An overview of magnesiumuse in the emergencydepai ent
A u t h o r : M i c h a e l A. F r a k e s , L a w r e n c e , K a n s a s
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I n t r a v e n o u s m a g n e s i u m sulfate is b e c o m i n g a m o r e
c o m m o n t h e r a p y in e m e r g e n c y m e d i c i n e . O n c e
called " t h e f o r g o t t e n ion," m a g n e s i u m is n o w r e c o g -
n i z e d as p o t e n t i a l l y b e n e f i c i a l in a n u m b e r of e m e r -
g e n t c o n d i t i o n s , a n d t h e i n c i d e n c e a n d risks of h y p o -
m a g n e s e m i a are b e t t e r u n d e r s t o o d . This article dis-
c u s s e s p h y s i o l o g y , electrolyte depletion, a n d t h e
p r o v e n a n d p o s t u l a t e d roles of m a g n e s i u m in t h e
emergency department.
Physiology
M a g n e s i u m is t h e fourth m o s t c o m m o n c a t i o n in t h e
b o d y a n d is t h e s e c o n d m o s t c o m m o n intracellular
cation. It is a cofactor in m o r e t h a n 300 b i o c h e m i c a l
reactions, including potassium and calcium metabo-
lism, a d e n o s i n e t r i p h o s p h a t e e n e r g y reactions, fat a n d
p r o t e i n s y n t h e s i s , a n d c a r b o h y d r a t e metabolismfl, 2
T h e a d u l t r e c o m m e n d e d d i e t a r y a l l o w a n c e of
m a g n e s i u m is 300 to 360 mg. Grains, nuts, b e a n s ,
shellfish, a n d g r e e n leafy v e g e t a b l e s are g o o d sources.
D i e t a r y m a g n e s i u m is a b s o r b e d in t h e small i n t e s t i n e
a n d e x c r e t e d in t h e k i d n e y s . 2
T h e s e r u m m a g n e s i u m level m e a s u r e s only t h e
1% of m a g n e s i u m t h a t e x i s t s extracellularly, so it is n o t
a l w a y s a n a c c u r a t e reflection of total b o d y m a g n e -
sium. More a c c u r a t e m e a s u r e s are t h e m a g n e s i u m
c o n t e n t of e r y t h r o c y t e s , m u s c l e s , or bones, or t h e as-
Michael A. Frakes is a paramedic, Douglas County Division of EMS,
Lawrence, Kansas, and a clinical faculty member, Division of Math,
Science and Health Care, Johnson County (KS)Community College,
Overland Park, Kansas.
Reprints not available from author.
J Emerg Nurs 1996;22:213-20.
Copyright 9 1996 by the Emergency Nurses Association.
0099-1767/96 $5.00 + 0 18/1/72917
s e s s m e n t of m a g n e s i u m o u t p u t after t h e a d m i n i s t r a -
tion of a n i n t r a v e n o u s l o a d i n g dose. 2 A s e r u m value
b e l o w t h e n o r m a l r a n g e of 1.8 to 3.0 m g / d l is c o n s i d -
e r e d to i n d i c a t e a n overall m a g n e s i u m deficiency.
Hypomagnesemia
M a g n e s i u m d e f i c i e n c y is a c o m m o n , often u n r e c o g -
n i z e d problem. A r e v i e w of r o u t i n e electrolyte s t u d i e s
o r d e r e d in an u r b a n h o s p i t a l found low s e r u m m a g n e -
s i u m levels in 7% of t h e s a m p l e s . Interestingly, d e t e r -
m i n a t i o n of t h e m a g n e s i u m level h a d b e e n o r d e r e d for
only 10% of t h e h y p o m a g n e s e m i c p a t i e n t s ; t h u s elec-
trolyte d e p l e t i o n w o u l d h a v e r e m a i n e d u n d e t e c t e d
90% of t h e time. s
Several c o m m o n clinical c o n d i t i o n s are associ-
a t e d w i t h h y p o m a g n e s e m i a . Up to 85% of alcoholic
p a t i e n t s w h o h a v e h a d t e s t i n g for m e t a b o l i t e s h a v e
b e e n found to h a v e low m a g n e s i u m levels, a n d other
at-risk g r o u p s i n c l u d e u s e r s of n o n - p o t a s s i u m - s p a r i n g
diuretics, d i a b e t i c p a t i e n t s in k e t o a c i d o s i s , a n d p a -
t i e n t s r e c e i v i n g a m i n o g l y c o s i d e antibiotics.2, 4, 5 S o m e
42% of p a t i e n t s w h o are h y p o k a l e m i c are also hypo-
m a g n e s e m i c ; t h e r e f o r e a low s e r u m p o t a s s i u m level
should p r o m p t a n e v a l u a t i o n of t h e m a g n e s i u m level. 5
The clinical m a n i f e s t a t i o n s of h y p o m a g n e s e m i a
are n u m e r o u s a n d nonspecific; t h e y c o m p r i s e four
general categories: neuromuscular hyperactivity, psy-
c h i a t r i c a n d c e n t r a l n e r v o u s effects, c a r d i a c effects,
a n d c a l c i u m / p o t a s s i u m a b n o r m a l i t i e s . 1 Table 1 lists
c o m m o n e x a m p l e s in e a c h c a t e g o r y , l, 2
H y p o m a g n e s e m i a from a n y c a u s e h a s b e e n linked
w i t h i n c r e a s e d mortality. T h e A c u t e Physiologic a n d
Chronic H e a l t h E v a l u a t i o n (APACHE) score is a
s e v e r i t y - a d j u s t e d r a t i n g s y s t e m b a s e d on 27 p h y s i o -
logic, health, a n d a g e v a r i a b l e s t h a t is u s e d to p r e d i c t
patient outcomes. Patients who are hypomagnesemic
on a d m i s s i o n to t h e h o s p i t a l h a v e b e e n s h o w n to h a v e
m o r t a l i t y r a t e s n e a r l y t w i c e a s h i g h as normo-
m a g n e s e m i c p a t i e n t s w i t h c o m p a r a b l e A P A C H E II
scores, e v e n after t h e d e f i c i e n c y is corrected. In a d d i -
tion, p a t i e n t s w i t h h y p o m a g n e s e m i a in t h e ICU set-
t i n g d i e d a p p r o x i m a t e l y 8 d a y s sooner t h a n d i d
p a t i e n t s in t h e ICU w i t h n o r m a l m a g n e s i u m levels a n d
similar A P A C H E II scores. This s u g g e s t s t h a t low
June 1996 2 1 3
JOURNAL OF EMERGENCYNURSING/Frakes

