# Asthma - Magnesium vs. Epi.



## NYMedic828 (Jun 19, 2012)

So what's the more "practical" move when treating a patient.

Both of my partners tend to want to go right to 0.3mg 1:1000 epi IM when we have a severe asthmatic. (unless they are particulary elderly)

Usually give decadron along with that, and nebulizer treatment.

Our protocols also allow for 2g of magnesium sulfate IV drip over 10 minutes, but very few people ever utilize it. Granted it takes time to mix and set up vs. just sticking them in the shoulder. Any time I see a bad asthmatic in the ER, excluding pediatrics they usually put them on a magnesium drip.

So what's really the better way to go? With short transport times like we have in NYC is it really viable to start a mag drip?


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## usalsfyre (Jun 19, 2012)

They work via different pathways, it's not really a "one or the other" situation. For truly severe asthma they likely need both


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## the_negro_puppy (Jun 19, 2012)

If Imminent arrest/silent chest etc

I.M Adrenaline

Secure IV access

IV Magnesium
IV Hydrocortisone 
IV Ventolin/Salbutamol
Consider atrovent and further nebulised ventolin upon improvement


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## Cawolf86 (Jun 19, 2012)

I used to work in a system where we had Mag Sulfate available. I always had great success with using Mag and Epi on asthmatic adults that were beyond Albuterol and needed more immediate relief. 

I had less pharmacological choices than thenegropuppy but I followed a similar path with my medications. Immediate IM Epi while partner applies albuterol/O2 and gets IV access. Followed by the 2 grams Mag IV if no immediate change is seen.

My understanding of their pathways is basic but I do know that studies I have read generally refer to the use of Mag with Epi, Steroids, and/or Beta-2 agonists.

http://www.ccmcresidents.com/wp-content/uploads/2011/03/cochrane-review-on-Mag.pdf

Inducing a state of hypermagneseamia has been shown to cause smooth muscle relaxation - including the small bronchioles. Studies show it has benefits in severe asthma and limited effect in mild to moderate asthma.


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## Doczilla (Jun 19, 2012)

Magnesium is a natural calcium channel blocker. Calcium is needed for all contractions in the somatic nervous system, as well as playing a role in bronchial smooth muscle tone. So we can extrapolate how it controls brochospasm, as opposed to the sympathomimetics, which oppose the action of acetylcholine. (Notice I didn't say BLOCKS, which is where ipatropium comes in. ) 

The three principal characteristics of asthma are bronchospasm, secretions, and inflammation, which is where steroids come in. 

Im suprised that some systems use decadron for this, since solu medrol has faster dissemination into tissues. Thats why some docs use it for blunt spinal trauma.


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## Smash (Jun 19, 2012)

Doczilla said:


> Im suprised that some systems use _dexamethasone _for this, since _methylprednisolone_ has faster dissemination into tissues. Thats why some docs use it for blunt spinal trauma.



Fixed that so everyone else doesn't have to google trade names...

The med references I have give dexamethasone as having onset of 1 hour for IM, and 30 minutes for IV administration compared with methylprednisolone at 2 hours for IM and 30 - 60 minutes for IV.

Puppy, do you use much IV salbutamol?  Do people like using it?


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## CANMAN (Jun 19, 2012)

Agree with sick asthma patients need both if your transport time permits. Also something most providers will fail to do is adequately give fluids. NS boluses do asthmatics well, esp. children.


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## mycrofft (Jun 19, 2012)

Given average response time to receiving facility, how would they prefer to get the pt, with the IV running, or not?
Asthma kills. Epi first and follow with rescue MDI enroute unless the other tx/Rx are in use that fast and they are contraindicated with Albuterol (Salbutamol) etc. 
Get med info from pt as well, often often often even long-term asthmatics are misusing their meds so their hx and their pharmacologic state may be hanky. Many instances where people are using steroid  inhalers a rescue inhalers, nor part of an asthmatic rescue routine.


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## the_negro_puppy (Jun 19, 2012)

Smash said:


> Fixed that so everyone else doesn't have to google trade names...
> 
> The med references I have give dexamethasone as having onset of 1 hour for IM, and 30 minutes for IV administration compared with methylprednisolone at 2 hours for IM and 30 - 60 minutes for IV.
> 
> Puppy, do you use much IV salbutamol?  Do people like using it?



