# Magnesium Sulfate in Asthma



## MonkeyArrow (Jun 22, 2016)

Can someone explain the physiology/pharmacology behind why mag sulfate is indicated as a rescue treatment for severe acute asthma? I have read it has bronchodilatory and anti-inflammatory effects but I have never heard of it being used outside of the cardiac context.


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## Carlos Danger (Jun 22, 2016)

Is is a direct smooth muscle relaxant. Same mechanism by which it is an effective tocolytic.


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## Carlos Danger (Jun 22, 2016)

Also an effective analgesic adjunct.


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## TrueNorthMedic (Jun 22, 2016)

I believe it inhibits Ca+ from entering the cell. This causes the smooth muscle relaxant effect. We're getting mag sulfate added to our protocols soon. I've heard it works well.


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## DesertMedic66 (Jun 22, 2016)

I was finally granted orders for it on my last asthma patient. RR in the high 40s and EtCO2 in the 15mmHg range. 

CPAP, albuterol, Atrovent, Mag drip (2gms over 10 mins). Upon arrival at the hospital the patients RR was in the high 20 range and EtCO2 was in the 30mmHg range.


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## Carlos Danger (Jun 22, 2016)

Research actually shows it doesn't help much in refractory asthma.

Still worth trying though, IMO.


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## SeeNoMore (Jun 25, 2016)

I know more Paramedics than I can count who swear by this intervention. In fact, you know the call  was serious when "I got the order for Mag!". They know for sure it helped. Just ask them.   Many of these patients did not receive Epi (IM or otherwise) despite apparently being on death's doorstep. It's all well and good to incorporate new interventions, but you should not automatically prioritize them for no good reason.


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## NPO (Jun 25, 2016)

Remi said:


> Research actually shows it doesn't help much in refractory asthma.
> 
> Still worth trying though, IMO.


We use it quite frequently, and to great success. 

We're 'supposed to' get orders for it, but most medics don't, and use a clause in our protocols that allows us to forego base contact if calling the hospital will delay an immediately needed intervention. 

We even have an employee with known severe asthma. We run on her a few times per year. The only thing that works is mag, and on her it's a first line treatment.


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## Carlos Danger (Jun 25, 2016)

NPO said:


> We use it quite frequently, and to great success.
> 
> We're 'supposed to' get orders for it, but most medics don't, and use a clause in our protocols that allows us to forego base contact if calling the hospital will delay an immediately needed intervention.
> 
> We even have an employee with known severe asthma. We run on her a few times per year. The only thing that works is mag, and on her it's a first line treatment.



I know a lot of people swear by mag.

I'm not saying it doesn't work or that it doesn't have its place, but my understanding is that it is not strongly supported by the literature as compared to other interventions.

I use it liberally in the OR as an analgesic adjunct. As long as the renal function is good there is little risk.


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## Brandon O (Jun 25, 2016)

Remi said:


> I use it liberally in the OR as an analgesic adjunct.



News to me. Can you elaborate?


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## StCEMT (Jul 7, 2016)

I was talking to a student in another program yesterday who said he has used it a few times and it workes really well. I havent used it personally, but I have heard good things about it from others.


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## Nova1300 (Jul 9, 2016)

Brandon O said:


> News to me. Can you elaborate?



There are a handful of relatively well-done, although small, trials looking at post-op opiate consumption in patients given magnesium as a supplemental analgesic.  There is a consistent trend among several of those trials toward a decrease use in opiates and better pain scores with magnesium.  The current thought on mechanism is an augmentation of the NMDA receptor.  

I see little harm and perhaps a good deal of benefit to administration of magnesium in either case.  Although the jury is still out in reactive airway disease, I do think it has some efficacy in analgesia. Hypermagnesemia is uncommon outside of the OB suite where large amounts are given as infusions for tocolysis. While renal failure may decrease clearance of excess magnesium, I have never seen it get to dangerous levels.  It takes a LOT of magnesium to become toxic.  

What we see relatively consistently in the ICU is hypomagnesemia.  There seems to be a brisk washout of magnesium in patients administered crystaloid.  I'm not sure if it's ever been studied, but anecdotally most of my patients will have laboratory evidence of hypomagnesemia post op and many require consistent supplementation during critical illness.  

So I think in most cases the risk-benefit ratio of magnesium administration favors giving it while the jury is still deliberating.


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## Brandon O (Jul 9, 2016)

Interesting stuff, thanks! I wonder if this could be extrapolated to mean that giving mag to an ICU patient under continual sedation may (mysteriously) increase their level of somnolence.


