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An overviewof magnesiumuse in the emergencydepai ent

Author:

Michael

A.

Frakes,

Lawrence,

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I ntravenous magnesium sulfate is becoming a more common therapy in emergency medicine. Once

called "the forgotten ion," magnesium is now recog- nized as potentially beneficial in a number of emer- gent conditions, and the incidence and risks of hypo- magnesemia are better understood. This article dis- cusses physiology, electrolyte depletion, and the proven and postulated roles of magnesium in the emergency department.

Physiology

Magnesium is the fourth most common cation in the body and is the second most common intracellular cation. It is a cofactor in more than 300 biochemical reactions, including potassium and calcium metabo- lism, adenosine triphosphate energy reactions, fat and protein synthesis, and carbohydrate metabolismfl, 2 The adult recommended dietary allowance of magnesium is 300 to 360 mg. Grains, nuts, beans, shellfish, and green leafy vegetables are good sources. Dietary magnesium is absorbed in the small intestine and excreted in the kidneys. 2 The serum magnesium level measures only the 1% of magnesium that exists extracellularly, so it is not always an accurate reflection of total body magne- sium. More accurate measures are the magnesium content of erythrocytes, muscles, or bones, or the 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

sessment of magnesium output after the administra-

tion of an

below the normal range of 1.8 to 3.0 mg/dl is consid- ered to indicate an overall magnesium deficiency.

intravenous loading dose. 2 A serum value

Hypomagnesemia Magnesium deficiency is a common, often unrecog- nized problem. A review of routine electrolyte studies ordered in an urban hospital found low serum magne- sium levels in 7% of the samples. Interestingly, deter- mination of the magnesium level had been ordered for only 10% of the hypomagnesemic patients; thus elec- trolyte depletion would have remained undetected 90% of the time. s Several common clinical conditions are associ- ated with hypomagnesemia. Up to 85% of alcoholic patients who have had testing for metabolites have been found to have low magnesium levels, and other at-risk groups include users of non-potassium-sparing diuretics, diabetic patients in ketoacidosis, and pa- tients receiving aminoglycoside antibiotics.2, 4, 5 Some 42% of patients who are hypokalemic are also hypo- magnesemic; therefore a low serum potassium level should prompt an evaluation of the magnesium level.5 The clinical manifestations of hypomagnesemia are numerous and nonspecific; they comprise four general categories: neuromuscular hyperactivity, psy- chiatric and central nervous effects, cardiac effects, and calcium/potassium abnormalities. 1 Table 1 lists common examples in each category, l, 2 Hypomagnesemia from any cause has been linked with increased mortality. The Acute Physiologic and Chronic Health Evaluation (APACHE) score is a severity-adjusted rating system based on 27 physio- logic, health, and age variables that is used to predict patient outcomes. Patients who are hypomagnesemic on admission to the hospital have been shown to have mortality rates nearly twice as high as normo- magnesemic patients with comparable APACHE II scores, even after the deficiency is corrected. In addi- tion, patients with hypomagnesemia in the ICU set- ting died approximately 8 days sooner than did patients in the ICU with normal magnesium levels and similar APACHE II scores. This suggests that low

June 1996

213

JOURNALOF EMERGENCYNURSING/Frakes

Table 1

Clinical sequelae of hypomagnesemia

Neuromuscular effects Hyperreflexia

Muscle cramping

Paresthesias

Fasciculations

Tetany

Muscle twitching/tremor Psychiatric and central nervous system effects Agitation

Delirium

Coma

Depression

Seizures

Cardiac effects

Dysrhythmias

Atrial fibrillation Paroxysmal supraventricular tachycardia Premature ventricular complexes Ventricular tachycardia Ventricular fibrillation Torsades de pointes

EKG changes

Prolonged PR interval

Widened QRS complex

Prolonged QT interval

Hypertension

Hypotension

Anemia

Coronary artery spasm

Calcium/potassium abnormalities

Concomitant hypocalcemia Concomitant hypokalemia

magnesium levels on admission may indicate an un- derlying disturbance that prevents homeostasis and is therefore associated with increased mortality.6

