Magnesium sulphate.qxd

Magnesium Sulfate in Prehospital
Magnesium sulfate is also used, generally ous case studies show dramatic reversal of in the hospital setting, for acute MI with By Michael Silverman, EMT-P
class IIb (acceptable, possibly helpful) when admissions in that group of patients.
given prophylactically, although the literature suggests the latter treatment offers little to no in the healthcare setting for many years.
benefit.9–11 It is unlikely that magnesium Group concluded that although indiscrimi- Over-the-counter (OTC) products like mag- would be used in the prehospital setting for nate use was not warranted in the ED set- ting, there was “sufficient evidence to sup- (magaldrate, Antiflux, Lowsium, Riopan) are identify and articulate to on-line medical port its use in a subgroup of patients experi- control that the MI patient uses or misuses encing severe asthma who appear to respond (Doan’s pills, Magan, Mobidin) are used as diuretics, and has poor dietary intake and differently to the administration of magne- sium. These patients benefited both in terms salts (Milk of Magnesia) are used for consti- of admission rates and improved pulmonary pation.1 This article focuses on the more pro- tory VF/VT (cardiac arrest) is 1 or 2 grams function.”14 The researcher later said, “It gressive uses of intravenous magnesium sul- (magnesium sulfate) costs virtually nothing fate that are beginning to appear in prehos- and is incredibly safe, especially in the doses pital care protocols and trial studies, specifi- higher doses up to 5–10 grams have been we use for acute asthma.” In the prehospital used. The dose for acute MI is 1–2 grams setting, any patient who does not respond to over 5–60 minutes. Prehospital dosage for the initial beta-agonist dose should be classi- cardiac arrest tends to be IV push or as an fied as severe and a candidate for intra- infusion over a period up to three minutes.
Eclampsia
being well tolerated. Side effects at these pendently, reached similar conclusions. The only significant difference was that this that occurs during pregnancy and can cause hypotension, absent or decreased deep ten- headaches, vision problems, abdominal pain, don reflexes, respiratory depression, circula- nausea, vomiting and sudden swelling of the tory collapse, diaphoresis and drowsiness.
Although this treatment will generally not face, hands or feet. Eclampsia, a Greek word for “bolt from the blue,” can present with Severe Asthma
monary function, given the potential benefit seizures—the hallmark of eclampsia—along The use of magnesium sulfate for treating of this medication, low incidence of side with agitation, altered level of consciousness effects, cost-effectiveness and its presence in Although not a primary therapy in the pre- most paramedic drug inventories, it should hospital setting, it may prove useful in the be routinely used in prehospital care when a port, oxygen therapy, large-bore IV with NS patient presents with severe asthma and ini- should be aware of this secondary potential- tial therapies are not effective. If your assess- the patient in the left lateral position. Seizure ment indicates the patient is not improving activity is typically treated with intravenous after initial beta-agonist treatment and the magnesium sulfate, 4 grams over three min- tion in asthma is well known, prehospital patient has a history of intubation and/or utes. In the prehospital setting, diazepam care tends to focus on bronchodilation using hospital admission after similar episodes, this (Valium) or midazolam (Versed) can be used beta-agonists such as albuterol and epineph- would be an excellent candidate for magne- rine (in extremis), and anticholinergic agents sium sulfate. The optimal dose is 25–100 seizure.7 The only definitive treatment for such as ipratropium bromide. Some systems nisolone to treat airway edema, as well as period.14 Treating acute asthmatic patients Cardiac Care
chemical sedation should intubation become with a less dramatic history should not be Magnesium deficiency is associated with a “high frequency of cardiac arrhythmias, symptoms of cardiac insufficiency and sud- acetylcholine release and muscle excitability.
Magnesium Sulfate and Stroke
den cardiac death.” As a result, many pre- It is known that acute temporary elevation of Acute stroke is the third-leading cause of hospital protocols include the use of magne- serum magnesium can result in bronchodila- death in the United States, after heart attack sium sulfate for treating refractory VF/VT and cancer, and the leading cause of long- or the presence of torsade de pointes: Class patients with normal magnesium levels.
