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beyond all hope said:
I think you're right on - flushing and n/v can happen with too-rapid administration of Mag, along with hypotension. I've only read about these, though - haven't seen it.
er intubations
- Thread starter m32b
- Start date
I think you're right on - flushing and n/v can happen with too-rapid administration of Mag, along with hypotension. I've only read about these, though - haven't seen it.
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m32b said:
Sure, when I was a paramedic we had them in the airway kit.
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I've never heard of this. Please explain the logic behind Benadryl and Mag.
I always use Tylenol and Phenergan.
If you've got a new way to treat headache, I'll all ears.
I always use Tylenol and Phenergan.
If you've got a new way to treat headache, I'll all ears.
D
deleted6669
magnesium in a non-code situation is normally given as an infusion, not as an iv push med. this may be why your pts get nausea/vomiting. I usually order 2 gm mgso4 in 100 cc ns over 15-20 minutes.I have seen some pts get flushed from this, but not enough that they wouldn't want it again. the use of mag has helped me several times with pts who I thought were on the road to intubation. I have also heard about the use of very low dose ketamine in severe asthmatics but have not yet tried it myself.
my headache cocktail( if no contraindications) is ivns + toradol/reglan/benadryl and sometimes ativan in the anxious h/a pt. the benadryl helps blunt the side effects sometimes seen with reglan. I used to use inapsine fairly regularly, but with the new black box warnings it makes it a pain to use because the nurses want an ekg and constant monitoring, etc
my headache cocktail( if no contraindications) is ivns + toradol/reglan/benadryl and sometimes ativan in the anxious h/a pt. the benadryl helps blunt the side effects sometimes seen with reglan. I used to use inapsine fairly regularly, but with the new black box warnings it makes it a pain to use because the nurses want an ekg and constant monitoring, etc
So for everybody using Mg where is the evidence that it works. I'm not sure I've seen anything for headaches but for asthma I've seen a number of papers which all said it pretty much didn't make a bit of difference.
D
deleted6669
Discussion
there is sufficient evidence to support its use in a subgroup of patients experiencing severe asthma attacks who appear to respond differently to the administration of magnesium. Patients who presented with severe asthma appeared to benefit from the use of intravenous magnesium sulfate, both in terms of pulmonary functions and admission rates. The NNT for this treatment in severe asthma is small (5 patients), further illustrating its effectiveness.
The clinical significance of the magnitude of the pulmonary function improvement is difficult to determine, since the minimally clinically important difference for lung function tests in severe acute asthma have not been determined. In chronic asthma, an improvement of 12% predicted has been quoted,[12] and for acute studies, some have suggested an increase in PEFR of as little as 30 L/min is clinically important.[41] The improvement of approximately 10% predicted FEV1 or 50 L/min PEFR demonstrated in this review represents what we believe may be important improvement in lung function, especially considering the severity at the start of therapy. Moreover, these lung function improvements correspond with important reductions in admissions.
In support of these subgroup findings, others have demonstrated magnesium sulfate to be of benefit in severe acute asthma. For example, Schiermeyer and Finkelstein [43] reported success with rapid magnesium sulfate infusion in children experiencing severe asthma and impending respiratory failure. Pabon et al[44] reported on the success of intravenous magnesium sulfate in children who had not responded to conventional treatment. Finally, high doses of intravenous magnesium sulfate have been used to treat ventilated patients to decrease peak airway pressure.[45] In summary, the use of magnesium sulfate in patients with asthma appears justified on the basis of this meta-analysis and other research evidence.
One potential concern in this systematic review is the classification of the "severe" subgroup. It was based on primary authors' designation of "severe" (usually based on initial pulmonary function test results, and/or a failure to respond to therapy) and an examination of the admission rate in the placebo group by the review research team. Severe asthma was defined differently across studies, but included:
# 25% to 30% predicted PEFR at presentation (adults)
# Failure to respond to initial treatments (adults and children)
# Failure to improve beyond 60% predicted after 1 hour of care (children)
In 4 studies, designation of severe by the author was concordant with high (>75%) admission rates. In 2 others, designation of mild-moderate was concordant with low admission rates (<25%). Only one study reported low admission rates (29% in placebo arm) among patients classified by the authors as "severe." [41] We chose to classify the results from this study as "discordant" and present the data as a separate analyses. However, most emergency physicians will no doubt agree with the classification of severe assigned by the review team and used in this metaanalysis.