It a p p e a r s that the most severely d i s t r e s s e d asth-

Table 1 m a t i c s obtain the g r e a t e s t benefit from m a g n e s i u m
Clinical sequelae of h y p o m a g n e s e m i a therapy. A recent study s h o w e d that the majority of
Neuromuscular effects p a t i e n t s with a s t h m a did not benefit overall from the
Hyperreflexia addition of 2 gm of IV m a g n e s i u m over 20 minutes to
Muscle cramping their t r e a t m e n t regimen, but that the s u b s e t of
Paresthesias p a t i e n t s with an FEV1 less than 25% of p r e d i c t e d
Fasciculations
s h o w e d statistically significant i n c r e a s e s in FEV1 and
Tetany
Muscle twitching/tremor d e c r e a s e s in admission rates. ~5 Dramatic s u c c e s s also
Psychiatric and central nervous s y s t e m effects has b e e n shown from the administration of i to 2 gm
Agitation of m a g n e s i u m given during a 2- to 5-minute period to
Delirium severely d i s t r e s s e d a s t h m a t i c s who are also receiving
Coma
a g g r e s s i v e [~-agonist therapy. 16,17
Depression
Seizures Overall, the use of m a g n e s i u m in the "routine"
Cardiac effects e m e r g e n c y care of p a t i e n t s with a s t h m a is discour-
Dysrhythmias aged.15, 15 However, m a g n e s i u m m a y be infused ei-
Atrial fibrillation ther slowly or rapidly in acutely ill a s t h m a t i c s who are
Paroxysmal supraventricular tachycardia
Premature ventricular complexes seen in the e m e r g e n c y department.
Ventricular tachycardia
Ventricular fibrillation Preeclampsia and eclampsia
Torsades de pointes P r e e c l a m p s i a is the p r e s e n c e in the s e c o n d half of
EKG changes p r e g n a n c y of hypertension (blood pressure e x c e e d i n g
Prolonged PR interval
Widened QRS complex
140/90 m m Hg in a previously normotensive patient)
Prolonged QT interval a c c o m p a n i e d by proteinuria, edema, or both. The
Hypertension p r e s e n c e of seizures in a p r e e c l a m p t i c p a t i e n t defines
Hypotension eclampsia. 19 M a g n e s i u m is the most frequently used
Anemia a g e n t in the United States for the prevention of
Coronary artery s p a s m
Calcium/potassium abnormalities
eclamptic seizures. The A m e r i c a n College of Obste-
Concomitant hypocalcemia tricians a n d Gynecologists r e c o m m e n d s m a g n e s i u m
Concomitant hypokalemia in preeclampsia, and 100% of obstetricians in one
study of p r e e c l a m p s i a u s e d magnesium. 19, 20 Patients
are usually given a loading dose of 4 gm intravenously
m a g n e s i u m levels on a d m i s s i o n m a y indicate an un- during a 5- to 15-minute period, then a therapeutic
derlying d i s t u r b a n c e that prevents h o m e o s t a s i s and is level is m a i n t a i n e d with either a m a i n t e n a n c e infusion
therefore a s s o c i a t e d with i n c r e a s e d mortality. 6 of 2 to 3 gm/hr or boluses of 5 gm intramuscularly ev-
R e p l a c e m e n t t h e r a p y for m a g n e s i u m - d e f i c i e n t ery 4 hours. 21, 22 A n t i h y p e r t e n s i v e s such as hydrala-
p a t i e n t s is usually 6 gm intravenously during a 3-hour zine, labetalol, and m e t h y l d o p a are s o m e t i m e s given
period initially, followed by 10 gm within 21 hours and concurrently. 19
6 gm per d a y thereafter. 2 Once seizures occur, there is some d e b a t e about
therapy. Some physicians advocate initiating or in-
Asthma creasing m a g n e s i u m therapy, and p a t i e n t s treated
The d a t a on IV m a g n e s i u m t h e r a p y for a s t h m a are with m a g n e s i u m have h a d a 98% lower mortality rate
contradictory. Several studies have shown that mag- (0.4% versus 20%). 19, 23-25 Others claim that b e c a u s e
n e s i u m p r o d u c e s i n c r e a s e s in p e a k expiratory flow eclamptic seizures are identical to other seizures, an-
rate a n d forced expiratory volume at 1 s e c o n d (FEV1) ticenvulsants such as phenytoin or d i a z e p a m should
that last up to 30 minutes. 5-11 Other studies have be used. M a g n e s i u m does not have clearly demon-
shown no beneficial effect. 12, 13 The physiologic ef- strated anticonvulsant properties, and its neuromus-
fects of m a g n e s i u m are also unclear, b u t m a y include cular m e c h a n i s m of action in e c l a m p s i a is uncer-
smooth muscle relaxation from inhibited calcium up- tain.19, 25
take, altered acetylcholine release, a n d i n c r e a s e d res- Two other important considerations regarding
piratory power. 5, 9 M a g n e s i u m does potentiate the the use of m a g n e s i u m exist. First, m a g n e s i u m is a to-
cardiovascular and metabolic effects of [3-agenist colytic, a n d delivery of the fetus is the definitive ther-
drugs. 14 apy for eclampsia. Additionally, some studies have

