Unorthodox Magnesium

[ERDoc]

I'm always up for a good challenge. I disagree that it would be hard to design a study. In fact, I argue that it would be just the opposite. The is no ethical or legal questions. An IRB would approve the study with very little difficulty. After a very brief pubmed search, I did find one article that showed an improved outcome for pts with severe asthma who were given MagSulf. The improvement was not as good for those with mild-moderate. The consensus seems to be that Mag is safe, but there is a paucity of studies supporting or not supporting it. Might be a great idea for a study. I got DIBS!

http://www.ncbi.nlm.nih.gov/entrez/query.f...t_uids=12171821

Quick shout out to my hometown peeps on Long Island.

[akflightmedic]

Squint, I have no studies, only personal experience.

The times I used it and it worked was during my Alaska days, you know what I am talking about...where I had a 2.5 hour MINIMUM flight by plane to get anywhere near definitive care. I had exhausted all resources and yes, plenty of time had gone by for the other meds to kick in if they were going to work, but they didnt. Once MS was given, there was immediate relief and turnaround.

I think it should be considered more often and earlier in status asthmaticus.

[AZCEP]

Sorry DOC and the rest of you:

No reason to be sorry. You have a different view of the utility of this medication. So be it.

Mag sulfate is a trace element (elecrtolye as we know) it is used on spec. with those that may have nutritional or ETOH abuse PMHX in our CCUs. Poor nutrition has been linked with some of the population of asthmatic/ obese children.

It is also adversely effected by the overuse of Albuterol MDI's for the rescue of reactive airway disease.

Fact of the matter is one needs a whole heck of a lot of Mag. Sulf. to see loss of DEEP TENDON reflexes. Mag Sulfate was used for years to slow premature delivery, but we loaded 4 times the standard dosage that one presently carries on car these days, for torsades.

Quite the broad brush there. Every patient is going to respond a bit differently to this and every medication. Deep Tendon reflexes are just one sign that you may have used too much magnesium. It is also a therapeutic end point. We are allowed 8 grams, and when given too fast, can cause the loss of DTR. Not common, but it is possible.

You know....... I can not believe that EMS and some ERs have jumped on this "BANDWAGON"... now..... for those evidence based medicine dudes and duddettes, I challenge you and throw down this gauntlet.

There are just as many that haven't, so take it easy with the aim of your gauntlet.

1- I bet $$$$ that for every anecdotal remark that Ventolin and Atrovent (concomitantly) is already on board as with "standard of care" in patient treatment and usually (MS) started within 15 minutes. So the question is: Just what are the peak effects/vs time with Ventolin.....hmmmmm....your going to tell me M. S. this is definitive conclustion to patient improvement?......please think again, cough, splutter, wheeze.

The typical administration of magnesium is following a number of patient administered rescue MDI treatments. The 2-3 SVN administered beta 2/anti-cholinergics are not going to magically alter the peak effect/onset times of the medications. Most often they are already in the middle of the time span for these to be happening.

2-Your comparing 2 drug modalities at the very the same time and drawing the a concusion......NONSENSE! Your beating the horse with 2 whips, this so NOT science.

Unless we are doing a randomized examination of the individual treatments, why would we not administer the first line treatment and progress to an adjunctive modality? Discussing one over the other as definitive is a bit problematic, but the end result of better ventilation/oxygenation is where our concern lies.

3- SHOW ME THE STUDIES! for every one you show me I will show you a study that disproves it, The first (study?) was a young asthmatic female that was weaned from a ventilator....this study is totally a shame and has absolutly no EMS application.

Without the studies that have been done, the mere suggestion that magnesium may be helpful could not be made. Are they directly applicable? Probably not, but they have fostered the discussion.