A consistent marker of the severity appears to be a failure to respond to initial beta-agonist treatment (Table 2). For example, 4 studies in this review used this criterion to define severity.[36] [38] [41] This observation leads to the recommendation that a failure to respond to initial beta-agonist treatment may be an appropriate method of identifying those individuals who may benefit from magnesium sulfate treatment.[44]
It is important to evaluate the validity of subgroup analyses in conjunction with these results. Guidelines for subgroup analyses have been published,[46] and should be considered within the context of this review. This meta-analysis used a subgroup based on baseline asthma severity that meets the above guidelines (ie, planned a priori and used in other airway reviews).[47] In addition, the differences in pooled estimates were large (OR 0.1 versus 1.36), demonstrated homogeneity across studies, and were physiologically reasonable. Furthermore, the subgroup results generated from both within[40] and between study comparisons were consistent.
Intravenous administration of magnesium sulfate was shown to be safe in those studies where vital signs and side effects were recorded. For example, magnesium treatment did not change pulse or respiratory rates; the minor change in systolic blood pressure was clinically insignificant. Although this may seem counterintuitive, we suggest that the poor reliability and validity of respiratory rate measurement might explain these findings. For example, in one large ED study, almost all of the respiratory rates were recorded as 20/min.[14] Caution is advised when interpreting the safety and adverse reaction data, since the total pooled sample size is insufficient to detect rare adverse events.
There is a possibility of publication bias in this meta-analysis.[48] [49] For example, by missing unpublished trials indicating negative results, we may be overestimating the effect of magnesium treatment. However, to reduce bias, a comprehensive and systematic search of the published and unpublished literature for potentially relevant studies was conducted. [31] This was followed by attempts to contact corresponding and first authors. One unpublished trial was identified, and several trials indicating negative results were uncovered; however, we recognize that more of these types of trials may exist.
There is also a possibility of study selection bias.[50] [52] However, we used 2 independent reviewers and are confident that the studies excluded were done so for consistent and appropriate reasons. Our search was comprehensive and has been updated, so it is unlikely that there are any published trials that were missed.
Recent publications have questioned the validity of results generated from meta-analyses. For example, LeLorier et al[53] concluded that agreement between large clinical trials and systematic reviews was low. However, careful examination of their results indicates systematic reviews provided conservative and surprisingly similar results to the mega-trials. Moreover, therapeutic mega-trials in most ED treatments are rare, expensive, and unlikely to be completed. Conversely, the alternative of individual clinicians approaching this problem will promote the practice variation in treatment we are currently experiencing. Thus, systematic reviews present an attractive alternative approach to treatment decisions and discordance can often be explained.[54]
Finally, systematic reviews that pay close attention to methodologic quality[31] [50] [52] have been shown to provide conservative and reasonable estimates of treatment effect. [55] Although they do not represent a panacea, they remain an important and growing component of evidence-based emergency medicine.[56] [57] They should be used in conjunction with clinical judgment and with patient preference in mind.[56] [58]
Many questions regarding the treatment of acute asthma with magnesium sulfate remain unanswered. Most importantly, additional research is required to determine the optimal dose and duration of therapy. Additional studies are needed to confirm the subgroup findings from this review suggesting no effect of magnesium sulfate in mild and moderate asthma. In future studies, severity must be clearly defined and based on presenting pulmonary function results and response to initial beta-agonist therapy whenever possible. Studies involving very young children need to be performed to determine the effect of magnesium sulfate treatment in this age group.