214 Volume 22, Number 3


s h o w n c e s a r e a n s e c t i o n r a t e s in m a g n e s i u m - t r e a t e d
p a t i e n t s to b e m o r e t h a n four t i m e s h i g h e r t h a n t h e
r a t e for o t h e r p a t i e n t s . 19, 26
B e c a u s e d e f i n i t i v e clinical trials h a v e not b e e n
c o m p l e t e d to d e t e r m i n e t h e ideal t r e a t m e n t for
eclampsia, the emergency nurse can expect the
a d m i n i s t r a t i o n of m a g n e s i u m to b o t h p r e e c l a m p t i c
a n d e c l a m p t i c p a t i e n t s , b u t s h o u l d not b e s u r p r i s e d
t h a t a n t i c o n v u l s a n t s a r e g i v e n for e c l a m p t i c s e i z u r e s
a s well.
Cardiac dysrhythmias
I n t r a v e n o u s m a g n e s i u m is clearly i m p o r t a n t in t h e
t r e a t m e n t of c a r d i a c d y s r h y t h m i a s . It is t h e t h e r a p y of
c h o i c e for t o r s a d e s d e p o i n t e s , a u n i q u e p o l y m o r p h i c
v e n t r i c u l a r t a c h y c a r d i a c h a r a c t e r i z e d b y QRS c o m -
p l e x e s t h a t t w i s t a r o u n d t h e i s o e l e c t r i c line a n d a r e
usually a c c o m p a n i e d b y a p r o l o n g e d QT interval. 27
T h e A d v a n c e d C a r d i a c Life S u p p o r t (ACLS) g u i d e -
lines r e c o m m e n d m a g n e s i u m for t o r s a d e s d e p o i n t e s ,
and conversion has been reported with both repeated
2 g m b o l u s e s a n d w i t h infusions of 50 m g / m i n . 27-29
T h e r e is still s p e c u l a t i o n
that magnesium,
administered either before
r e p e r f u s i o n or w i t h i n 1 to 2
m i n u t e s after it t a k e s place,
c a n p r o t e c t t h e h e a r t from
damage called "stunning,"
w h i c h o c c u r s in t h e first
m i n u t e s of r e p e r f u s i o n .
Other v e n t r i c u l a r d y s r h y t h m i a s r e s p o n d to m a g -
n e s i u m . T h e f r e q u e n c y of p r e m a t u r e ventricular c o m -
p l e x e s h a s b e e n found to b e i n v e r s e l y r e l a t e d to s e r u m
m a g n e s i u m levels, a n d ACLS protocol s u g g e s t s t h a t 1
to 2 g m m a g n e s i u m m a y b e a n effective t r e a t m e n t in
refractory v e n t r i c u l a r t a c h y c a r d i a a n d v e n t r i c u l a r fi-
brillation 29, 3o
R e s e a r c h also s h o w s t h a t p a t i e n t s w i t h atrial fi-
brillation w h o w e r e g i v e n m a g n e s i u m in a d d i t i o n to
d i g o x i n w e r e m o r e likely to h a v e c o n v e r s i o n to s i n u s
r h y t h m , w i t h c o n v e r s i o n a c h i e v e d m o r e rapidly t h a n
p a t i e n t s w h o w e r e n o t g i v e n m a g n e s i u m . 31 The d o s e
u s e d w a s a 2 g m bolus, followed b y an 8 g m infusion
Frakes/JOURNALOF EMERGENCYNURSING
Table 2
S u m m a r y of m a g n e s i u m d o s a g e r e g i m e n s *
Hypomagnesemia
6 gm IV initially, followed by 10 gm IV over
21 hours, then 6 g i n / d a y IV
Asthma
2 gm IV over 20 minutes or 1-2 gm IV over
2-5 minutes
Preeclampsia and eclampsia
4 gm IV over 5-15 minutes, followed b y either a
2-3 gm/hr infusion or 5 gm IM every 4 hours
Cardiac dysrhythmias
Torsades de pointes: 2 gm IV b o l u s e s or
50 mg/min IV infusion
Refractory ventricular fibrillation or tachycardia:
1-2 gm IV bolus
Atrial fibrillation: 2 gm IV bolus followed by 8 gm
IV infusion over 6 hours
Myocardial infarction
2 gm IV over 5 minutes, possibly followed by
16 gm Iv' infusion over 24 hours
*Some of the indications, d o s e s in this table are unlabeled or
investigational.
over 6 hours. M a n y p a t i e n t s w i t h initial a b n o r m a l car-
d i a c r h y t h m m a y b e n e f i t from m a g n e s i u m therapy.
Myocardial infarction
S t u d i e s r e g a r d i n g t h e u s e of m a g n e s i u m in t h e treat-
m e n t of m y o c a r d i a l infarction p r e s e n t conflicting
results. Initially, m a g n e s i u m t h e r a p y looked p r o m i s -
ing; d a t a on m o r e t h a n 3900 p a t i e n t s s h o w e d statis-
tically s i g n i f i c a n t d e c r e a s e s in mortality, h e a r t failure,
a n d d y s r h y t h m i a s w h e n p a t i e n t s w i t h m y o c a r d i a l in-
farctions w e r e g i v e n IV m a g n e s i u m in v a r y i n g
doses.3Z, as However, t h e F o u r t h I n t e r n a t i o n a l S t u d y of
Infarct Survival (ISIS-4) followed m o r e t h a n 58,000 p a -
t i e n t s a n d d i d not s h o w a s t a t i s t i c a l l y s i g n i f i c a n t
c h a n g e in survival r a t e s b e t w e e n p a t i e n t s g i v e n m a g -
n e s i u m a n d t h o s e not g i v e n m a g n e s i u m . In fact, ISIS-4
s h o w e d i n c r e a s e s in h e a r t failure a n d c a r d i o g e n i c
s h o c k in m a g n e s i u m - t r e a t e d p a t i e n t s . 34
Results from this s t u d y d i d not resolve t h e issue.
T h e r e is still s p e c u l a t i o n t h a t m a g n e s i u m , a d m i n i s -
t e r e d e i t h e r before r e p e r f u s i o n or w i t h i n i to 2 m i n u t e s
after it t a k e s place, c a n p r o t e c t t h e h e a r t from d a m a g e
called " s t u n n i n g , " w h i c h o c c u r s in t h e first m i n u t e s
of reperfusion, s5 B e c a u s e no s t u d y t h a t r e q u i r e d t h a t
m a g n e s i u m b e g i v e n before t h r o m b o l y t i c t h e r a p y h a s
b e e n c o n d u c t e d , d e b a t e a b o u t this p o s s i b l e b e n e f i t
continues.34, 35 Until t h e s e q u e s t i o n s a r e resolved, t h e
t r e a t m e n t of s o m e p a t i e n t s w i t h m y o c a r d i a l infarction
m a y i n c l u d e a n i m m e d i a t e 2 g m m a g n e s i u m bolus