Replacement

therapy

for magnesium-deficient

patients is usually 6 gm intravenously during a 3-hour

period initially, followed by 10 gm within 21 hours and

6 gm per day thereafter. 2

Asthma

The data on IV magnesium therapy for asthma are contradictory. Several studies have shown that mag- nesium produces increases in peak expiratory flow

rate and forced expiratory volume at 1 second (FEV1) that last up to 30 minutes. 5-11 Other studies have

The physiologic ef-

fects of magnesium are also unclear, but may include smooth muscle relaxation from inhibited calcium up- take, altered acetylcholine release, and increased res- piratory power. 5, 9 Magnesium does potentiate the

shown no beneficial effect. 12, 13

cardiovascular

and

metabolic effects of [3-agenist

drugs. 14

It appears that the most severely distressed asth- matics obtain the greatest benefit from magnesium therapy. A recent study showed that the majority of patients with asthma did not benefit overall from the addition of 2 gm of IV magnesium over 20 minutes to their treatment regimen, but that the subset of patients with an FEV1 less than 25% of predicted showed statistically significant increases in FEV1 and decreases in admission rates. ~5 Dramatic success also has been shown from the administration of i to 2 gm of magnesium given during a 2- to 5-minute period to severely distressed asthmatics who are also receiving aggressive [~-agonist therapy. 16,17

Overall, the use of magnesium in the

"routine"

emergency care of patients with asthma is discour- aged.15, 15 However, magnesium may be infused ei- ther slowly or rapidly in acutely ill asthmatics who are seen in the emergency department.

Preeclampsiaand eclampsia

Preeclampsia is the presence in the second half of pregnancy of hypertension (blood pressure exceeding 140/90 mm Hg in a previously normotensive patient) accompanied by proteinuria, edema, or both. The presence of seizures in a preeclamptic patient defines eclampsia. 19 Magnesium is the most frequently used agent in the United States for the prevention of eclamptic seizures. The American College of Obste- tricians and Gynecologists recommends magnesium in preeclampsia, and 100% of obstetricians in one study of preeclampsia used magnesium. 19, 20 Patients are usually given a loading dose of 4 gm intravenously during a 5- to 15-minute period, then a therapeutic level is maintained with either a maintenance infusion of 2 to 3 gm/hr or boluses of 5 gm intramuscularly ev- ery 4 hours. 21, 22 Antihypertensives such as hydrala- zine, labetalol, and methyldopa are sometimes given concurrently. 19 Once seizures occur, there is some debate about therapy. Some physicians advocate initiating or in- creasing magnesium therapy, and patients treated with magnesium have had a 98% lower mortality rate (0.4% versus 20%). 19, 23-25 Others claim that because

eclamptic seizures are identical to other seizures, an- ticenvulsants such as phenytoin or diazepam should be used. Magnesium does not have clearly demon- strated anticonvulsant properties, and its neuromus-

cular mechanism

of action in eclampsia is uncer-

tain.19, 25

Two other important considerations regarding the use of magnesium exist. First, magnesium is a to- colytic, and delivery of the fetus is the definitive ther- apy for eclampsia. Additionally, some studies have

shown

patients

rate for other patients. 19, 26 Because definitive clinical trials have not been completed to determine the ideal treatment for eclampsia, the emergency nurse can expect the administration of magnesium to both preeclamptic and eclamptic patients, but should not be surprised that anticonvulsants are given for eclamptic seizures as well.

cesarean section rates in magnesium-treated

to be more than

four times higher than

the

Cardiac dysrhythmias

Intravenous magnesium is clearly important in the treatment of cardiac dysrhythmias. It is the therapy of choice for torsades de pointes, a unique polymorphic ventricular tachycardia characterized by QRS com- plexes that twist around the isoelectric line and are usually accompanied by a prolonged QT interval. 27 The Advanced Cardiac Life Support (ACLS) guide- lines recommend magnesium for torsades de pointes, and conversion has been reported with both repeated 2 gm boluses and with infusions of 50 mg/min. 27-29

There is still speculation that magnesium, administered either before reperfusion or within 1 to 2 minutes after it takes place, can protect the heart from damage called "stunning," which occurs in the first minutes of reperfusion.