Further studies are required to examine the effect of magnesium sulfate based on the prior inhaled steroid use for patients presenting to the ED with acute asthma. The effect of treatment may differ based on inhaled steroid use,[16] and the answer to this question remains unclear. Inhaled steroids are increasingly used, and the development of high-dose inhaled steroids with lower systemic activity suggests that this would be an important area for future research. Finally, acute asthma research must concentrate on well-defined outcomes that may lead to more informative reviews in the future. More specifically, criteria for discharge and reporting of lung function test data in a systematic fashion would assist in further work.
l
there is sufficient evidence to support its use in a subgroup of patients experiencing severe asthma attacks who appear to respond differently to the administration of magnesium. Patients who presented with severe asthma appeared to benefit from the use of intravenous magnesium sulfate, both in terms of pulmonary functions and admission rates. The NNT for this treatment in severe asthma is small (5 patients), further illustrating its effectiveness.
The clinical significance of the magnitude of the pulmonary function improvement is difficult to determine, since the minimally clinically important difference for lung function tests in severe acute asthma have not been determined. In chronic asthma, an improvement of 12% predicted has been quoted,[12] and for acute studies, some have suggested an increase in PEFR of as little as 30 L/min is clinically important.[41] The improvement of approximately 10% predicted FEV1 or 50 L/min PEFR demonstrated in this review represents what we believe may be important improvement in lung function, especially considering the severity at the start of therapy. Moreover, these lung function improvements correspond with important reductions in admissions.
In support of these subgroup findings, others have demonstrated magnesium sulfate to be of benefit in severe acute asthma. For example, Schiermeyer and Finkelstein [43] reported success with rapid magnesium sulfate infusion in children experiencing severe asthma and impending respiratory failure. Pabon et al[44] reported on the success of intravenous magnesium sulfate in children who had not responded to conventional treatment. Finally, high doses of intravenous magnesium sulfate have been used to treat ventilated patients to decrease peak airway pressure.[45] In summary, the use of magnesium sulfate in patients with asthma appears justified on the basis of this meta-analysis and other research evidence.
One potential concern in this systematic review is the classification of the "severe" subgroup. It was based on primary authors' designation of "severe" (usually based on initial pulmonary function test results, and/or a failure to respond to therapy) and an examination of the admission rate in the placebo group by the review research team. Severe asthma was defined differently across studies, but included:
# 25% to 30% predicted PEFR at presentation (adults)
# Failure to respond to initial treatments (adults and children)
# Failure to improve beyond 60% predicted after 1 hour of care (children)
In 4 studies, designation of severe by the author was concordant with high (>75%) admission rates. In 2 others, designation of mild-moderate was concordant with low admission rates (<25%). Only one study reported low admission rates (29% in placebo arm) among patients classified by the authors as "severe." [41] We chose to classify the results from this study as "discordant" and present the data as a separate analyses. However, most emergency physicians will no doubt agree with the classification of severe assigned by the review team and used in this metaanalysis.
A consistent marker of the severity appears to be a failure to respond to initial beta-agonist treatment (Table 2). For example, 4 studies in this review used this criterion to define severity.[36] [38] [41] This observation leads to the recommendation that a failure to respond to initial beta-agonist treatment may be an appropriate method of identifying those individuals who may benefit from magnesium sulfate treatment.[44]
It is important to evaluate the validity of subgroup analyses in conjunction with these results. Guidelines for subgroup analyses have been published,[46] and should be considered within the context of this review. This meta-analysis used a subgroup based on baseline asthma severity that meets the above guidelines (ie, planned a priori and used in other airway reviews).[47] In addition, the differences in pooled estimates were large (OR 0.1 versus 1.36), demonstrated homogeneity across studies, and were physiologically reasonable. Furthermore, the subgroup results generated from both within[40] and between study comparisons were consistent.
Intravenous administration of magnesium sulfate was shown to be safe in those studies where vital signs and side effects were recorded. For example, magnesium treatment did not change pulse or respiratory rates; the minor change in systolic blood pressure was clinically insignificant. Although this may seem counterintuitive, we suggest that the poor reliability and validity of respiratory rate measurement might explain these findings. For example, in one large ED study, almost all of the respiratory rates were recorded as 20/min.[14] Caution is advised when interpreting the safety and adverse reaction data, since the total pooled sample size is insufficient to detect rare adverse events.