a n d p o s s i b l y a 16 g m infusion d u r i n g t h e n e x t 24
hours. 35
June 1996 2 1 5
JOURNAL OF EMERGENCYNURSING/Erakes
Care of the patient receiving magnesium
M o s t d o s a g e r e g i m e n s d i s c u s s e d in this article in-
c l u d e p r o l o n g e d i n f u s i o n s or r a p i d b o l u s e s t h a t m i g h t
i n c r e a s e t h e p a t i e n t risk of m a g n e s i u m toxicity. W h a t
s h o u l d b e k e p t in m i n d w h e n a d m i n i s t e r i n g m a g n e -
s i u m to a p a t i e n t ?
More serious side effects
include the following:
cardiac c o n d u c t i o n c h a n g e s
occurring at levels of 6 to
12 mg/dl, and m a n i f e s t e d
by a p r o l o n g e d PR interval
and QRS duration; loss of
reflexes, especially patellar
reflexes, at 23 mg/dl; and
respiratory d e p r e s s i o n at
18 mg/dl.
Mos* r e c o m m e n d a t i o n s a d v i s e not to e x c e e d 333
m g / m i n w h e n g i v i n g m a g n e s i u m intravenously, s& 37
H o w e v e r , s t u d i e s of large n u m b e r s of p a t i e n t s receiv-
i n g 2 to 4 g m i n t r a v e n o u s l y for 5 m i n u t e s h a v e s h c w n
m i n i m a l s i d e effects. 2& 3s T h e m o s t c o m m o n s i d e ef-
fects are f l u s h i n g of t h e skin, n a u s e a , a n d vomiting. 1
M o r e s e r i o u s s i d e effects i n c l u d e t h e following: car-
d i a c c o n d u c t i o n c h a n g e s o c c u r r i n g at levels of 6 to 12
mg/dl, a n d m a n i f e s t e d b y a p r o l o n g e d PR interval a n d
QRS duration; loss of reflexes, e s p e c i a l l y patellar re-
flexes, at 23 mg/dl; a n d r e s p i r a t o r y d e p r e s s i o n at 18
mg/dl. A level of 30 m g / d l is usually f a t a l 9
In p a t i e n t s r e c e i v i n g m a g n e s i u m t h e r a p y b y IV
b o l u s or b y r a p i d IV infusion, it is i m p o r t a n t to m o n -
itor c o n t i n u o u s l y their EKG a n d r e s p i r a t o r y status, a n d
to e v a l u a t e d e e p t e n d o n reflexes frequently. 37 Intrave-
n o u s c a l c i u m g l u c o n a t e is u s e d to r e v e r s e t h e effects
of e x c e s s i v e m a g n e s i u m a d m i n i s t r a t i o n . 36
M a g n e s i u m is c o n t r a i n d i c a t e d in t h e p r e s e n c e of
h i g h - g r a d e h e a r t block (Mobitz II a n d t h i r d - d e g r e e
block) b e c a u s e of t h e p o t e n t i a l for EKG c h a n g e s , a n d
it will p o t e n t i a t e n e u r o m u s c u l a r b l o c k i n g a g e n t s s u c h
a s curare, p a n c u r o n i u m , a n d v e c u r o n i u m . It s h o u l d b e
g i v e n w i t h c a u t i o n to l a c t a t i n g m o t h e r s , b u t it is a
p r e g n a n c y c a t e g o r y A drug, so t h e r e is no e v i d e n c e of
h a r m to t h e fetus w h e n a d m i n i s t e r e d to g r a v i d
wolYlen.36, 37
216 Volume 22, Number 3
Smn~a~f
M a g n e s i u m is an i m p o r t a n t ion. M a n y ED p a t i e n t s
m a y b e at risk of h y p o m a g n e s e m i a . I n t r a v e n o u s m a g -
n e s i u m sulfate h a s b e e n p r o v e n to b e effective in t h e
t r e a t m e n t of v a r i o u s d y s r h y t h m i a s , a n d t h e r e is suffi-
cient s u p p o r t for its u s e in m y o c a r d i a l infarction,
p r e e c l a m p s i a , a n d e c l a m p s i a to w a r r a n t t h e a t t e n t i o n
of e m e r g e n c y nurses. W i t h s i m p l e monitoring, t h e
d r u g c a n b e g i v e n safely, a n d it should b e i n t e r e s t i n g
to e v a l u a t e t h e results of m a g n e s i u m t h e r a p y w h e n
g i v e n in c a s e s in w h i c h its u s e is controversial.
References
1. McLean R. Magnesium and its therapeutic uses: a
review. Am J Med 1994;96:63-76.
2. Tso EL, Barish RA. Magnesium: clinical considerations.
J Emerg Med 1992;10:743-5.
3. Whang R, Ryder KW. Frequency of hypomagnesemia and
hypermagnesemia: requested versus routine. JAMA 1990;
263:3063-4.
4. Dyckner T, Wester PO. Potassium/magnesium depletion
tn patients with cardiovascular disease. Am J Med 1987;
82(3A):11-7.
5. Whang, R. Magnesium deficiency: pathogenesis, preva-
lence, and clinical implications. Am J Med 1987;82(3A):24-9.
6. Rubeiz GJ, Thill-Baharozian M, Hardie D, et aI. Associa-
tion of hypomagnesemia and mortality in acutely ill medical
patients. Crit Care Med 1993;21:203-9.
7. Flink EB. Therapy of rnagnesium deficiency. Ann N u
Acad Sci 1969;162:901-5.
8. Okayama H, Aikawa T, Okayama M, Sesaki S, Mue S,
Takishima T. Bronchodilating effect of intravenous magne-
sium sulfate in bronchial asthma. JAMA 1987;257:1076-8.
9. Skobeloff EM, Spivey WH, McNamara RM, Greenspoon E.
Intravenous magnesium sulfate for the treatment of acute
asthma in the emergency department. JAMA 1989;262:1201 -
13.
10. Noppen M, Vanmaele L, Impens N, Schandevyll W.
Brenchedilating effect of intravenous magnesium sulfate in
acute severe bronchial asthma. Chest 1990;97:373-6.
11. Rella G, Bucca C, Carie E, et aI. Acute effect of intrave-
nous magnesium sulfate on airway obstruction of asthmatic
patients. Ann Allergy 1988;61:388-91.
12. Green SM, Rethreck SG. Intravenous magnesium for
acute asthma: failure to decrease emergency treatment du-
ration or need for hospitalization. Ann gmerg Med 1992;21:
260-5.
13. Tiffany BR, Berk WA, Todd IK, White SR. Magnesium
bolus or infusion fails to improve expiratory flow in acute
asthma exacerbations. Chest 1993;104:831-4.
14. Skorodin MS, Freebeck PC, Yetter B, et al. Magnesium
sulfate potentiates several cardiovascular and metabolic
actions of terbutaline. Chest 1994;106:701-5.
15. Bloch H, Silverman R, Mancherje N, et al. Intravenous
magnesium sulfate as an adjunct in the treatment of acute
asthma. Chest 1995;107:1576-81.