Other ventricular dysrhythmias respond to mag- nesium. The frequency of premature ventricular com-

plexes has been found to be inversely related to serum magnesium levels, and ACLS protocol suggests that 1 to 2 gm magnesium may be an effective treatment in

refractory ventricular tachycardia brillation 29, 3o

that patients with atrial fi-

brillation who were given magnesium in addition to digoxin were more likely to have conversion to sinus rhythm, with conversion achieved more rapidly than patients who were not given magnesium. 31 The dose

used was a 2 gm bolus, followed by an 8 gm infusion

and ventricular fi-

Research also shows

Frakes/JOURNALOF EMERGENCYNURSING

Table 2

Summary of magnesium

Hypomagnesemia

dosage regimens*

6 gm IV initially, followed by 10 gm IV over

21 hours, then 6 gin/day 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 by either a

2-3 gm/hr infusion or 5 gm IM every 4 hours

Cardiac dysrhythmias Torsades de pointes: 2 gm IV boluses 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, doses in this table are unlabeled or investigational.

over 6 hours. Many patients with initial abnormal car-

diac rhythm may benefit from magnesium

therapy.

Myocardial

infarction

Studies regarding the use of magnesium in the treat- ment of myocardial infarction present conflicting results. Initially, magnesium therapy looked promis- ing; data on more than 3900 patients showed statis- tically significant decreases in mortality, heart failure, and dysrhythmias when patients with myocardial in- farctions were given IV magnesium in varying doses.3Z, as However, the Fourth International Study of Infarct Survival (ISIS-4) followed more than 58,000 pa- tients and did not show a statistically significant change in survival rates between patients given mag- nesium and those not given magnesium. In fact, ISIS-4 showed increases in heart failure and cardiogenic shock in magnesium-treated patients. 34 Results from this study did not resolve the issue. There is still speculation that magnesium, adminis- tered either before reperfusion or within i to 2 minutes after it takes place, can protect the heart from damage called "stunning," which occurs in the first minutes of reperfusion, s5 Because no study that required that magnesium be given before thrombolytic therapy has been conducted, debate about this possible benefit

continues.34, 35 Until these questions

treatment of some patients with myocardial infarction may include an immediate 2 gm magnesium bolus

and

hours. 35

are resolved, the

the

next

24

possibly a

16

gm

infusion

during

June 1996

215

JOURNALOF EMERGENCYNURSING/Erakes

Care of the patient receiving magnesium

Most dosage regimens discussed in this article in- clude prolonged infusions or rapid boluses that might increase the patient risk of magnesium toxicity. What should be kept in mind when administering magne- sium to a patient?

More serious side effects include the following:

cardiac conduction changes

occurring at levels of 6 to

12 mg/dl, and manifested

by a prolonged PR interval and QRS duration; loss of reflexes, especially patellar reflexes, at 23 mg/dl; and respiratory depression at

18 mg/dl.

Mos* recommendations advise not to exceed 333

intravenously, s& 37

However, studies of large numbers of patients receiv- ing 2 to 4 gm intravenously for 5 minutes have shcwn minimal side effects. 2& 3s The most common side ef- fects are flushing of the skin, nausea, and vomiting. 1 More serious side effects include the following: car- diac conduction changes occurring at levels of 6 to 12 mg/dl, and manifested by a prolonged PR interval and QRS duration; loss of reflexes, especially patellar re- flexes, at 23 mg/dl; and respiratory depression at 18 mg/dl. A level of 30 mg/dl is usually fatal9 In patients receiving magnesium therapy by IV bolus or by rapid IV infusion, it is important to mon- itor continuously their EKG and respiratory status, and to evaluate deep tendon reflexes frequently. 37 Intrave- nous calcium gluconate is used to reverse the effects of excessive magnesium administration. 36 Magnesium is contraindicated in the presence of high-grade heart block (Mobitz II and third-degree block) because of the potential for EKG changes, and it will potentiate neuromuscular blocking agents such as curare, pancuronium, and vecuronium. It should be given with caution to lactating mothers, but it is a pregnancy category A drug, so there is no evidence of harm to the fetus when administered to gravid