There is a possibility of publication bias in this meta-analysis.[48] [49] For example, by missing unpublished trials indicating negative results, we may be overestimating the effect of magnesium treatment. However, to reduce bias, a comprehensive and systematic search of the published and unpublished literature for potentially relevant studies was conducted. [31] This was followed by attempts to contact corresponding and first authors. One unpublished trial was identified, and several trials indicating negative results were uncovered; however, we recognize that more of these types of trials may exist.
There is also a possibility of study selection bias.[50] [52] However, we used 2 independent reviewers and are confident that the studies excluded were done so for consistent and appropriate reasons. Our search was comprehensive and has been updated, so it is unlikely that there are any published trials that were missed.
Recent publications have questioned the validity of results generated from meta-analyses. For example, LeLorier et al[53] concluded that agreement between large clinical trials and systematic reviews was low. However, careful examination of their results indicates systematic reviews provided conservative and surprisingly similar results to the mega-trials. Moreover, therapeutic mega-trials in most ED treatments are rare, expensive, and unlikely to be completed. Conversely, the alternative of individual clinicians approaching this problem will promote the practice variation in treatment we are currently experiencing. Thus, systematic reviews present an attractive alternative approach to treatment decisions and discordance can often be explained.[54]
Finally, systematic reviews that pay close attention to methodologic quality[31] [50] [52] have been shown to provide conservative and reasonable estimates of treatment effect. [55] Although they do not represent a panacea, they remain an important and growing component of evidence-based emergency medicine.[56] [57] They should be used in conjunction with clinical judgment and with patient preference in mind.[56] [58]
Many questions regarding the treatment of acute asthma with magnesium sulfate remain unanswered. Most importantly, additional research is required to determine the optimal dose and duration of therapy. Additional studies are needed to confirm the subgroup findings from this review suggesting no effect of magnesium sulfate in mild and moderate asthma. In future studies, severity must be clearly defined and based on presenting pulmonary function results and response to initial beta-agonist therapy whenever possible. Studies involving very young children need to be performed to determine the effect of magnesium sulfate treatment in this age group.
Further studies are required to examine the effect of magnesium sulfate based on the prior inhaled steroid use for patients presenting to the ED with acute asthma. The effect of treatment may differ based on inhaled steroid use,[16] and the answer to this question remains unclear. Inhaled steroids are increasingly used, and the development of high-dose inhaled steroids with lower systemic activity suggests that this would be an important area for future research. Finally, acute asthma research must concentrate on well-defined outcomes that may lead to more informative reviews in the future. More specifically, criteria for discharge and reporting of lung function test data in a systematic fashion would assist in further work.
l
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Your'e right. For every article that says Mag works, there's another article that says there's no significant difference. However, perhaps some humans have Mag receptors that are responsible for some reversible airway disease. Who knows... that's why I'm not QuinnDOphud...ERMudPhud said:
But, if it works, awesome. If it doesn't work, no biggie, I wasn't really expecting it to work. And so far (in my long winded 11 months of internship) I haven't had any problems giving Mag.
And as for the "headache cocktail" I'll post the abstracts here when I get home.
Q, DO
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Ann Emerg Med. 1990 Oct;19(10):1083-7. Related Articles, Links
Comment in:
* Ann Emerg Med. 1991 Jun;20(6):711-2.
A prospective, double-blind study of metoclopramide hydrochloride for the control of migraine in the emergency department.
Tek DS, McClellan DS, Olshaker JS, Allen CL, Arthur DC.
Department of Emergency Medicine, Naval Hospital, San Diego, California 92134-5000.