16. Schiermeyer RP, Finkelstein JA. Rapid infusion of mag-
n e s i u m sulfate obviates n e e d for intubation in status asth-
maticus. A m J E m e r g Med 1994;12:164-6.
17. Pabon H, M o n e m G, Kissoon N. Safety and efficacy of
m a g n e s i u m sulfate infusions in children with status asth-
maticus. Pediatr E m e r g Care 1994;10:200-3.
18. Skobeloff EM, M c N a m a r a RM. Intravenous m a g n e s i u m
for acute asthma [comment]. Ann Emerg Med 1993;22:618.
19. M c C o m b s J. Treatment of preeclampsia and eclampsia.
Clinical Pharmacy 1992;11:236-45.
20. A m e r i c a n College of Obstetricians and Gynecologists.
M a n a g e m e n t of pre-eclampsia. ACOG Tech Bull 1986; Feb-
ruary 91:1-4.
21. Pritchard JA. The use of the m a g n e s i u m ion in the
m a n a g e m e n t of eclampogenic toxemias. Surg Gynecol Ob-
stet 1955;100:131-40.
22. Z u s p a n FP. Treatment of severe pre-eclampsia and
eclampsia. Clin Obstet Gynecol 1966;9:954-72.
23. Pritchard JA, Cunningham FG, Pritchard SA. The Park-
land Memorial Hospital protocol for treatment of eclampsia:
evaluation ef245 cases. Am J Obstet Gyneco11984;148:951-63.
24. Zuspan FP. Problems encountered in the treatment of
p r e g n a n c y - i n d u c e d hypertension. A m J Obstet Gynecol
1978;131:591-6.
25. Kaplan PW, Lesser RP, Fisher RS, Repke JT, Hanley DF.
No, m a g n e s i u m sulfate should not be used in treating
eclamptic seizures. Arch Neurol 1988;45:1361-4.
26. Goodlin RC. M a g n e s i u m sulfate is not an ideal anticon-
vulsant [see reply]. A m J Obstet Gynecol 1990;163:1714-5.
27. Tzivoni D, Banal S, Schuger C, et al. Treatment of tor-
sade de pointes with m a g n e s i u m sulfate. Circulation 1988;
77:392-7.
28. Perticone F, Adinolfi L, Bonaduce D. Efficacy of magne-
sium sulfate in the treatment of torsade de pointes. A m
Heart J 1986;112:847-9.
29. Cummins Re, ed. Textbook of A d v a n c e d Cardiac Life
Support. Dallas: A m e r i c a n Heart Association, 1994:1-17,
1-39.
30. Tsuji H, Venditti F J, Evans JC, et al. The associations of
levels of serum potassium and m a g n e s i u m with ventricular
premature complexes. A m J Cardiol 1994;74:232-5.
31. Brodsky MA, Orlov MV, Capparelli EV, et al. M a g n e s i u m
therapy in n e w - o n s e t atrial fibrillation. Am J Cardiol
1994;73:1227-9.
32. Tee KK, Yusuf S. Role ef m a g n e s i u m in reducing mor-
tality in acute myocardial infarction. Drugs 1993;46:347-59.
33. Hampton EM, Whang DD, Whang R. Intravenous mag-
nesium therapy in acute myocardial infarction. Ann Phar-
macother 1994;28:212-9.
34. Fourth International Study of Infarct Survival Collabora-
tive Group. ISIS-4: a randomised factorial trial assessing
early oral captopril, oral mononitrate, and intravenous mag-
nesium sulphate in 58,050 patients with suspected acute
myocardial infarction. Lancet 1995;345:669-85.
35. Woods KL, Fletcher S. Long-term outcome after intra-
venous m a g n e s i u m sulphate in s u s p e c t e d acute myocardial
infarction: the second Leicester Intravenous M a g n e s i u m
Trial (LIMIT-2). Lancet 1994;343:816-9.
Frakes/JOURNAL OF EMERGENCY NURSING
36. Skidmore-Roth L. Mosby's nursing drug reference.
St Louis: Mesby, 1992.
37. Gahart B. Intravenous medication. 9th ed. St Louis:
Mosby-Year Book, 1993.
38. Wacker WEC, Parisi AF. M a g n e s i u m metabolism.
N Engl J Med 1968;278:658-63, 712-7, 772-6.
CONTINUINGEDUCATIONTESTINSTRUCt"IONS
To receive continuing education (CE) credit for h o m e
study of this article after you have read it, darken the appro-
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O ~ S
After completing this offering, the learner will be able to:
1. Explain the physiology of m a g n e s i u m in the body.
2. Describe the incidence, signs, and s y m p t o m s of hypo-
magnesemia.
3. Discuss the administration of m a g n e s i u m in patients
with acute asthma, eciampsia, and cardiac dysrhyth-
mias.
4. List those patients in w h o m m a g n e s i u m therapy is con-
traindicated.
5. Outline the side effects of m a g n e s i u m therapy and the
appropriate nursing actions.
June 1996 217
JOURNAL OF EMERGENCY NURSING/Frakes
TEST rl~_.M$
1. T h e article d i s c u s s e d t h e i n c i d e n c e of d i a g n o s e d m a g -
n e s i u m deficiency. W h i c h of t h e following s t a t e m e n t s is
most accurate?
a. M a g n e s i u m deficiencies are often identified.
b. A m a g n e s i u m deficiency w a s identified in 7% of
hospitalized patients.
c. M a g n e s i u m deficiencies are p r e s e n t m u c h more of-
t e n t h a n is recognized.
d. T h e r e m a y b e a n u n d e r l y i n g m a g n e s i u m deficiency
in 90% of hospital cases.
2. Of t h e following p a t i e n t s , w h o is m o s t likely to b e m a g -
n e s i u m deficient?
a. A n i n s u l i n - d e p e n d e n t d i a b e t i c w h o s e initial s y m p -
tom is a h e a d a c h e
b. A h y p e r t e n s i v e p a t i e n t t a k i n g lisinopril (Prinivil) w h o
h a s b r e a t h i n g difficulty
c. A n alcoholic p a t i e n t w i t h a n i m p a i r e d level of con-
sciousness
d. A w o m a n in her t w e n t y - e i g h t h w e e k of p r e g n a n c y
who has nausea and vomiting
3. W h i c h of t h e following m o s t accurately reflects t h e re-
lationship b e t w e e n a b n o r m a l m a g n e s i u m a n d potas-
s i u m levels?
a. No correlation h a s b e e n established.
b. T h e r e is a n i n v e r s e correlation b e t w e e n p o t a s s i u m
a n d m a g n e s i u m levels.