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## Nova1300 (Jul 10, 2016)

Brandon O said:


> Interesting stuff, thanks! I wonder if this could be extrapolated to mean that giving mag to an ICU patient under continual sedation may (mysteriously) increase their level of somnolence.



 I'm sure if you got the serum levels high enough, you would see somnolence and decreased reflexes, as you do when patients in OB get toxic.  However, HYPOmagnesemia can cause a profound muscular weakness and in turn cause failure to liberate from the ventilator and look like oversedation. So really, it can go either way.  You just have to be aware of the symptpms at both ends of the spectrum.  

 The other clinical symptoms of hypomagnesemia are somewhat similar to those of hypocalcemia... chovstek sign, tetany, spasms, etc. and hypomagnesemia and hypocalcemia frequently co-exist.  Same goes for K+.  It's easy to miss if you're not looking.


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## Carlos Danger (Jul 12, 2016)

Brandon O said:


> Interesting stuff, thanks! I wonder if this could be extrapolated to mean that giving mag to an ICU patient under continual sedation may (mysteriously) increase their level of somnolence.



I don't doubt that it could mean that. Anecdotally, I've been using it pretty routinely for maybe my past 15 "big" cases ("big" being relative, of course) and it seems to roughly double the effectiveness of whatever narcotic I use. Today it was a 52 kg patient having a total lap hysterectomy. She was asleep for about 2.5 hours and in that time I gave her a total of 1.4mg of hydromorphone and 3g of mag. I gave 1mg of dilaudid right after induction, and some ketamine a couple min before incision. Then I gave the rest of the dilaudid about halfway through the case, and the mag was given in multiple small boluses spread fairly evenly throughout the case. No local from the surgeon. She woke up looking like she'd had at least 3mg of hydromorphone (actually woke more slowly than I would have liked), and PACU didn't have to give her anything else until her PO med shortly before she was discharged.

I'm not sure how that translates to ICU sedation - never mind the EMS setting - but there may be some application there.

P.S. It causes a very (IME, anyway) noticeable potentiation of neuromuscular blockade, as well.


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## CentralCalEMT (Jul 12, 2016)

Mag (2 Grams a 250 bag of saline run in over 10 minutes) is a standing order here for severe asthma that does not respond to Albuterol, Epi, CPAP, etc. What I have noticed is either the mag works as a wonder drug when nothing else works, or it has absolutely no effect on the patient. I have seen patients in severe distress on death's doorstep go from one word dyspnea to speaking in complete sentences by the time we got to the hospital a couple of times. However, I have had multiple occasions where the patient did not improve at all with the mag drip. I have never seen it cause hypotension which they tell us to watch for. I wonder if there are certain factors/certain populations that research has not yet identified yet that immensely benefit from mag; while for the rest, it does nothing. I do know paramedics that swear by mag. But for me, it has only worked in a few instances.


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## Alan L Serve (Jul 13, 2016)

Epi before Mag.


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## bakertaylor28 (Feb 1, 2017)

CentralCalEMT said:


> Mag (2 Grams a 250 bag of saline run in over 10 minutes) is a standing order here for severe asthma that does not respond to Albuterol, Epi, CPAP, etc. What I have noticed is either the mag works as a wonder drug when nothing else works, or it has absolutely no effect on the patient. I have seen patients in severe distress on death's doorstep go from one word dyspnea to speaking in complete sentences by the time we got to the hospital a couple of times. However, I have had multiple occasions where the patient did not improve at all with the mag drip. I have never seen it cause hypotension which they tell us to watch for. I wonder if there are certain factors/certain populations that research has not yet identified yet that immensely benefit from mag; while for the rest, it does nothing. I do know paramedics that swear by mag. But for me, it has only worked in a few instances.



It works and all in terms of the theory of muscle relaxant properties, but for the fact that Magnesium Sulfate is a mild acid ( pH of approximately 5.5 - 6.5 ) Hence, it would stand that since elevated CO2 tends to cause respiratory acidosis, we wouldn't  want to be making things more acidic. (Think the reasons we use Sodium Bicarbonate in cardiac arrest cases.)


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## NomadicMedic (Feb 1, 2017)

bakertaylor28 said:


> It works and all in terms of the theory of muscle relaxant properties, but for the fact that Magnesium Sulfate is a mild acid ( pH of approximately 5.5 - 6.5 ) Hence, it would stand that since elevated CO2 tends to cause respiratory acidosis, we wouldn't  want to be making things more acidic. (Think the reasons we use Sodium Bicarbonate in cardiac arrest cases.)



