In case the maximum dose of Atropine (3 mg) has been administered but the blood pressure remains under 90 and heart rate is under 50, what is the next step?

In situations where maximum doses of Atropine (up to 3 mg) have been given without improvement in blood pressure and heart rate, administering push dose epinephrine is a critical next step. This is because push dose epinephrine is an effective method for quickly raising vascular tone and heart rate, particularly in the context of bradycardia or severe hypotension.

Push dose epinephrine involves administering a small bolus of epinephrine that can help stimulate the heart and improve cardiac output, thus potentially stabilizing the patient’s hemodynamics. It acts on the alpha and beta-adrenergic receptors, which can increase heart rate and blood pressure, providing immediate support in emergency situations.

Administering fluids might seem logical for addressing hypotension, but in the presence of bradycardia, this alone may not correct the underlying rhythm issue, and the fluid administration could be less effective without addressing the heart rate itself.

Considering pacing is also appropriate in bradycardic conditions, but the immediate action to stabilize the patient would be to provide a medication like push dose epinephrine before setting up for pacing, which can take more time.

Performing CPR is indicated in cases of arrest situations, but in this context where the patient