STUDY OBJECTIVE: To determine the effectiveness of IV metoclopramide as sole therapy for relieving the pain of acute migraine in the emergency department. DESIGN: Prospective study. Fifty patients were divided randomly into subjects and placebo controls with blinding of the treating physician and the patient. PARTICIPANTS: Patients presenting to the ED with migraine requiring parenteral treatment. INTERVENTIONS: Subjects received 10 mg IV metoclopramide and controls received IV normal saline; patient assessment of relief was followed by means of a numerical scale. MEASUREMENTS AND MAIN RESULTS: Sixty-seven percent of subjects compared with 19% of controls had effective pain relief within one hour (P less than .001). Subjects achieved mean relief scores of 2.46 compared with 1.69 for controls (P less than .02). No significant side effects were observed. CONCLUSION: IV metoclopramide as a single agent is effective and safe therapy for migraine in the ED.
Publication Types:
* Clinical Trial
* Randomized Controlled Trial
Acad Emerg Med. 1995 Jul;2(7):597-602. Related Articles, Links
Intravenous chlorpromazine vs intravenous metoclopramide in acute migraine headache.
Cameron JD, Lane PL, Speechley M.
Department of Emergency Medicine, St. Joseph's Health Center, London, Ontario, Canada.
OBJECTIVE: To compare the efficacy of IV chlorpromazine with that of IV metoclopramide in the treatment for acute migraine headache in the ED. METHODS: A prospective randomized double-blind trial was undertaken at two university-affiliated urban EDs with a combined annual census of more than 85,000 patients. Included in the study were patients presenting to the ED with a diagnosis of migraine headache. The subjects were randomized to receive 0.1 mg/kg/dose IV of either chlorpromazine (CPZ) or metoclopramide (MC), up to a total of three doses. RESULTS: Ninety-one patients completed the protocol; 44 received MC and 47 received CPZ. The demographics of the two groups were similar. Both drugs provided, for the majority of patients, adequate pain relief as measured on a visual analog scale (VAS) completed every 15 minutes from T = 0 minutes to T = 45 minutes. The average pain relief over 45 minutes (delta VAS) for CPZ was 4.87 cm, vs 4.34 cm for MC (p = 0.35). There also was no statistically significant difference in blood pressure (BP) changes (delta BP < 2 mm Hg for both systolic and diastolic BPs, p = 0.47 and 0.33) or numbers of patients reporting adverse effects (AEs) (CPZ: 16 of 35; MC: 13 of 29, p = 0.43). There was no severe AE with either study drug. CONCLUSIONS: Metoclopramide and chlorpromazine administered IV are both effective in the management of acute migraine headache. They are associated with similar minor side-effect profiles.
Emerg Med J. 2004 May;21(3):323-6. Related Articles, Links
Ann Emerg Med. 2001 Feb;37(2):125-31. Related Articles, Links
Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial.
Vinson DR, Drotts DL.
Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA.
STUDY OBJECTIVES: The utility of intravenous prochlorperazine as an antiemetic agent and abortive therapy for headache may be limited by the frequent occurrence of akathisia, the distressing effects of which have been shown to disrupt patient care. We tested the hypothesis that adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine. METHODS: This randomized, double-blind, placebo-controlled trial was conducted in the emergency department of an academic tertiary care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of 100 adult patients who received 10 mg of intravenous prochlorperazine for the treatment of nausea/vomiting or headache. Subjects were randomly assigned to receive a 2-minute infusion of prochlorperazine with either 50 mg of diphenhydramine or placebo. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. To measure the influence of treatment on sedation, the subjects noted, on a 100-mm visual analog scale, their degree of sedation before and after treatment. RESULTS: Akathisia developed in 18 (36%) of 50 subjects in the control group and in 7 (14%) of 50 subjects in the diphenhydramine group, a 61% relative reduction. The addition of adjunct diphenhydramine resulted in an absolute reduction of 22% in the incidence of akathisia (95% confidence interval [CI] 6% to 38%; P = .01). The odds ratio for akathisia with the use of adjuvant diphenhydramine was 0.39 (95% CI 0.18 to 0.85). Mean sedation scores increased 12 mm after infusion of prochlorperazine alone (95% CI 3 to 21 mm) compared with a 33-mm increase after infusion of prochlorperazine with adjuvant diphenhydramine (95% CI 24 to 42 mm). The 12-mm difference between the groups was statistically significant (95% CI 9 to 34 mm, P < .001). CONCLUSION: Adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine and is associated with an increase in sedation.