Again, where do you come from?

You post some of the most inane content I've ever seen.


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## bakertaylor28 (Feb 1, 2017)

DEmedic said:


> Again, where do you come from?
> 
> You post some of the most inane content I've ever seen.



And you have major issues if you didn't see it coming. Look it up. The general rule of basic underlying thought process is to avoid further acidifying a hypercapnic patient. (Remember that thing about CO2 being an acid?) Of course its a rather old school thought process....that let me guess they don't teach anymore??? And I'm willing to bet that an asthmatic is probably going to be significantly hypercapnic by the time they call us up. Just a hunch. So, Gee, Barbie, why don't you get your panties out of a wad,  apply your lipstick to the right side of your face, and get on with yourself. Because FRANKLY I don't have time for what ever personal agenda you have going on. [Slam door in face HERE]


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## VentMonkey (Feb 1, 2017)

bakertaylor28 said:


> And you have major issues if you didn't see it coming. Look it up. The general rule of basic underlying thought process is to avoid further acidifying a hypercapnic patient. (Remember that thing about CO2 being an acid?) Of course its a rather old school thought process....that let me guess they don't teach anymore??? And I'm willing to bet that an asthmatic is probably going to be significantly hypercapnic by the time they call us up. Just a hunch. So, Gee, Barbie, why don't you get your panties out of a wad,  apply your lipstick to the right side of your face, and get on with yourself. Because FRANKLY I don't have time for what ever personal agenda you have going on. [Slam door in face HERE]


Aren't you the same guy who claimed to be a med student, and now a paramedic? Which one is it? Both? Meh, either way yet another troll banned soon enough. You make absolutely no sense to anyone on here, quit while you're ahead. 


bakertaylor28 said:


> So, Gee, Barbie, why don't you get your panties out of a wad,  apply your lipstick to the right side of your face, and get on with yourself. Because FRANKLY I don't have time for what ever personal agenda you have going on. [Slam door in face HERE]


And to this I say: "Shirley, you can't be serious." The guy is a reputable paramedic respected on here, and you? Well, you're 77 posts in without a single like. Take a hint already, bud.


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## StCEMT (Feb 1, 2017)

How much will a mag drip effect their pH? If it works, they will breathe better. If they breathe better, then they can start breathing off that CO2. So yea, you might add something acidic, but they are better able to compensate for it.


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## VentMonkey (Feb 1, 2017)

StCEMT said:


> How much will a mag drip effect their pH? If it works, they will breathe better. If they breathe better, then they can start breathing off that CO2. So yea, you might add something acidic, but they are better able to compensate for it.


The biggest worry that I was taught, and it isn't anything to take lightly, is hypermagnesemia.  Probably not something you're going to induce with 1-2 grams in a 50-100 NS bag, but definitely worth keeping in the back of your mind. Now riddle me this young padawon:

What's your reversal agent?*

*it's carried in every ALS kit/ gear/ system/ protocol that I know of.


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## bakertaylor28 (Feb 1, 2017)

VentMonkey said:


> Aren't you the same guy who claimed to be a med student, and now a paramedic? Which one is it? Both? Meh, either way yet another troll banned soon enough. You make absolutely no sense to anyone on here, quit while you're ahead.
> 
> And to this I say: "Shirley, you can't be serious." The guy is a reputable paramedic respected on here, and you? Well, you're 77 posts in without a single like. Take a hint already, bud.



Its called being an EMT-P (mostly working special events, extra staffing, sick leave, etc.) While going to med school. I would suggest you familiarize yourself with that concept as that's how things work anymore in order to pay for things, as some of us were not born with the silver spoon in our mouths and hence have to find ways to put extra money in the bank to FUND med school - and unfortunately, minimum wage jobs just don't cut the butter anymore.


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## VFlutter (Feb 1, 2017)

StCEMT said:


> How much will a mag drip effect their pH? If it works, they will breathe better. If they breathe better, then they can start breathing off that CO2. So yea, you might add something acidic, but they are better able to compensate for it.



You can trend ETC02. For every 10 change in PC02 you should get about 0.08 change in ph in the opposite direction. It will be an estimate unless you know the patients actual ETC02/PC02 gradient.