term disability. Public awareness campaigns Evidence also shows that magnesium acts as emphasizing “brain attack” education, early (acceptable, probably useful and effective) a competitive antagonist with calcium and and class I (useful and effective) for tor- reduces the neutrophilic burst associated sade.8,11 Since this medication is far down the with the inflammatory response in asthma.14 Regardless, the beneficial effect of magne- longer just supportive. Early recognition sium is controversial because a large clinical opens the door for more effective interven- trial has not been done, even though numer- stroke. For example, early recognition of ischemic stroke allows Early Recognition of Stroke
providers to consider thrombolytic treatment, although the benefit-to- There are two well-known tools to help a prehospital risk ratio due to intracerebral hemorrhage and overall effectiveness is provider rapidly and reliably identify a stroke patient: the Los quite controversial.17,26 Prehospital providers need not focus on these Angeles Prehospital Stroke Screen20 (LAPSS) and the controversial treatment issues. Rather, we should focus on supportive Cincinnati Prehospital Stroke Scale (CPSS).25 care and rapid transportation to the most appropriate facility. Magnesium is well known as a neuroprotective agent. A $16 million Phase 3 trial titled “FAST-MAG” has just been funded at the If all of the following criteria are met, the patient is identified University of California, Los Angeles (UCLA) to demonstrate “that as meeting the LAPSS criteria for a “code stroke.” The last paramedic initiation of IV magnesium sulfate within two hours of known time the patient was at baseline or deficit-free and symptom onset improves the long-term functional outcome of hyper- acute stroke patients.”18 The initial pilot study, conducted between May 2000 and January 2002, showed that “paramedics initiated the • History of seizures or epilepsy absent drug much more quickly compared to the usual approach of waiting until the patient was in the hospital, and patients tended to make a bet- • At baseline, patient not wheelchair-bound or bedridden Patients in the UCLA trial study met the following criteria: age 40–95; identified in the Los Angeles stroke screen criteria; identified within two hours of onset of symptoms; continued to have symptoms Arm strength—normal, drifts down or falls rapidly Patients excluded from the study met the following criteria: coma; Based on above exam for asymmetry, patient has only unilat- rapidly improving; SBP <90 or >220; severe renal dysfunction (on eral weakness. If the above are yes or unknown, the patient dialysis); severe respiratory distress (oxygen saturation <90%); sec- ond- or third-degree heart block; major head trauma in the last 24hours; stroke within the last 30 days.
A critical part of the study was reliable identification of stroke The CPSS does not include criteria for acute stroke therapy, patients using the Los Angeles Prehospital Stroke Screen (LAPSS) but is a good screening tool to identify stroke patients.
described in the sidebar.19 The trial study selected a prehospital mag- Facial Droop
nesium sulfate dosage of 4 grams over 15 minutes, followed by a Action: Have patient show teeth or smile.
maintenance infusion of 16 grams over 24 hours in the hospital set- Normal: Both sides of face move equally well.
Abnormal: One side of face does not move as well as the Although there are a number of neuroprotective agents, extensive clinical experience with magnesium demonstrates patients’ ability to Arm Drift
tolerate it safely. Magnesium increases cerebral blood flow to ischemic Action: Have patient close both eyes and hold both arms out.
brain areas by dilating blood vessels and prevents damaging calcium Normal: Both arms move the same or both arms do not move buildup in injured nerve cells.20,21,22 If the outcome of this trial is posi- tive, it has the potential to significantly change our approach to stroke Abnormal: One arm does not move or one arm drifts down treatment in the prehospital and emergency department settings. Although potential routine treatment of stroke with intravenous magnesium sulfate is many years away, prehospital care providers Action: Have the patient say, “You can’t teach an old dog new should now concentrate on early recognition, supportive care and rapid transport of suspected stroke patients to the most appropriate Normal: Patient uses correct words with no slurring. facility. Many prehospital protocols now support rapid transport of Abnormal: Patient slurs words, uses inappropriate words or is stroke patients to the most appropriate facility with a “stroke team” rather than the closest facility, especially when patients meet specific criteria such as baseline health status and known time of onset.20,23,24,26 ˆ 3. Abbott J. Complications related to pregnancy. Emergency Medicine: Concepts and Another Potential Application
Clinical Practice, 3rd Ed. St. Louis, MO: Mosby, 1992.
ˆ 4. Hals G, Crump T. The pregnant patient: Guidelines for management of com- Although this section has little to do with prehospital emergency mon life-threatening medical disorders in the emergency department. Emerg Med care, it was interesting to find that magnesium sulfate is being studied to determine if prenatal use—specifically before preterm birth—can ˆ 5. Hansen WF. Problems in pregnancy. Emergency Medicine: A Comprehensive Study improve pediatric outcomes, such as total mortality, reduction in neu- Guide, 4th Ed. New York, NY: McGraw-Hill Professional, 1996.
rosensory disability, motor dysfunction and cerebral palsy.27 Although ˆ 6. Rivers EP. Preeclampsia, eclampsia, and other hypertensive disorders of preg- these studies are not strong enough to recommend widespread use, nancy. The Clinical Practice of Emergency Medicine, 2nd Ed., 1996.
