Brady W J, Swart G, DeBehnke D J, Ma O J, Aufderheide T P
Department of Emergency Medicine, University of Virginia, Charlottesville 22908, USA.
Resuscitation. 1999 Jun;41(1):47-55. doi: 10.1016/s0300-9572(99)00032-5.
To determine the efficacy of atropine therapy in patients with hemodynamically compromising bradycardia or atrioventricular block (AVB) in the prehospital and emergency department settings.
Retrospective review of prehospital, emergency department, and hospital records.
Prehospital patients with hemodynamically compromising bradycardia or AVB with evidence of spontaneous circulation who received atropine as delivered by emergency medical services personnel (advanced life support level).
Urban/suburban fire department-based emergency medical service system with on-line medical control serving a population of approximately 1.6 million persons.
Hemodynamic instability was defined as the presence of any of the following: ischemic chest pain, dyspnea, syncope, altered mental status, and systolic blood pressure less than 90 mmHg. Bradycardia was defined as sinus bradycardia, junctional bradycardia, or idioventricular bradycardia (grouped as bradycardia) while AVB included first-, second- (types I and II), or third-degree (grouped as AVB). The response that occurred within one minute following each dose of atropine was defined as none, partial, complete, or adverse.
Of 172 patients meeting entry criterion complete data was available for 131 (76.1%) and constitutes the study population. The mean age was 71 years. Fifty-one percent were female. Forty-five patients had AVB and 86 bradycardia. Patients with AVB were more likely to have a presenting systolic blood pressure less than 90 mmHg than those with bradycardia. In the 131 patients, responses to atropine were as follows: 26 (19.8%) = partial, 36 (27.5%) = complete, 65 (49.6%) = none, and 4 (2.3%) = adverse. Patients presenting with bradycardia (compared to AVB) more commonly: (1) received a single dose of atropine; (2) a lower total dose of atropine in the prehospital interval; (3) were more likely to arrive in the ED with a normal sinus rhythm; and (4) were less likely to receive additional atropine or isoproterenol in the ED. Those patients who achieved normal sinus rhythm over the total course of care were likely to have achieved that rhythm during the prehospital interval. There was no difference between groups in the likelihood of leaving the ED with a normal sinus rhythm achieved during the ED interval. Acute myocardial infarction was more common in patients presenting with AVB (55.5%) than with bradycardia (23.2%, P = 0.001).
Approximately one-half of patients who received atropine in the prehospital setting for compromising rhythms had either a partial or complete response to therapy. Adverse responses were uncommon. Those patients who presented with hemodynamically unstable bradycardia to EMS personnel responded more commonly to a single dose and a lower total dose of atropine compared to similar patients with AVB. Those patients who achieve normal sinus rhythm by ED discharge were likely to have achieved it during the prehospital interval.
确定在院前及急诊科环境中，阿托品治疗对血流动力学不稳定的心动过缓或房室传导阻滞（AVB）患者的疗效。
对院前、急诊科及医院记录进行回顾性分析。
血流动力学不稳定的心动过缓或AVB且有自主循环证据的院前患者，这些患者接受了紧急医疗服务人员（高级生命支持水平）给予的阿托品治疗。
基于城市/郊区消防部门的紧急医疗服务系统，有在线医疗控制，服务人口约160万。
血流动力学不稳定定义为存在以下任何一种情况：缺血性胸痛、呼吸困难、晕厥、精神状态改变以及收缩压低于90 mmHg。心动过缓定义为窦性心动过缓、交界性心动过缓或室性逸搏心律（归为心动过缓），而AVB包括一度、二度（I型和II型）或三度（归为AVB）。每次给予阿托品后一分钟内出现的反应定义为无反应、部分反应、完全反应或不良反应。
172例符合入选标准的患者中，131例（76.1%）有完整数据，构成研究人群。平均年龄为71岁。51%为女性。45例患者有AVB，86例有心动过缓。与心动过缓患者相比，AVB患者就诊时收缩压低于90 mmHg的可能性更大。在这131例患者中，对阿托品的反应如下：26例（19.8%）为部分反应，36例（27.5%）为完全反应，65例（49.6%）无反应，4例（2.3%）为不良反应。表现为心动过缓的患者（与AVB患者相比）更常见的情况是：（1）接受单剂量阿托品；（2）院前期间阿托品总剂量较低；（3）更有可能以正常窦性心律到达急诊科；（4）在急诊科接受额外阿托品或异丙肾上腺素的可能性较小。在整个治疗过程中实现正常窦性心律的患者很可能在院前期间就已实现该心律。在急诊科期间实现正常窦性心律并离开急诊科的可能性在两组之间没有差异。AVB患者中急性心肌梗死比心动过缓患者更常见（55.5%对23.2%，P = 0.001）。
在院前环境中因节律异常接受阿托品治疗的患者中，约一半对治疗有部分或完全反应。不良反应不常见。与类似的AVB患者相比，向紧急医疗服务人员表现出血流动力学不稳定心动过缓的患者对单剂量和较低总剂量的阿托品反应更常见。到急诊科出院时实现正常窦性心律的患者很可能在院前期间就已实现。