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## bakertaylor28 (Feb 1, 2017)

VentMonkey said:


> The biggest worry that I was taught, and it isn't anything to take lightly, is hypermagnesemia.  Probably not something you're going to induce with 1-2 grams in a 50-100 NS bag, but definitely worth keeping in the back of your mind. Now riddle me this young padawon:
> 
> What's your reversal agent?*
> 
> *it's carried in every ALS kit/ gear/ system/ protocol that I know of.



Calcium Gluconate is the definitive antidote to Magnesium Sulfate.


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## Handsome Robb (Feb 1, 2017)

This is so entertaining. 


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## VentMonkey (Feb 1, 2017)

bakertaylor28 said:


> Calcium Gluconate is the definitive antidote to Magnesium Sulfate.


You must work at one well funded event stand by service, and hardly a silver spoon in my mouth. Last I checked CaCl- was just as effective, lasted longer, and was plenty available and stocked within most ALS protocols. But whatever you say, you're the doctor. You ain't worth a ban hammer, killer.


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## gonefishing (Feb 1, 2017)

VentMonkey said:


> You must work at one well funded event stand by service, and hardly a silver spoon in my mouth. Last I checked CaCl- was just as effective, lasted longer, and was plenty available and stocked within most ALS protocols. But whatever you say, you're the doctor. You ain't worth a ban hammer, killer.


In case he doesn't know or forgot that's Calcium Chloride 

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## bakertaylor28 (Feb 1, 2017)

VentMonkey said:


> You must work at one well funded event stand by service, and hardly a silver spoon in my mouth. Last I checked CaCl- was just as effective, lasted longer, and was plenty available and stocked within most ALS protocols. But whatever you say, you're the doctor. You ain't worth a ban hammer, killer.



It is true that the two are pretty well bio-equivalent. However, We also optimally don't want to be overdoing the chloride ion, either. Remember that since NS is a chloride and in practice there is a sizable list of drugs that are compounded as clorides, we will end up eventually raising the chloride levels in the CMP to some degree or another. (which can cause dehydration, diarrhea, vomiting, and kidney failure, among other things, if the chloride level is raised enough.) Hence, the reasoning behind the Gluconate instead of the chloride, but either way.


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## gonefishing (Feb 1, 2017)

bakertaylor28 said:


> It is true that the two are pretty well bio-equivalent. However, We also optimally don't want to be overdoing the chloride ion, either. Remember that since NS is a chloride and in practice there is a sizable list of drugs that are compounded as clorides, we will end up eventually raising the chloride levels in the CMP to some degree or another. (which can cause dehydration, diarrhea, vomiting, and kidney failure, among other things, if the chloride level is raised enough.) Hence, the reasoning behind the Gluconate instead of the chloride, but either way.


Your service has this at hand?..... 

Sent from my SM-G920P using Tapatalk


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## TXmed (Feb 1, 2017)

Getting back on topic instead of the bickering match.

I have used Mag for asthma several times and i believe it works well. Although i encourage everyone to go to epi (IM or inhaled) early and often. I believe prehospital we use Mag,epi, and CPAP too late and would better served using it early rather than later. It is always better to be active rather than reactive. it does not bother me when a receiving doctor says "that was a little overkill dont ya think?". 

As far as the hypermagnesia i believe (not certain) it is more of a concern for higher dosages than 50mg/kg or for longer use such as eclampsia with mag drip lasting several hours rather than 1-2grams over 10-20minutes.

* DISCLAIMER* i have never treated nor caused hypermagnesia


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## VFlutter (Feb 1, 2017)

TXmed said:


> As far as the hypermagnesia i believe (not certain) it is more of a concern for higher dosages than 50mg/kg or for longer use such as eclampsia with mag drip lasting several hours



Agreed. Never happened to me personally but It has happened on our HROB transfers a few times.


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## VentMonkey (Feb 1, 2017)

TXmed said:


> Getting back on topic instead of the bickering match.
> 
> I have used Mag for asthma several times and i believe it works well. Although i encourage everyone to *go to epi* (IM or inhaled) early and often. I believe prehospital we use Mag,epi, and CPAP too late and would better served using it early rather than later. It is always better to be active rather than reactive. it does not bother me when a receiving doctor says "that was a little overkill dont ya think?".
> 
> ...


I like it too and have had similar success at times. As far as Epi goes, any adult 40 plus years of age with the co-morbidities who also smoke doesn't get it.

I'll forego the Epi in favor of the in-line DuoNeb and a Mag. gtt, time permitting refractory to CPAP and DuoNebs alone.