c. Nearly half of t h e t i m e t h e r e is a correlation b e t w e e n
low p o t a s s i u m a n d low m a g n e s i u m levels.
d. There is a direct correlation b e t w e e n p o t a s s i u m a n d
m a g n e s i u m levels m o r e t h a n 75% of t h e time.
4. W h i c h of t h e following b e s t d e s c r i b e s EKG c h a n g e s t h a t
occur in r e s p o n s e to low m a g n e s i u m levels?
a. Heart block
b. C o n d u c t i o n slowing
c. C o n d u c t i o n i n c r e a s e
d. W a n d e r i n g p a c e m a k e r
5. On t h e b a s i s of k n o w n manifestations, w h i c h of t h e fol-
lowing would rate t h e h i g h e s t i n d e x of suspicion for
possible h y p o m a g n e s e m i a ?
a. A 73-year-old m a n w i t h a history of h y p e r t e n s i o n w h o
has hemiplegia
b. A 56-year-old w o m a n w i t h a history of seizure disor-
der w h o h a s focal seizures
c. A 38-year-old w o m a n w i t h a history of multiple scle-
rosis w h o h a s n u m b n e s s of t h e legs
d. A 65-year-old m a n w i t h a history of d i a b e t e s mellitus
w h o h a s s e v e r e c r a m p i n g p a i n in t h e calves of his
legs
6. The article i n d i c a t e s t h a t low m a g n e s i u m levels h a v e a n
i m p a c t on all of t h e following s y s t e m s e x c e p t the:
a. respiratory system.
b. n e u r o m u s c u l a r system.
c. cardiovascular system.
d. central n e r v o u s system.
7. W h i c h of t h e following m o s t accurately cor pletes t h e
s t a t e m e n t ? T h e mortality potential a s s o c i a t e d w i t h low
m a g n e s i u m levels is increased:
a. in all cases.
b. w h e n h y p o m a g n e s e m i a is not corrected.
218 Volume 22, Number 3
c. w h e n it occurs in c o n j u n c t i o n w i t h chronic illness.
d. w h e n APACHE scores are significantly abnormal.
8. W h i c h of t h e following is t h e m o s t a c c u r a t e s t a t e m e n t
about magnesium?
a. Low m a g n e s i u m levels m a y i n d i c a t e s o m e underly-
ing d i s t u r b a n c e i n h i b i t i n g h o m e o s t a s i s .
b. Chronic illnesses s u c h as h y p e r t e n s i o n m a y precip-
itate low m a g n e s i u m .
c. M a g n e s i u m t h e r a p y s h o u l d b e u s e d only for p a t i e n t s
w i t h mild a s t h m a s y m p t o m s .
d. Altered m a g n e s i u m levels h a v e b e e n a s s o c i a t e d w i t h
e n v i r o n m e n t a l pollutants.
9. On t h e b a s i s of t h e information p r e s e n t e d in the article,
w h i c h of t h e following p a t i e n t s w i t h a c u t e a s t h m a is
m o s t likely to benefit from a d m i n i s t r a t i o n of m a g n e -
sium?
a. A 6-year-old child w i t h bilateral inspiratory w h e e z i n g
w h o tried a h o m e inhaler twice; respirations 40 p e r
minute, oxygen s a t u r a t i o n 90%, pulse 120 b e a t s / m i n
b. A 24-year-old m a n w i t h w h e e z i n g a n d bilateral
d e c r e a s e d b r e a t h sounds; respirations 39 per minute,
oxygen s a t u r a t i o n 85%, pulse 140 b e a t s / m i n
c. A 56-year-old m a n w i t h bilateral inspiratory a n d ex-
piratory w h e e z i n g ; respirations 28 p e r minute, oxy-
g e n s a t u r a t i o n 91%, pulse 100 b e a t s / m i n
d. A 32-year-old w o m a n w i t h bilateral w h e e z i n g a n d
rales w h o ran out of m e d i c a t i o n s 3 days ago; respi-
rations 32 p e r minute, oxygen s a t u r a t i o n 89%, pulse
92 b e a t s / m i n
10. O n t h e b a s i s of t h e information provided in t h e article,
w h i c h of t h e following t r e a t m e n t a p p r o a c h e s should a
n u r s e e x p e c t to s e e for a p a t i e n t with e c l a m p s i a ?
a. M a g n e s i u m t h e r a p y
b. A n t i c o n v u l s a n t s
c. M a g n e s i u m t h e r a p y w i t h or w i t h o u t a n t i c o n v u l s a n t s
d. A n t i c o n v u l s a n t s w i t h or w i t h o u t m a g n e s i u m t h e r a p y
11. A 22-year-old w o m a n in t h e thirty-second w e e k of
p r e g n a n c y is b r o u g h t to t h e e m e r g e n c y d e p a r t m e n t b y
a m b u l a n c e after e x p e r i e n c i n g blurred vision a n d de-
c r e a s e d sensorium. Her h u s b a n d n o t e d her s p e e c h w a s
slurred a n d b e c a m e c o n c e r n e d . He called 911 w h e n h e
ceuld not g e t her out of t h e e a s y chair. On a s s e s s m e n t
you find t h e p a t i e n t c o n s c i o u s a n d r e s p o n d i n g verbally
to physical stimulation. Her r e s p o n s e s to your q u e s t i o n s
are appropriate b u t vague. Her blood p r e s s u r e is 180/98
m m Hg. She h a s +4 p i t t i n g e d e m a of t h e ankles. The di-
a g n o s i s of p r e e c l a m p s i a a n d t h e initiation of m a g n e s i u m
t h e r a p y is primarily b a s e d on her:
a. inability to r e s p o n d verbally a n d hypertension.
b. hypertension, e d e m a , a n d s t a g e of p r e g n a n c y .
c. p e d a l edema, sensorium, a n d s p e e c h c h a n g e s .
d. s t a g e of p r e g n a n c y , orientation, a n d blurred vision.
12. Current t r e a t m e n t r e c o m m e n d a t i o n s for various ven-
tricular d y s r h y t h m i a s c a n b e b e s t s u m m a r i z e d b y stat-
ing t h a t t r e a t m e n t w i t h m a g n e s i u m :
a. is not clearly established.
b. is c o n t r a i n d i c a t e d in atrial dysrhythmias.
c. works well w i t h m a n y ventricular dysrhythmias.
d. is r e c o m m e n d e d for s o m e ventricular dysrhythmias.
 Frakes/JOURNAL OF EMERGENCY NURSING