ˆ 7. Inland Counties EMS Agency. Obstetrical Emergencies. ALS Protocol additional research may one day offer a treatment that can provide an overall reduction in the prevalence of cerebral palsy.28 „ ˆ 8. Dyckner T, Wester PO. Magnesium in cardiology. Acta Med Scand 661(suppl):27–31, 1982.
References
ˆ 9. Ebel H, Gunther T. Role of magnesium in cardiac diseases. J Clin Chem Clin ˆ 1. Mosby’s Nursing Drug Reference. St. Louis, MO: Mosby, 2000.
ˆ 2. Brooks MD. Pregnancy, eclampsia. www.emedicine.com/emerg/ ˆ 10. Ceremuzynski L, Jurgiel R, Kulakowski P, Glbalska J. Threatening arrhyth- mias in acute myocardial infarction are prevented byintravenous magnesium sulfate. Am Heart J118:1333–1334, 1989.
ˆ 11. Advanced Cardiac Life Support. AmericanHeart Association, 1–20 and 1–55, 1997–1999. ˆ 12. Asthma and the Influence of Magnesium,www.asthmaworld.org/mag.htm.
ˆ 13. Kirchner FT. Intravenous magnesium sulfateis effective in pediatric asthma. Amer Fam Phy, May2001.
ˆ 14. Rowe BH, Bretzlaff JA, Bourdon C, et al.
Intravenous magnesium sulfate treatment for acuteasthma in the emergency department: A systematicreview of the literature. Ann Emerg Med 36:181–190,Sept 2000.
ˆ 15. Alter HJ, Koepsell TD, Hilty WM.
Intravenous magnesium as an adjuvant in acute bron-chospasm: A meta-analysis. Ann Emerg Med 36:191–197, 2000.
ˆ 16. Preventing Strokes Interactive Tutorial.
www.nim.gov/medlineplus.
ˆ 17. Muir KW. Br J Clin Pharmacol 42:681–682,1996.
ˆ 18. Saver JL, Kidwell CS, Hamilton S, et al. TheField Administration of Stroke Therapy—Magnesium (FAST-MAG) Phase 3 Trial. AmericanStroke Association Conference, Jan. 2003.
ˆ 19. Waddell A. Two hours to save a life: Strokestudy funded. UCLA Today 24:3, Oct 7, 2003.
ˆ 20. Kidwell CS, Starkman S, Eckstein M, et al.
Identifying stroke in the field: Prospective validationof the Los Angeles prehospital stroke screen. Stroke31:71–76, 2000.
ˆ 21. Muir KW, Lees KR. Dose optimization ofintravenous magnesium sulfate after acute stroke.
Stroke 29:918–923, 1998.
ˆ 22. Bradford A, Lees KR. Design of the intra-venous magnesium efficacy in acute stroke trial. CurrControl Trials Med 1(3):184–190, 2000.
ˆ 23. National Stroke Association. Stroke: Acutetreatment and research. www.strokeassociation.org.
ˆ 24. Hayes C. Stroke alert programs: Your patient’sstroke doesn’t have to be a “stroke of bad luck.”www.emsvillage.com. Dec. 10, 2001.
ˆ 25. Kothari RU, et al. Cincinnati prehospital strokescale: Reproducibility and validity. Ann Emerg Med33:373–378, Apr. 1999.
ˆ 26. Ween JE. The inland empire regional strokeinitiative. Loma Linda University. www.llu.edu/llumc/neurosciences/ier-stroke.htm.
ˆ 27. Crowther CA, Hiller JE, Doyle LW, HaslamRR. Effect of magnesium sulfate given for neuroprotection before preterm birth: A randomized con-trolled trial. JAMA 290:2669–2676, 2003.
ˆ 28. Tyson JE, Gilstrap LC. Hope for perinatal pre-vention of cerebral palsy. JAMA 290:2730–2731,2003.
Michael Silverman, EMT-P, is a paramedic for American Medical Response in San BernardinoCounty, CA. Contact him at [email protected].

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