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## TXmed (Feb 1, 2017)

VentMonkey said:


> I like it too and have had similar success at times. As far as Epi goes, any adult 40 plus years of age with the co-morbidities who also smoke don't get it.
> 
> I forego the Epi in favor of the in-line DuoNeb and a Mag. gtt, time permitting refractory to CPAP and DuoNebs alone.



Ive had some good success with inhaled epi early. example being a person who has used their albuteral inhaler several times and calls, ill use inhaled epi and follow it with an A&A if need be. 

as far as the epi in the 40+ patients, i understand the thought behind the contraindication but see it more as something to take into account. if their respiratory status is to the point i wanna give epi then i believe (as well as my MD) that the risk/benefit leans more towards epi being used. i might reduce my dose or what just a little longer to give it (we dont carry terb). but if need be i will give it, especially to help avoid RSI (which is hard on the heart).


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## Carlos Danger (Feb 1, 2017)

bakertaylor28 said:


> It is true that the two are pretty well bio-equivalent. However, We also optimally don't want to be overdoing the chloride ion, either. Remember that since NS is a chloride and in practice there is a sizable list of drugs that are compounded as clorides, we will end up eventually raising the chloride levels in the CMP to some degree or another. (which can cause dehydration, diarrhea, vomiting, and kidney failure, among other things, if the chloride level is raised enough.) Hence, the reasoning behind the Gluconate instead of the chloride, but either way.



Is that really the reasoning behind Ca gluconate vs. Ca choride?

What happens to the chloride ion in the body?



bakertaylor28 said:


> It works and all in terms of the theory of muscle relaxant properties, but for the fact that Magnesium Sulfate is a mild acid ( pH of approximately 5.5 - 6.5 ) Hence, it would stand that since elevated CO2 tends to cause respiratory acidosis, we wouldn't  want to be making things more acidic. (Think the reasons we use Sodium Bicarbonate in cardiac arrest cases.)



Does elevated C02 cause respiratory acidosis?

Does that fact that a drug comes packaged in a mildly acidic formulation mean that it will actually decrease the serum pH? If so, how much would 4ml (2g) of mag at a pH of 5.5 be expected to change the serum pH?

Is this affected at all by the IVF you are using, and the rate that it is running at?

If the patient has good renal function (most asthmatics probably do), how does that factor in?

What can we do for an asthmatic patient to decrease their metabolic demand and C02 production?

Do we actually use sodium bicarb in arrest?

Why not just give sodium bicarb with the mag?


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## Carlos Danger (Feb 1, 2017)

double post


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## StCEMT (Feb 1, 2017)

VentMonkey said:


> The biggest worry that I was taught, and it isn't anything to take lightly, is hypermagnesemia.  Probably not something you're going to induce with 1-2 grams in a 50-100 NS bag, but definitely worth keeping in the back of your mind. Now riddle me this young padawon:
> 
> What's your reversal agent?*
> 
> *it's carried in every ALS kit/ gear/ system/ protocol that I know of.


Calcium, but admittedly I don't remember the science as to why. I will look it up once I get out of class.



Chase said:


> You can trend ETC02. For every 10 change in PC02 you should get about 0.08 change in ph in the opposite direction. It will be an estimate unless you know the patients actual ETC02/PC02 gradient.


Good to know. I wish I had a way to see this first hand to solidify the idea.


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## VentMonkey (Feb 1, 2017)

StCEMT said:


> Good to know. I wish I had a way to see this first hand to solidify the idea.


Here's a quick tutorial with some relevance...


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## Handsome Robb (Feb 1, 2017)

VentMonkey said:


> Here's a quick tutorial with some relevance...



ROME is the only reason I can understand ABGs.


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## VFlutter (Feb 1, 2017)

StCEMT said:


> Good to know. I wish I had a way to see this first hand to solidify the idea.



A down and dirty example...

You pick up a IFT patient that was intubated for respiratory failure. Their ABG is something like this.

pH 7.16
PC02 70
ETC02 65 

You put them on the ventilator with appropriate settings and monitor their ETC02, by the time you get to the receiving facility their ETC02 is now 45. So you changed their ETC02 by 20 (which should equal a PC02 of 50). So for each 10 change in C02 the pH should change 0.08 in the opposite direction. So for this patient it should change by 0.16 (0.8x2) You drove the c02 down so the pH should go up. When they draw a blood gas the patients pH should be 7.32 (7.16+0.16). If you wanted the patient to have a perfect pH of 7.40 then you would have to decrease their c02 another 10. If that makes sense.