wolYlen.36, 37

mg/min

when

giving magnesium

Smn~a~f

Magnesium is an important ion. Many ED patients may be at risk of hypomagnesemia. Intravenous mag- nesium sulfate has been proven to be effective in the treatment of various dysrhythmias, and there is suffi- cient support for its use in myocardial infarction, preeclampsia, and eclampsia to warrant the attention of emergency nurses. With simple monitoring, the drug can be given safely, and it should be interesting to evaluate the results of magnesium therapy when given in cases in which its use 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.

Frakes/JOURNAL OF EMERGENCYNURSING

16.

Schiermeyer RP, Finkelstein JA. Rapid infusion of mag-

36.

Skidmore-Roth L. Mosby's nursing drug reference.

nesium sulfate obviates need for intubation in status asth-

St

Louis: Mesby, 1992.

maticus.

Am J Emerg Med 1994;12:164-6.

37.

Gahart B. Intravenous medication. 9th ed. St Louis:

17. Pabon H, Monem G, Kissoon N. Safety and efficacy of

magnesium

maticus. Pediatr Emerg Care 1994;10:200-3.

18. Skobeloff EM, McNamara RM. Intravenous magnesium

for acute asthma [comment]. Ann Emerg Med 1993;22:618.

19. McCombs J. Treatment of preeclampsia and eclampsia.

Clinical Pharmacy 1992;11:236-45.

20. American College of Obstetricians and Gynecologists.

Management of pre-eclampsia. ACOG Tech Bull 1986; Feb- ruary 91:1-4.

21. Pritchard JA. The use of the magnesium ion in the

management of eclampogenic toxemias. Surg Gynecol Ob-

stet 1955;100:131-40.

22. Zuspan 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.

sulfate infusions in children with status asth-

24. Zuspan FP. Problems encountered in the treatment of

pregnancy-induced hypertension. Am J Obstet Gynecol

1978;131:591-6.

25. Kaplan PW, Lesser RP, Fisher RS, Repke JT, Hanley DF.

No, magnesium sulfate should not be used in treating eclamptic seizures. Arch Neurol 1988;45:1361-4.

26. Goodlin RC. Magnesium sulfate is not an ideal anticon-

vulsant [see reply]. Am J Obstet Gynecol 1990;163:1714-5.

27. Tzivoni D, Banal S, Schuger C, et al. Treatment of tor-

sade de pointes with magnesium 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. Am Heart J 1986;112:847-9.

29. Cummins Re, ed. Textbook of Advanced Cardiac Life

Support. Dallas: American Heart Association, 1994:1-17,

1-39.

30. Tsuji H, Venditti FJ, Evans JC, et al. The associations of

levels of serum potassium and magnesium with ventricular

premature complexes. Am J Cardiol 1994;74:232-5.

31. Brodsky MA, Orlov MV, Capparelli EV, et al. Magnesium

therapy in new-onset atrial fibrillation. Am J Cardiol

1994;73:1227-9.

32. Tee KK, Yusuf S. Role ef magnesium 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 magnesium sulphate in suspected acute myocardial infarction: the second Leicester Intravenous Magnesium Trial (LIMIT-2). Lancet 1994;343:816-9.

Mosby-Year Book, 1993.

38. Wacker WEC, Parisi AF. Magnesium metabolism.

N Engl J Med 1968;278:658-63,

712-7, 772-6.

