From the Research

Management Plan

• The patient has developed hypotension after being treated with atropine for bradycardia, indicating the need for a vasopressor to support blood pressure 3, 4.
• Noradrenaline (norepinephrine) is a suitable option for managing hypotension in this context, as it can help increase blood pressure and improve perfusion of vital organs 5, 6.
• The dosage of noradrenaline should be titrated carefully to achieve the desired blood pressure, while minimizing potential side effects such as increased pulmonary vascular resistance 5.

SOAP Note

• S: The patient is experiencing hypotension, with a systolic blood pressure less than 100 mmHg, despite initial treatment with atropine for bradycardia.
• O: The patient's vital signs indicate a need for vasopressor support to maintain adequate blood pressure and perfusion of vital organs.
• A: The patient's hypotension is likely due to the underlying condition that caused the bradycardia, and the use of atropine may have unmasked the hypotension.
• P: The plan is to initiate noradrenaline (norepinephrine) infusion, titrating the dose to achieve a mean arterial blood pressure of at least 65 mmHg, while monitoring the patient's vital signs and adjusting the dosage as needed 5, 6.