I don't/haven't used it, at our ACP (advanced care paramedic) level we only given nebulised salbutamol. However our intensive care paramedics (ICPs) carry the drug and do use it for severe asthma. I have not seen it used myself but have heard anecdotally that it works quite well. The main benefit I can see is being able to administer with minimal air movement/silent chest as opposed to the nebulised route

The IV dosage given is 250 mcg q5 max total dose 1mg/1000mcg


Apparently the FDA does not allow IV salbutamol/ventolin in the US?


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## TransportJockey (Jun 20, 2012)

Used Mag once and loved it. Much better than Epi, especially as my minimum code 3 transport time to any hospital is 25 minutes or more. But since we can't get our hands on any mag at all right now, we've gone to giving Solumedrol, continuous albuterol nebs, and possibly nebulized epi if the situation warrants it.


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## Handsome Robb (Jun 20, 2012)

TransportJockey said:


> Used Mag once and loved it. Much better than Epi, especially as my minimum code 3 transport time to any hospital is 25 minutes or more. But since we can't get our hands on any mag at all right now, we've gone to giving Solumedrol, continuous albuterol nebs, and possibly nebulized epi if the situation warrants it.



No duoneb? We don't carry 
steroids "the transport times are too short for it to be reasonable" which is generally true but we do have areas that you could end up driving code for 40+ minutes although it's rare we run priority 1 calls without HEMS on an airborne or at minimum a ground (rare) standby when we get out that far. We do have mag but no protocol for it when it comes to reactive airway diseases.

We do albuterol, duo, duo, then continuous albuterol. IM epi if it's warranted then IV epi on standing orders if something real bad is happening.

I've never had an asthmatic/breather bad enough to get to the point of using epi and never seen mag used so I can comment on a personal preference.


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## Veneficus (Jun 20, 2012)

Doczilla said:


> Magnesium is a natural calcium channel blocker. Calcium is needed for all contractions in the somatic nervous system, as well as playing a role in bronchial smooth muscle tone. So we can extrapolate how it controls brochospasm, as opposed to the sympathomimetics, which oppose the action of acetylcholine. (Notice I didn't say BLOCKS, which is where ipatropium comes in. )
> 
> The three principal characteristics of asthma are bronchospasm, secretions, and inflammation, which is where steroids come in.
> 
> Im suprised that some systems use decadron for this, since solu medrol has faster dissemination into tissues. Thats why some docs use it for blunt spinal trauma.



Additionally it has properties which block t-cell ICAMS and division.

Mag has a variety of effects.


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## Doczilla (Jun 20, 2012)

Yeah the only parenteral B2 agonists that I've seen in the US is terbutaline, puppy. And I've only seen that in one SOP so far.


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## Veneficus (Jun 20, 2012)

the_negro_puppy said:


> Apparently the FDA does not allow IV salbutamol/ventolin in the US?



It is not that it is not allowed, but the local effect as well as the mix with saline that is supposed to help with mucous secretion is consdered preferable. 

Haven't seen a massive amount of evidence suggesting it is better myself.


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## WestMetroMedic (Jun 20, 2012)

We recently took Epi out of our protocols for asthma and moved mag from "ask first" to standing order, but our first intervention for asthma is SQ Terbutaline.  Followed by 2 rounds of Albuterol/Atrovent nebs.  If they do not respond to that, then you start cooking with gas and give 1 gram of mag diluted in 10 ml over 1 min.  We also added in CPAP to our protocol, but i'm mixed on CPAP in asthma, i've seen it go both ways.

For an apneic patient, they actually moved Epi from a standing order, to an "ask first" med.  I can't remember the science behind it because there was something shiny in the room that was distracting me while they explained it, but I guess there is good research suggesting Epi may not be the best option.  It is still a great med for anaphylaxis obviously, but its a different pathology than asthma.

I haven't used the asthma protocol since our new guidelines came out 2 weeks ago, but i'm excited to try out mag.


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## CANMAN (Jun 20, 2012)

TransportJockey said:


> Used Mag once and loved it. Much better than Epi, especially as my minimum code 3 transport time to any hospital is 25 minutes or more. But since we can't get our hands on any mag at all right now, we've gone to giving Solumedrol, continuous albuterol nebs, and possibly nebulized epi if the situation warrants it.



You guys use racemic or nebulized epi for asthma???? Continous Albuterol > Nebulized Epi for asthmatics in my opinion/experience. Racemic/Neb epi is better utilized for croup and or bronchiolitis. 

In my service >35kgs gets a round of 15mg Albuterol over an hour, Epi 1:1,000, Mag 75mg/kg, NS bolus, SoluMedrol 2mg/kg, and Terb gtt if needed and no improvement with above interventions.