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After completing this offering, the learner will be able to:

1. Explain the physiology of magnesium in the body.

2. Describe the incidence, signs, and symptoms of hypo- magnesemia.

3. Discuss the administration of magnesium in patients with acute asthma, eciampsia, and cardiac dysrhyth- mias.

4. List those patients in whom magnesium therapy is con- traindicated.

5. Outline the side effects of magnesium therapy and the appropriate nursing actions.

June 1996

217

JOURNAL OF EMERGENCY NURSING/Frakes

TESTrl~ M$

1. The article discussed the incidence of diagnosed mag- nesium deficiency. Which of the following statements is

most accurate?

a. Magnesium deficiencies are often identified.

b. A magnesium deficiency was identified in 7% of hospitalized patients.

c. Magnesium deficiencies are present much more of- ten than is recognized.

d. There may be an underlying magnesium deficiency

in 90% of hospital cases.

2. Of the following patients, who is most likely to be mag-

nesium deficient?

a. An insulin-dependent diabetic whose initial symp- tom is a headache

b. A hypertensive patient taking lisinopril (Prinivil) who has breathing difficulty

c. An alcoholic patient with an impaired level of con-

sciousness

d. A woman in her twenty-eighth week of pregnancy who has nausea and vomiting

3. Which of the following most accurately reflects the re-

abnormal magnesium and potas-

lationship

between

sium levels?

a. No correlation has been established.

b. There is an inverse correlation between potassium

and magnesium levels.

c. Nearly half of the time there is a correlation between low potassium and low magnesium levels.

d. There is a direct correlation between potassium and magnesium levels more than 75% of the time.

4. Which of the following best describes EKG changes that occur in response to low magnesium levels?

c. when it occurs in conjunction with chronic illness.

d. when APACHE scores are significantly abnormal.

8. Which of the following is the most accurate statement about magnesium?

a. Low magnesium levels may indicate some underly- ing disturbance inhibiting homeostasis.

b. Chronic illnesses such as hypertension may precip- itate low magnesium.

c. Magnesium therapy should be used only for patients with mild asthma symptoms.

d. Altered magnesium levels have been associated with

environmental pollutants. 9. On the basis of the information presented in the article, which of the following patients with acute asthma is most likely to benefit from administration of magne-

sium?

a. A 6-year-old child with bilateral inspiratory wheezing who tried a home inhaler twice; respirations 40 per minute, oxygen saturation 90%, pulse 120 beats/min

b. A 24-year-old man with wheezing and bilateral decreased breath sounds; respirations 39 per minute, oxygen saturation 85%, pulse 140 beats/min

c. A 56-year-old man with bilateral inspiratory and ex- piratory wheezing; respirations 28 per minute, oxy- gen saturation 91%, pulse 100 beats/min

d. A 32-year-old woman with bilateral wheezing and rales who ran out of medications 3 days ago; respi- rations 32 per minute, oxygen saturation 89%, pulse

92 beats/min 10. On the basis of the information provided in the article, which of the following treatment approaches should a nurse expect to see for a patient with eclampsia?

a. Heart block

a.

Magnesium therapy

b. Conduction slowing

b.

Anticonvulsants

c. Conduction increase

c.

Magnesium therapy with or without anticonvulsants

d. Wandering pacemaker

d.

Anticonvulsants with or without magnesium therapy

5. On the basis of known manifestations, which of the fol-

11. A

22-year-old woman

in the thirty-second week of

lowing would

possible hypomagnesemia?

rate the highest index of suspicion for

a. A 73-year-old man with a history of hypertension who has hemiplegia

b. A 56-year-old woman with a history of seizure disor- der who has focal seizures

c. A 38-year-old woman with a history of multiple scle- rosis who has numbness of the legs

d. A 65-year-old man with a history of diabetes mellitus who has severe cramping pain in the calves of his legs

6. The article indicates that low magnesium levels have an impact on all of the following systems except the:

a. respiratory system.

b. neuromuscular system.

c. cardiovascular system.

d. central nervous system.