13. The preferred m a g n e s i u m d o s i n g m e t h o d to t r e a t dys- a. D e v e l o p m e n t of n a u s e a

r h y t h m i a s is: b. C h a n g e in t h e PR interval to 0.24
a. bolus. c. P a t i e n t n o w hyperreflexive
b. either bolus or infusion. d. D e v e l o p m e n t of notable facial flushing
c. bolus followed b y infusion.
d. infusion w i t h or w i t h o u t initial bolus. 16. T h e r e c o m m e n d e d t r e a t m e n t to reverse m a g n e s i u m
toxicity is:
a. to d i s c o n t i n u e t h e m a g n e s i u m .
QUESTIONS14 AND 15 PERTAINTO THE FOLLOWINGSCENARIO: b. variable d e p e n d i n g on level of toxicity.
You h a v e b e e n a s k e d to a d m i n i s t e r a 3 g m bolus of m a g n e - c. t h e a d m i n i s t r a t i o n of calcium gluconate.
s i u m to a 62-year-old m a n w i t h t o r s a d e s d e pointes. d. a d m i n i s t r a t i o n of calcium c h a n n e l blockers.
14. On t h e b a s i s of t h e information p r o v i d e d in t h e article, 17. M a g n e s i u m a d m i n i s t r a t i o n is absolutely contraindi-
h o w m u c h t i m e would you take to a d m i n i s t e r t h e bolus? c a t e d for patients:
a. 2 m i n u t e s a. w h o are n u r s i n g mothers.
b. 4 m i n u t e s b. w h o require paralyzing drugs.
c. 9 m i n u t e s c. w h o h a v e received thrombolytics.
d. 15 m i n u t e s d. w h o s e P w a v e s are not a s s o c i a t e d w i t h a QRS com-
15. W h e n m o n i t o r i n g t h e p a t i e n t d u r i n g a n d after t h e m a g - plex.
n e s i u m bolus, w h i c h of t h e following would require im-
mediate response? (Answer sheet on page 220)