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## OzAmbo (Jun 20, 2012)

Interesting about the ditching IMI adrenaline for Mag, i bet i can get my IMI adrenaline in before you get your mag infusion set up 

Corticos make no difference pre-hospitally, but the reduction in length of hospital stay and mortality is hwere its at, 10 bucks of dexemethesone saves a few grand on the medical ward.

Does anyone here use PMDI inhalers for those with acute asthma but with adequate ventilation?


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## WestMetroMedic (Jun 20, 2012)

Yes, Epi is much quicker.  No contest, but is it the most correct tool for the job, research that I can't cite right now being on my phone, is indicating no.  

Magnesium isn't our first line med either.  It can have consequences and should be properly appreciated.


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## mycrofft (Jun 20, 2012)

I apologize for the unfortunate spellcheck-addled typos above.


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## TransportJockey (Jun 20, 2012)

CANMAN13 said:


> You guys use racemic or nebulized epi for asthma???? Continous Albuterol > Nebulized Epi for asthmatics in my opinion/experience. Racemic/Neb epi is better utilized for croup and or bronchiolitis.
> 
> In my service >35kgs gets a round of 15mg Albuterol over an hour, Epi 1:1,000, Mag 75mg/kg, NS bolus, SoluMedrol 2mg/kg, and Terb gtt if needed and no improvement with above interventions.



Its one we can ask for if needed but I've never done it. I have to call for orders per nm state scope for Albuterol over 10mg during transport. But most docs will give it to my service due to transport length. No terb or mag here... mag we can't get and terb is not in state scope


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## Akulahawk (Jun 20, 2012)

A medic I learned from (way back when) used to somewhat regularly transport a patient that was allergic (or some similar deal) to albuterol. It was a known contraindication for that patient. Instead of using neb albuterol, they would have to call for an order to nebulize terbutaline. They were never refused once the base doc understood the issue. Yes, this patient was an asthmatic and pretty much always had their own terbutaline 'bullets' available for the Paramedics to put into their nebulizer. 

Upon reviewing Sacramento Protocols, it appears that Mag sulfate is no longer available for anything. Then again, most of the time, our transport times are short enough that even if it were in our protocols, we're rarely use it.


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## Handsome Robb (Jun 20, 2012)

Akulahawk said:


> A medic I learned from (way back when) used to somewhat regularly transport a patient that was allergic (or some similar deal) to albuterol.



Don't even get me started. 

We have a "patient" here who's "allergic" to albuterol but can somehow tolerate duonebs...so she got her own protocol written for her. 

Not saying it isn't real but hearing those two words in the same sentence strikes a nerve haha.


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## Akulahawk (Jun 20, 2012)

NVRob said:


> Don't even get me started.
> 
> We have a "patient" here who's "allergic" to albuterol but can somehow tolerate duonebs...so she got her own protocol written for her.
> 
> Not saying it isn't real but hearing those two words in the same sentence strikes a nerve haha.



This patient actually _was/is_ allergic to it... I just don't remember the specifics about the "why" behind it. This patient couldn't tolerate duoneb. I don't recall if they had Atrovent available, if they did, they may have started the patient on that while getting the order for nebulized terbutaline. That was one reason we were educated about other meds (Beta-adrenergic agonists (albuterol, epinephrine, isoproterenol, metaproterenol, and terbutaline), though we concentrated mostly on albuterol as that was what was in all the local protocols, and therefore was what was carried on all the ALS units.


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## Handsome Robb (Jun 23, 2012)

Akulahawk said:


> This patient actually _was/is_ allergic to it... I just don't remember the specifics about the "why" behind it. This patient couldn't tolerate duoneb. I don't recall if they had Atrovent available, if they did, they may have started the patient on that while getting the order for nebulized terbutaline. That was one reason we were educated about other meds (Beta-adrenergic agonists (albuterol, epinephrine, isoproterenol, metaproterenol, and terbutaline), though we concentrated mostly on albuterol as that was what was in all the local protocols, and therefore was what was carried on all the ALS units.



I'm sure she was. It's absolutely possible. Sorry that was me ranting about a specific frequent flyer in our system who pretty much burned her bridge with every medic in our system when she pulled a handgun on a crew. 

I'll admit that while we covered beta agonists other than albuterol in school I definitely need to put more time in on learning them to be more familiar. I hate hearing a med and it ringing a bell but not remembering what it is.


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