7. Which of the following most accurately cor pletes the statement? The mortality potential associated with low

magnesium levels is increased:

a. in all cases.

b. when hypomagnesemia is not corrected.

pregnancy is brought to the emergency department by ambulance after experiencing blurred vision and de- creased sensorium. Her husband noted her speech was

slurred and became concerned. He called 911 when he ceuld not get her out of the easy chair. On assessment

you find the patient conscious and responding verbally

to physical stimulation. Her responses to your questions are appropriate but vague. Her blood pressure is 180/98

mm Hg. She has +4 pitting edema of the ankles. The di-

agnosis of preeclampsia and the initiation of magnesium therapy is primarily based on her:

a. inability to respond verbally and hypertension.

b. hypertension, edema, and stage of pregnancy.

c. pedal edema, sensorium, and speech changes.

d. stage of pregnancy, orientation, and blurred vision.

12. Current treatment recommendations for various ven- tricular dysrhythmias can be best summarized by stat-

ing that treatment with magnesium:

a. is not clearly established.

b. is contraindicated in atrial dysrhythmias.

c. works well with many ventricular dysrhythmias.

d. is recommended for some ventricular dysrhythmias.

13. The preferred magnesium dosing method to treat dys- rhythmias is:

a. bolus.

b. either bolus or infusion.

c. bolus followed by infusion.

d. infusion with or without initial bolus.

QUESTIONS14 AND 15 PERTAINTO THEFOLLOWINGSCENARIO:

You have been asked to administer a 3 gm bolus of magne- sium to a 62-year-old man with torsades de pointes.

14. On the basis of the information provided in the article, how much time would you take to administer the bolus?

a. 2 minutes

b. 4 minutes

c. 9 minutes

d. 15 minutes

15. When monitoring the patient during and after the mag- nesium bolus, which of the following would require im-

mediate response?

Frakes/JOURNAL OF EMERGENCY NURSING

a. Development of nausea

b. Change in the PR interval to 0.24

c. Patient now hyperreflexive

d. Development of notable facial flushing

16. The

recommended

toxicity is:

treatment

to

reverse

magnesium

a. to discontinue the magnesium.

b. variable depending on level of toxicity.

c. the administration of calcium gluconate.

d. administration of calcium channel blockers.

17. Magnesium

administration is absolutely contraindi-

cated for patients:

a. who are nursing mothers.

b. who require paralyzing drugs.

c. who have received thrombolytics.

d. whose P waves are not associated with a QRS com-

plex.

(Answer sheet on page 220)

A Look Bade Kills germs on contact

sheet on page 220) A Look Bade Kills germs on contact Two monumental discoveries during the

Two monumental discoveries during the nineteenth century made modern-day surgery possible: safe anesthesia and control of wound infections. Anesthetics were discovered first and allowed surgeons to perform longer, more intricate operations. The benefits of surgery soon diminished, though, as wound infections soared. Infections were thought to be caused by a chemical reaction between body tissues and air. In ancient times, antiseptics, such as wine and vinegar, were recognized as helpful. Later remedies included tight bandaging of wounds with adhesive materials, such as col- lodion (a solution of gun-cotton in ether and alcohol) and cattle intestine membranes to keep the air out. Unfortunately, as we know today, these practices only made matters worse. The mortality rate from infections ranged from 40% to 60% and sometimes was higher.

Bacteriology evolved into a science during the last quarter of the nineteenth century when a French professor of chem- istry, Louis Pasteur (1822-1895), proved microorganisms in the air and on the hands could produce disease. Joseph Lister (1827-1912), a British surgeon, capitalized on Pasteur's work by using antiseptics during and after surgery to reduce postoperative infections. Lister read that the city of Carlisle rid itself of sewer stench by pouring carbolic acid into the sewer drains. In 1865 he began dipping bandages and ligatures in carbolic acid and pouring the acid into wounds, greatly decreasing the death rate from gangrene. Initially carbolic acid was applied directly onto wounds, but this practice was very irritating to living tissues. However, carbolic acid solutions greatly enhanced asepsis when sprayed onto surgical instruments. Although crude, his method worked, launching the world's first true antiseptic treatment. Many of Lister's colleagues initially scoffed at his approach to antisepsis including, interestingly, Florence Nightingale.--Linda Manley,

RN, BSN, CEN, CCRN

June 1996

219

JOURNAL OF EMERGENCYNURSING/Frakes

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1.O

a

2.O

a

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a

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material? O Yes O No

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clearly?

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