versed vs mag for postpartum eclampsia.

NomadicMedic

NomadicMedic

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Thoughts on midazolam vs mag for a postpartum eclamptic seizure?

Last night, I had a 35 year old that was 2 weeks postpartum, had a first time seizure in the morning and went to the local CAH. They prescribed lisinopril (?) and sent her home. She had another seizure witnessed by her husband a few hours later and he called EMS. I got there, found her postictal, pressure was about 140/90. I decided to transport the 40 minutes to the city hospital, as she would have wound up there eventually. She became more cognizant as the transport went on and we had a conversation. Then she had another tonic/clonic seizure. I gave her 5 of versed IV, placed an NPA, suctioned her, 10lpm of oxygen via NRB. About 8 minutes to the ED from that point.

She wound up RSIed and the doc was a little pissy that I used versed instead of mag. (And that I didn't tube her, but she was totally protecting her own airway.)

My "at the time" thought? We carry mag in 1G vials, so I would have needed to draw up four and slow push it over a few minutes, or I could just grab Versed and go.

Thoughts?
 
How interesting. I've never seen a patient fit with eclampsia, and I am told, in the entire country, as an ambulance service, there might be one per year if it's a bad year otherwise could go years without seeing one.

They are included in the standard guideline which is midazolam and valproate. Unless there is any evidence magnesium is vastly superior and worth the extra trouble of carrying it, replacing it and administering something different for a specific presentation of an otherwise not uncommon set of patients then I don't think it's worth the effort to be honest.
 
Our protocols list for us to consider it up to 4 weeks post.

We can give a divided dose IM (5gms) or hang it as a 5gm/10ml over 10 mins drip.
 
I believe 5G IM is the new preferred method per the clinical coordinator id our L&D.

If the Versed worked I would roll with that.

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For what it's worth, we have benzos ahead of mag in our OB protocol. I believe she would still fit into that protocol, because preeclamptic seizures can occur up to six weeks postpartum.

And for seizure, it's still 4g slow push for me. I've not seen it recommended as IM anywhere.
 
I think we still use a very outdated 2mg drip and have to call for orders.

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I am no OB expert but the majority of literature I have seen recommends Magnesium as the first line treatment and Benzos second for refractory seizures. In my mind Magnesium is treating the cause and the problem where as Benzos are just attempting to control the problem. There are a few studies comparing Mag vs Benzos in prepartrum eclampsia and Mag has better outcomes for both mother and baby. I would assume that would hold true in postpartum eclampsia (LPPE) which can be tricky and lead to complications such as PRES.

On a side note don't be that guy who intubates the the mom on a magnesium drip instead of giving calcium. It probably happens more than you think.
 
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Even in my OB/eclampsia protocol, it calls for benzos first.
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Our protocol for active seizures in eclampsia is Mag Sulgate 4g IV bolus then 2g/hr infusion or Phenytoin. Then Lorazepam for refractory seizures. I will try to get a copy of our High Risk OB teams protocol but I would assume it is the same. I do not have any good OB specific books to reference but my google search supports Mag first and Benzos second.
 
I would be a liar if I said I remembered why and I don't know of anything immediately on hand that clarifies, but last time this came up in discussion for me I was told Mag was the way to go when they are postpartum like that.

For me it's 4g IV 5-10 min or 1g IM and then we go to 5mg Versed IV.
 
NomadicMedic said:
She wound up RSIed and the doc was a little pissy that I used versed instead of mag. (And that I didn't tube her, but she was totally protecting her own airway.)
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That's a really dumb thing for a doc to get pissy about.

So, the main reasons that mag is considered first line as a seizure prophylactic in preeclampsia probably has little to do with it being better at preventing seizures than the alternatives. It likely has more to do with 1) avoiding benzos, phenytoin, and other dirty drugs during pregnancy, and 2) the idea that magnesium somehow "treats the underlying cause", though that can't really be claimed since the mechanism by which magnesium treats preeclampsia is not well understood. It basically comes down to the fact that we know it's safe for mom and baby and it generally works well, so it's what we use. Same for treating the seizures if they happen.

Once the baby is out, the reason for avoiding other anticonvulsants is gone, and while mag may (or may not) still be the best drug for treating eclampsia, there's absolutely no reason why it should be the only choice, or even necessarily the first choice in every case.

Also, while mag is generally safe, it isn't always benign. I'd wager that repeated boluses of mag are responsible for far more cases of clinically important respiratory compromise than benzos are. Maybe that's why your doc ended up tubing this lady.