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## TXmed (Feb 1, 2017)

@VentMonkey i use ABA/BAB its a little too lengthy to explain on here. But ROME was nice to learn, thanks for sharing.


Since we are talking ABG's i also encourage people to research permissive hypercapnia.
Essentially we hurt asthmatics and copd'ers by striving for normocapnia. When a PCO2 of up to 80 (although i strive for less than 70) can be well tolerated with the absence of metabolic acidosis.

And with patients of other illness a slightly elevated CO2 can be beneficial. Example: ROSC patients get better cerebral blood flow when their CO2 is between 45-60. 

But it is not for everyone.


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## VentMonkey (Feb 1, 2017)

Now we're getting back on topic, thanks @TXmed. The article is over 10 years old, but it's still pertinent to protective lung strategies as far as I know...
https://www.ncbi.nlm.nih.gov/m/pubmed/15659946/


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## TXmed (Feb 1, 2017)

Also a elevated co2 encourages patients to breath, so if you have a patient triggered ventilator you can just assist their breath. 

I say assist because ive seen people freak out about patients begining to "overbreath" amd move to massive sedation and paralytic instead of treating a little anxiety and a little pain and just let the patient drive themselves


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## VentMonkey (Feb 1, 2017)

TXmed said:


> Also a elevated co2 encourages patients to breath, so if you have a patient triggered ventilator you can just assist their breath.
> 
> I say assist because ive seen people freak out about patients begining to "overbreath" amd move to massive sedation and paralytic instead of treating a little anxiety and a little pain and just let the patient drive themselves


But would you agree this is patient/ physiological demand dependent? 

While encouraging a patient to overbreathe when the end goal is weaning is one thing. The acutely intubated patient may stand to benefit from a little bit of mechanical dependency, at least in the beginning phases (e.g., out of hospital/ scene) of ventilator management.


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## TXmed (Feb 1, 2017)

VentMonkey said:


> But would you agree this is patient/ physiological demand dependent?
> 
> While encouraging a patient to overbreathe when the end goal is weaning is one thing. The acutely intubated patient may stand to benefit from a little bit of mechanical dependency, at least in the beginning phases (e.g., out of hospital/ scene) of ventilator management.



Yes i agree with that, that is why i prefer using roc instead of sucs. Usually by the time roc has worn off i have established my treatment plan and ventilator strategy and thus they gradually come out of ventilator dependence. In the shorter term, and immediate treatment, i am mainly concerned with air trapping so as long as the SPO2 is adequate i will pop the vent/BVM off from time to time and push on their chest.

Our flight times range from 30min to an hour and a half so i have time to do this prior to getting to the hospital.


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## bakertaylor28 (Feb 1, 2017)

Remi said:


> Is that really the reasoning behind Ca gluconate vs. Ca choride?
> 
> What happens to the chloride ion in the body?
> 
> ...



To address your points (not in any particular order):
1. Not so much what happens to the chloride ion, its the fact of the body being able to do it quick enough to maintain state Vs. what we're infusing. Infusing considerable amounts of NS on its own has been known to do this sort of thing, but we have to remember that there are ALOT of drugs out there that are chloride salts. (Things like Ringer's lactate, if my mind serve me correctly are basic and will mitigate the acidosis.).
2. Its basic theory CO2 causes acidosis when it builds up- CO2 itself is an ACID.  Using Bicarb during an arrest was old-school protocol under the notion of correcting the acidosis caused by CO2 however, its fallen out of style in practice. (most probably because acidosis hasn't been systematically shown to correlate to isoelectric function of cardiac cells directly- though I'd tend to think that letting cells sit in their own waste product doesn't help things much.) However, if I remember correctly it has remained in the ACLS guidelines over the years, though anymore tends to be used after the code has been running a considerable length of time.
3.  Even if our patient has good kidney function we certainly don't want to do anything that tends to promote renal failure.
4. Decreasing metabolic demand is probably a discussion thread in and of itself. One we're not having today.
5 . If we were to use bicarb to neutralize mag, we would end up producing significant heat without having a catalyst to control the speed of the reaction. And most likely will still end with unreacted bicarb - assuming that we don't consider that the two are likely going to react to form a third salt.
6. With reference to your point as to a mild acid altering serum pH it's not as straight forward as it appears. It depends upon (A) what the serum pH is to begin with (as the more acidic a solution is the less buffer it has) (B) How many hydrogen atoms are involved in the equation. among other things. Your probably not going to be able to work a chemical equation out to enough precision without doing the kind of math that is a leading confirmed cause of migraine headaches.