4- That said: the discovery that Salbutamol was effective for use in smooth muscle relaxation was FIRST noted in the investigation of "slowing of premature delivery". (the patient was also an ashmatic) ps Ventolin IV, in the gravida patient has not been used for years, and disproven to be effective for that condition, just to big of a "hammer" no pun intended. :shock:

So you are saying the use of IV Ventolin is ineffective for relaxing uterine smooth muscle? This proves what exactly? There are many beta agonists that do work for relaxing the gravid uterus that aren't especially helpful for other reasons. Terbutaline anyone? I suppose I just need what you are trying to say here clarified.

6- The use of "early" use of nebulised steroids has far more promising with current studies...google it out, especially paeds.

The problem comes with the definition of early. Steroids help reduce morbidity/mortality in these patients, but they do not help to rescue the affected airways.

Ok: For the research crowd in EMS...a very rare breed....put together a study to actually study this supposed phenomenon in EMS....but medical legal ethical questions will get in the way....this I put $$$ on too.

These are the same questions that get in the way of every piece of research not relegated to animals or the newly deceased. Because the treatments in question have been used for such a long period of time, and have gathered support from those that have used them, we get the ethical dilemma of not giving a medication that we THINK works, without KNOWING it does.

[hammerpcp]

Hmmmmm..............vewy intewesting.

Apparently MagSulf increases the production of the vasodilator prostacyclin......Its antiarrhythmic effects may be related to its role in maintaining intercellular potassium.............and it may also act as a natural calcium channel blocker........

Who knew. Thanks for the insight(s) all. Perhaps it is not more widely used in COPD exacerbation because of the lack of scientific evidence?

[tniuqs]

tniuqs wrote:

4- That said: the discovery that Salbutamol was effective for use in smooth muscle relaxation was FIRST noted in the investigation of "slowing of premature delivery". (the patient was also an ashmatic) ps Ventolin IV, in the gravida patient has not been used for years, and disproven to be effective for that condition, just to big of a "hammer" no pun intended.

So you are saying the use of IV Ventolin is ineffective for relaxing uterine smooth muscle? This proves what exactly? There are many beta agonists that do work for relaxing the gravid uterus that aren't especially helpful for other reasons. Terbutaline anyone? I suppose I just need what you are trying to say here clarified.

tniuqs wrote

:

Yea was poorly written, I am trying to explain the History in the use of Ventolin, it was good observation on the researches part to not just focus on the labour but all the systems affected..... any beta will affect "smooth muscle" its a physiological fact jack...lol. Berotec is another that has lost favour as well as Terbutaline, (yes, I know you southern guys still get it prescribed by GPs for Asthmatic cases)

The reason that this Ventolin IV or (even S/S neb trialed in one ancient study) this has lost favour with the NeoNatal crowd is there are more effective medications with less serous side effects for the kid in utreo....( will not get into those really not applicable on this board) Pemature Labour and NICU transport Teams are the WAY to go with these gerbils and uncooperative Mothers.

The placental barrier could be just "theoretical" we are very aware that narcotics are not affected by this suspected barrier.

6- The use of "early" use of nebulised steroids has far more promising with current studies...google it out, especially paeds.

The problem comes with the definition of early. Steroids help reduce morbidity/mortality in these patients, but they do not help to rescue the affected airways.

Are YOU positive ?.....My southern brother ?......So just how much change do you have in your pocket? I do take CC as well. :twisted:

Frankly we know that Roids work but the exact mechanism is still NOT explained other than the fact that Roids stabilize cell membranes....hey when in ICU, and nothing else is working ....LOADING with ROIDs is a very common practice.

Unless we are doing a randomized examination of the individual treatments, why would we not administer the first line treatment and progress to an adjunctive modality? Discussing one over the other as definitive is a bit problematic, but the end result of better ventilation/oxygenation is where our concern lies.

Good point, add to the fact that just how do we evaluate "better ventilation/oxygenation" could we be talking ABG machines in the rig as well? An EMS study is frought with issues absolutely agreed.

[hr:9a18f9b802]

akflightmedic Posted:

Squint, I have no studies, only personal experience.