A Look Bade Kills germs on contact

Two m o n u m e n t a l discoveries d u r i n g t h e n i n e t e e n t h c e n t u r y m a d e m o d e r n - d a y surgery possible: safe a n e s t h e s i a a n d

control of w o u n d infections. A n e s t h e t i c s w e r e discovered first a n d allowed s u r g e o n s to perform longer, more intricate
operations. T h e b e n e f i t s of s u r g e r y soon diminished, t h o u g h , as w o u n d infections soared. Infections were t h o u g h t to b e
c a u s e d b y a c h e m i c a l r e a c t i o n b e t w e e n body t i s s u e s a n d air. In a n c i e n t times, antiseptics, s u c h as w i n e a n d vinegar,
were r e c o g n i z e d as helpful. Later r e m e d i e s i n c l u d e d t i g h t b a n d a g i n g of w o u n d s with a d h e s i v e materials, s u c h as col-
lodion (a solution of g u n - c o t t o n in e t h e r a n d alcohol) a n d cattle i n t e s t i n e m e m b r a n e s to keep t h e air out. Unfortunately,
as w e k n o w today, t h e s e p r a c t i c e s only m a d e m a t t e r s worse. T h e mortality rate from infections r a n g e d from 40% to 60%
a n d s o m e t i m e s w a s higher.

Bacteriology evolved into a s c i e n c e d u r i n g t h e last quarter of t h e n i n e t e e n t h c e n t u r y w h e n a F r e n c h professor of c h e m -

istry, Louis P a s t e u r (1822-1895), proved m i c r o o r g a n i s m s in t h e air a n d on t h e h a n d s could p r o d u c e disease. J o s e p h Lister
(1827-1912), a British surgeon, capitalized on P a s t e u r ' s work b y u s i n g a n t i s e p t i c s d u r i n g a n d after surgery to r e d u c e
p o s t o p e r a t i v e infections. Lister r e a d t h a t t h e city of Carlisle rid itself of s e w e r s t e n c h b y p o u r i n g carbolic acid into t h e
s e w e r drains. In 1865 h e b e g a n d i p p i n g b a n d a g e s a n d ligatures in carbolic acid a n d p o u r i n g t h e acid into wounds, greatly
d e c r e a s i n g t h e d e a t h rate from g a n g r e n e . Initially carbolic acid w a s applied directly onto wounds, b u t this p r a c t i c e w a s
very irritating to living tissues. However, carbolic acid solutions greatly e n h a n c e d a s e p s i s w h e n s p r a y e d onto surgical
i n s t r u m e n t s . A l t h o u g h crude, his m e t h o d worked, l a u n c h i n g t h e world's first t r u e antiseptic t r e a t m e n t . M a n y of Lister's
colleagues initially scoffed at his a p p r o a c h to a n t i s e p s i s including, interestingly, Florence Nightingale.--Linda Manley,
RN, BSN, CEN, CCRN

June 1996 2 1 9
JOURNAL OF EMERGENCY NURSING/Frakes

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below. (You m a y s e n d photocopies of t h e a n s w e r T h e d e a d l i n e for s u b m i t t i n g your enrollment/
form.) a n s w e r form is J u n e 30, 1997.

I n s t r u c t i o n s : Darken only one circle for your answer to each c~uestion. This is a standard form; use only the n u m b e r of
spaces required for the test you are taking.

1.O a 2 . O a 3.O a 4.O a 5.O a 6.O a 7.O a 8.O a 9.O a 10.O a 11.O a 12,O a 1 3 . O a 1 4 . O a 15.O a
Ob Ob Ob Ob Ob 0 b 0 b Ob 0 b Ob Ob 0 b Ob Ob Ob
Oc Oc Oc 0c Oc Oc Oc Oc 0c 0c Oc Oc 0c Oc Oc
Od Od 0 d Od 0 d Od Od Od 0 d Od Od Od Od 0 d Od

16,O a 1 7 . O a 18.O a 19,O a 20.O a 21.O a22. 0 a 23. 0 a 2 4 . 0 a 25. 0 a 2 6 . 0 a 27. 0 a 28. 0 a 29. 0 a 30.0 a
Ob Ob Ob Ob O b Ob Ob Ob Ob Ob Ob Ob Ob Ob Oh
Oc Oo 0c Oc 0 c Oc Oc Oo Oc Oc Oc Oc Oc Oc Oc
Od 0 d Od Od 0 d Od Od O d Od O d O d Od O d Od Od

P r o g r a m e v a l u a t i o n : Please rate this CE material b y d a r k e n i n g t h e a p p r o p r i a t e circles below.

1. Was m a t e r i a l 3. Did material m e e t t h e s t a t e d objectives? O Yes O No

O n e w or O r e v i e w for you? 4. Are you more confident of your abilities s i n c e c o m p l e t i n g this
2. Was material material? O Yes O No
a) p r e s e n t e d clearly? O Yes O No 5. How m u c h t i m e w a s u s e d to c o m p l e t e this CE offering?
b) covered a d e q u a t e l y ? O Yes O No Hours

6. S u g g e s t i o n s for future CE offerings:

Please print clearly

Last n a m e First n a m e Middle n a m e

Address
City State Zip
Phone ( ) Social security n u m b e r
State(s) of L i c e n s u r e a n d L i c e n s e No(s).
Position/title
Specialty area

M a k e c h e c k or m o n e y order payable to Mail to: Continuing Education Department

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N e w York, NY 10019-2961

220 Volume 22, Number 3