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## TXmed (Feb 1, 2017)

bakertaylor28 said:


> And FYI, VentMonkey, I'm not here to give you, nor anyone else, a rim job. so I could really care less about what you nor anyone else "likes". Put that in your pipe and smoke it, buddy.



Damn bruh, you do realize you can just log off or ignore cyber bullying right ?


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## VFlutter (Feb 1, 2017)

bakertaylor28 said:


> And FYI, VentMonkey, I'm not here to give you, nor anyone else, a rim job. so I could really care less about what you nor anyone else "likes". Put that in your pipe and smoke it, buddy.



You are going to have a great time in residency.


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## TXmed (Feb 1, 2017)

well lets not let this stop the thread. 

*Takes ritalin with red bull*

there is sooo much to talk about besides just mag drips, such as effectiveness of ketamine in non sedation dosages for asthma, questionable effectiveness of inline nebulizers for intubated patients, and have been itching to mention (although i cant remember where its from) i recently read a study that asthmatics have shown better outcomes with earlier RSI and effective ventilator stategies.


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## FLMedic311 (Feb 1, 2017)

bakertaylor28 said:


> To address your points (not in any particular order):
> 1. Not so much what happens to the chloride ion, its the fact of the body being able to do it quick enough to maintain state Vs. what we're infusing. Infusing considerable amounts of NS on its own has been known to do this sort of thing, but we have to remember that there are ALOT of drugs out there that are chloride salts. (Things like Ringer's lactate, if my mind serve me correctly are basic and will mitigate the acidosis.).
> *Your mind does not serve your correctly...*
> 
> ...


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## VentMonkey (Feb 1, 2017)

bakertaylor28 said:


> And FYI, VentMonkey, I'm not here to give you, nor anyone else, a --- ---. so I could really care less about what you nor anyone else "likes".


Yeah, I have nothing more to say other than clearly you're the bigger person.


TXmed said:


> Damn bruh, you do realize you can just log off or ignore *cyber bullying* right ?


This made me laugh just a little inside; the context, not the definition itself.


TXmed said:


> n the shorter term, and immediate treatment, i am mainly concerned with air trapping so as long as the SPO2 is adequate i will pop the vent/BVM off from time to time and push on their chest.


I was just revisiting Bauer's YouTube channel about this technique with patients prone to "breath stacking". Again, the asthmatic/ COPD (obstructive) patient. Our scene flights aren't typically that long.

As an aside, the ASV mode that the T1 offers is phenomenal for just about every patient besides the barotrauma prone patient with a chest tube and high potential for an air leak, or the met. acidotic patient (e.g., DKA/ salicylate OD). It's quite literally adapts to the patients needs, and/ or physiological demands from PRVC, SIMV, to CPAP if they begin to spontaneously breathe. It's our go to "scene call" mode post-RSI.


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## TXmed (Feb 1, 2017)

I have heard good things about ASV. I have no experience and have read only a little about it.


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## VentMonkey (Feb 1, 2017)

TXmed said:


> I have heard good things about ASV. I have no experience and have read only a little about it.


It's definitely a fascinatingly adaptive mode, as the name implies; the dynamic lung is merely a cool added bonus. We're waiting (impatiently) on our vent mount though. Here's a pretty down and dirty breakdown on it (page 2). Side note, that's my partner, lol. He's a cool cat; super smart, too.

http://hallamb.com/wp-content/uploads/2017/01/HallMark-JanFeb2017-web.pdf


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## CALEMT (Feb 1, 2017)

StCEMT said:


> How much will a mag drip effect their pH?



About as much as normal saline. Around the same pH. 

While I'm going to admit that I haven't read every single post on here yet and the fact that I'm still learning the pathophysiology associated with interventions acidosis is something to consider, but not on the top of my list. I'm more worried about the progressively worsening airway. Like Desertmedic66 said, mag sulfate we have to call for a base order and I've never seen it used but I have heard the wonder stories of it.


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## TXmed (Feb 1, 2017)

VentMonkey said:


> It's definitely a fascinatingly adaptive mode, as the name implies; the dynamic lung is merely a cool added bonus. We're waiting (impatiently) on our vent mount though. Here's pretty down and dirty breakdown on it (page 2). Side note, that's my partner, lol. He's a cool cat; super smart, too.
> 
> http://hallamb.com/wp-content/uploads/2017/01/HallMark-JanFeb2017-web.pdf



several questions

1. how much was the cost?