NomadicMedic said:
My "at the time" thought? We carry mag in 1G vials, so I would have needed to draw up four and slow push it over a few minutes, or I could just grab Versed and go.
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When you are alone in the back of an ambulance with a seizing patient, that is a perfectly reasonable approach, IMO. But that's probably a foreign concept for a MD who has a small army of minions scrambling to carry out their orders as quickly as he can bark them.
 
Perhaps I am in need of a review of OB related complaints, but I wouldn't have even considered pre eclampsia with a pressure that normal; so I also would have treated with benzos instead of mag.
 
hometownmedic5 said:
Perhaps I am in need of a review of OB related complaints, but I wouldn't have even considered pre eclampsia with a pressure that normal; so I also would have treated with benzos instead of mag.
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I assumed the Lisinopril kinda throws a curve ball for what we are used to looking for.
 
Our protocols are pretty much reversed from yours Nomad. Our first line is Mag. In order to use Versed we have to contact base for an order.
 
hometownmedic5 said:
Perhaps I am in need of a review of OB related complaints, but I wouldn't have even considered pre eclampsia with a pressure that normal; so I also would have treated with benzos instead of mag.
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Most references state SBP 140 and above. Most of the cases I have seen are only mildly hypertensive i.e. 140-160s
 
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Chase said:
On a side note don't be that guy who intubates the the mom on a magnesium drip instead of giving calcium. It probably happens more than you think.
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Can you please elaborate more on this. What are you using the calcium for? I only have protocols that indicate calcium for hyperkalemia and beta-blocker OD.

Chase said:
Our protocol for active seizures in eclampsia is Mag Sulgate 4g IV bolus then 2g/hr infusion or Phenytoin.
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Oh man I wish I had this. Only one of the four jurisdictions I'm registered in has protocols for Mag Sulfate for eclampsia and they call for a Loading Dose of 4g in 50ml over 20mins. Unless there are some magical properties of mag that I'm not aware of, anyone with a basic understanding of pharmacodynamics can recognize it's going to take a while before you're into the therapeutic index at this rate.

Re: anticonvulsants in general -- EMCrit did an episode on status with Tom Blek and it was stated @ 4:35min that "only the first drug you give has a reasonable chance of working".

Show Notes: https://emcrit.org/emcrit/status-epilepticus/

@NomadicMedic - I think your Versed/Midazolam decision can be supported based on Tom Blek's statement and my protocols would have had me done the same. As already stated, my understanding behind Mag over Midazolam is fetal safety. Now, if I had protocols where I could SIVP Mag, I'd go with whichever can provide the quickest reversal of the seizure activity (both in terms of preparation, administration, and the pharmacodynamics) followed by a drip of whichever has the greatest efficiency (I don't know the answer to either of these).


Here's a really good article on mag for eclampsia:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2663594/#!po=33.9286

One interesting point (p.7) is that they caution against considering mag an antihypertensive drug and suggest a targeted approach such as labetalol.


*if you liked this post, don't forget to 'like' and 'subscribe'. ;)
 
CWATT said:
Can you please elaborate more on this. What are you using the calcium for? I only have protocols that indicate calcium for hyperkalemia and beta-blocker OD.
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No offense but if you have a Magnesium IV/IVP protocol and Calcium reversal isn't part of it then Medical Control needs to seriously take another look at it. Many people don't remember that Calcium Gluconate is the treatment for Magnesium Toxicity. 10ml of 10% Calcium Gluconate over 2-5 mins for somnolence, loss of DTRs, or respiratory depression. It should reverse symptoms fairly quickly. It is easy to jump straight to intubation when you have a unresponsive apenic patient but it's bad form when it is cause is easily reversible.

Magnesium is a fairly safe drug when administered correctly by experienced providers however there are many cases of overdose due to unfamiliarity with the dosage, concentration, etc. But it is pretty rare for patients to develop toxicity without some sort of medication error.


http://www.doctorsforafghanistan.com/_articles/mis/Protocol for Management of Magnesium Toxicity.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799127/
 
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My thoughts are for active seizing patients, they'll get versed. In this case I'd give the versed then start prepping our 4gms in 20cc over 3-5 minutes.

Did she remain seizing until arrival to the ED? I'd like to see the doc tube a seizing patient alone in the back, or RSI someone alone in the back while managing her in 8 minutes.
 
CWATT said:
Can you please elaborate more on this. What are you using the calcium for? I only have protocols that indicate calcium for hyperkalemia and beta-blocker OD.
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As Chase already stated if you have Mag in your protocols you should either have calcium in your protocols or in the back of your mind as a reversal agent for Mag toxicity. Once you loose DTRs and get some CNS depression calcium works pretty quick.
 
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