The times I used it and it worked was during my Alaska days, you know what I am talking about...where I had a 2.5 hour MINIMUM flight by plane to get anywhere near definitive care. I had exhausted all resources and yes, plenty of time had gone by for the other meds to kick in if they were going to work, but they didnt. Once MS was given, there was immediate relief and turnaround. I think it should be considered more often and earlier in status asthmaticus.

OH I hear you man, when your down to there! I too have no problem in giving it a shot....have never said I haven't used myself, justification is what I need when I walk into the ICUs and get quizzed.

[hr:9a18f9b802]

Ok who mentioned CPAP or BIPAP.....now this is thinking outside the box a bit! Instead of using a "medical approach" and it fits on CHFer, COPDers, and Athmatics......now if we could just find a Ventilator, that was multi-roled, Invasive and non-Invasive... that didn't cost more than Hammers tuition fees for 2 years.

So just my 2 cents (and I know its off topic) but this would be where I would put all the cash "from all my winnings" !

ps, Oh yea that Gauntlet.... is more like a used Nitrile Glove.... :twisted:

[AZCEP]

Are YOU positive ?.....My southern brother ?......So just how much change do you have in your pocket? I do take CC as well.

I've got plenty. Thanks for asking. You have yet to prove your point.

Frankly we know that Roids work but the exact mechanism is still NOT explained other than the fact that Roids stabilize cell membranes....hey when in ICU, and nothing else is working ....LOADING with ROIDs is a very common practice.

You say it yourself, AFTER every other treatment is tried. How is this an "early" administration? Even at that, the recommendations are for inhaled/nebulized steroids, not the commonly available IV route that most EMS providers have.

Yes, we do use IV steroids for the management of reactive airway disorders. We do not see a response to that specific treatment until after the beta 2/anticholinergics are effective. The use of magnesium can supplement the other modes of management, and I doubt anyone will suggest using it to replace the beta 2s and steroids any time soon.

Good point, add to the fact that just how do we evaluate "better ventilation/oxygenation" could we be talking ABG machines in the rig as well? An EMS study is frought with issues absolutely agreed.

Why would you want an ABG? Waiting the requisite time for the equipment to give you a reading that should be accomplished by observing the patient is near negligent. Use your pulse oximetry/ECG/EtCO2/hands & eyes. Listen for changes in breath sounds. Feel for changes in skin condition. These are not difficult concepts.

[tniuqs]

Good point, add to the fact that just how do we evaluate "better ventilation/oxygenation" could we be talking ABG machines in the rig as well? An EMS study is frought with issues absolutely agreed.

Why would you want an ABG? Waiting the requisite time for the equipment to give you a reading that should be accomplished by observing the patient is near negligent. Use your pulse oximetry/ECG/EtCO2/hands & eyes. Listen for changes in breath sounds. Feel for changes in skin condition. These are not difficult concepts.

Ok we are really getting off topic here, but I will answer your queries as best as I can: Many longer distance transport teams use them in Canada...why not in the back of a rig?

An ABG is positive factual data "not negligent" thats nonsense dude, are you saying that ABGs done in a Hospital setting are? Its still the "golden standard" and prior threads disputing bedside the use of Peak flows (by Rid) so just how do we quantify FEV1 in the ER ? Or are you just attempting to start a argument here.

EYES EARS and Listening are JUST clinical observations and highly subjective especially when doing studies, in fact when the introduction of pulse oximetry the observations (a blind study with experiance flight guys "in your very own US of A") noted that cyanosis was not "observed until SaO2 was noted at less than 77%............hence the serious "world wide" introduction of this now accepted new vital sign.

cheers

[hammerpcp]

Okay guys and gals.....anticholinergics for reactive A/W disease? Like what?

[AZCEP]

Ipratropium (Atrovent)

[crazycanuck]

Interesting link to a drug trial of an oral anticholinergic tested vs. placebo and irpatropium bromide:

http://www.erj.ersjournals.com/cgi/content...6.06.00126005v1

Eur Respir J 2006, doi:10.1183/09031936.06.00126005

Also a good article, with plenty of med info at the end:

http://www.emedicine.com/EMERG/topic363.htm