2. surely the dynamic lung cannot give you an accurate representation with anyone with a lung pathologies (in asthma not every part of the lung is as obstructed as the next so air is introduced unequaly in ppv)? im guessing it is just a visual representation of the tidal volume/PIP/inspiratory time together?


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## VentMonkey (Feb 1, 2017)

TXmed said:


> several questions
> 
> 1. how much was the cost?
> 
> 2. surely the dynamic lung cannot give you an accurate representation with anyone with a lung pathologies (in asthma not every part of the lung is as obstructed as the next so air is introduced unequaly in ppv)? im guessing it is just a visual representation of the tidal volume/PIP/inspiratory time together?


Cost per unit I couldn't tell you off hand; short answer? Not cheap. As far as the dynamic lung features. It adapts to the lung compliance, e.g., if the patient has ARDS it will represent as a "boxier" shape, vs. a "healthy" patient which looks more rounded. Here's a better breakdown @TXmed:

https://www.hamilton-medical.com/en...LTON-T1.html?gclid=COuC6Oew8NECFca4wAodamkDdg


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## TXmed (Feb 1, 2017)

@VentMonkey wow impressive, i will remain skeptical till i try it myself, though very interesting thank you.


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## VentMonkey (Feb 1, 2017)

TXmed said:


> @VentMonkey wow impressive, i will remain skeptical till i try it myself, though very interesting thank you.


NP, I've found skepticism can often be the 
mark of an open-minded person; I remain the same with many things myself. 

It's a fairly new concept in The States, and definitely reflects how far we've come in regards to ventilatory management.


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## Nova1300 (Feb 2, 2017)

Ummmmm, what in the hell is going on in this thread?  

 And who wrote this kid's physiology textbook?


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## Handsome Robb (Feb 2, 2017)

Nova1300 said:


> And who wrote this kid's physiology textbook?



Dr. Oz. 


Sent from my iPhone using Tapatalk


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## akflightmedic (Feb 2, 2017)

As an acute observer of human behavior, there is a distinct difference in writing style when one is spewing medical knowledge/jargon versus when they ad lib at the end or in a separate post. Hence...I smell pseudomedicitis with possible pseudodocitis secondary infection.


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## VentMonkey (Feb 3, 2017)

akflightmedic said:


> I smell *pseudomedicitis* with possible *pseudodocitis* secondary infection.


Lol, too awesome not to highlight. Nothing a little realitychecktol can't keep at bay.


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## akflightmedic (Feb 3, 2017)

You forgot "hence"....when articulated or placed properly, it automatically spikes the intelligence and validity of one's post, hence I use it often.


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## NomadicMedic (Feb 3, 2017)

Almost as pretentious as "whilst"


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## VentMonkey (Feb 3, 2017)

_Whilst_ your point is well taken, _hence_forth I shall heed this warning when articulating the level of my intelligent posts.


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## Bullets (Feb 9, 2017)

We have mag in our standing orders, but it is behind Nebs, Solumedrol, and epi. IF were on Mag (and we have brethine in the same line) things are going poorly. I have found that it seems to improve patients, but with the proliferation of CPAP at the BLS level, we are using it less than before.

And FWIW, we carry calcium gluconate, our MD says he likes it better for hypermag


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## E tank (Feb 9, 2017)

I think that at least some of subjective improvement folks see after MgSo4 in these patients is a sedation effect just by the reduction of the distress of not being able to breathe. 

sorry if that had been pointed out already....quit reading most of the posts.


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## VentMonkey (Feb 17, 2017)

Here's a solid lecture from Bauer re: metabolic vs. respiratory acidosis vs. mixed disturbances and some of their common treatment therapies:

https://itunes.apple.com/us/podcast/the-flightbridgeed-podcast/id595147712?mt=2&i=1000378831541


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## RocketMedic (Feb 23, 2017)

Anecdotally, IM epi, CPAP and Mag worked wonders on a bad asthma last week.


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## Tigger (Feb 23, 2017)

RocketMedic said:


> Anecdotally, IM epi, CPAP and Mag worked wonders on a bad asthma last week.


What led you to add Mag to that? I feel like most of the reactive airway patients I put on CPAP usually still sound pretty tight, but generally so long as their SpO2 and end tidal (among others) normalize I'm ok.


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## RocketMedic (Feb 23, 2017)

Oh, we can't add it here....our medical director doesn't believe in it. But it worked well at the hospital


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