Publication Types:
* Clinical Trial
* Randomized Controlled Trial
Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes.
Cicek M, Karcioglu O, Parlak I, Ozturk V, Duman O, Serinken M, Guryay M.
Department of Emergency Medicine, Dokuz Eylul University Medical School, Izmir, Turkey. Department of Neurology, Dokuz Eylul University Medical School.
STUDY OBJECTIVE: To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED). METHODS: All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief. RESULTS: Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003). CONCLUSION: These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes.
PMID: 15107371 [PubMed - in process]
Comment in:
* Ann Emerg Med. 1991 Jun;20(6):711-2.
A prospective, double-blind study of metoclopramide hydrochloride for the control of migraine in the emergency department.
Tek DS, McClellan DS, Olshaker JS, Allen CL, Arthur DC.
Department of Emergency Medicine, Naval Hospital, San Diego, California 92134-5000.
STUDY OBJECTIVE: To determine the effectiveness of IV metoclopramide as sole therapy for relieving the pain of acute migraine in the emergency department. DESIGN: Prospective study. Fifty patients were divided randomly into subjects and placebo controls with blinding of the treating physician and the patient. PARTICIPANTS: Patients presenting to the ED with migraine requiring parenteral treatment. INTERVENTIONS: Subjects received 10 mg IV metoclopramide and controls received IV normal saline; patient assessment of relief was followed by means of a numerical scale. MEASUREMENTS AND MAIN RESULTS: Sixty-seven percent of subjects compared with 19% of controls had effective pain relief within one hour (P less than .001). Subjects achieved mean relief scores of 2.46 compared with 1.69 for controls (P less than .02). No significant side effects were observed. CONCLUSION: IV metoclopramide as a single agent is effective and safe therapy for migraine in the ED.
Publication Types:
* Clinical Trial
* Randomized Controlled Trial
Acad Emerg Med. 1995 Jul;2(7):597-602. Related Articles, Links
Intravenous chlorpromazine vs intravenous metoclopramide in acute migraine headache.
Cameron JD, Lane PL, Speechley M.
Department of Emergency Medicine, St. Joseph's Health Center, London, Ontario, Canada.
OBJECTIVE: To compare the efficacy of IV chlorpromazine with that of IV metoclopramide in the treatment for acute migraine headache in the ED. METHODS: A prospective randomized double-blind trial was undertaken at two university-affiliated urban EDs with a combined annual census of more than 85,000 patients. Included in the study were patients presenting to the ED with a diagnosis of migraine headache. The subjects were randomized to receive 0.1 mg/kg/dose IV of either chlorpromazine (CPZ) or metoclopramide (MC), up to a total of three doses. RESULTS: Ninety-one patients completed the protocol; 44 received MC and 47 received CPZ. The demographics of the two groups were similar. Both drugs provided, for the majority of patients, adequate pain relief as measured on a visual analog scale (VAS) completed every 15 minutes from T = 0 minutes to T = 45 minutes. The average pain relief over 45 minutes (delta VAS) for CPZ was 4.87 cm, vs 4.34 cm for MC (p = 0.35). There also was no statistically significant difference in blood pressure (BP) changes (delta BP < 2 mm Hg for both systolic and diastolic BPs, p = 0.47 and 0.33) or numbers of patients reporting adverse effects (AEs) (CPZ: 16 of 35; MC: 13 of 29, p = 0.43). There was no severe AE with either study drug. CONCLUSIONS: Metoclopramide and chlorpromazine administered IV are both effective in the management of acute migraine headache. They are associated with similar minor side-effect profiles.
Emerg Med J. 2004 May;21(3):323-6. Related Articles, Links
Ann Emerg Med. 2001 Feb;37(2):125-31. Related Articles, Links
Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial.
Vinson DR, Drotts DL.
Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA.
STUDY OBJECTIVES: The utility of intravenous prochlorperazine as an antiemetic agent and abortive therapy for headache may be limited by the frequent occurrence of akathisia, the distressing effects of which have been shown to disrupt patient care. We tested the hypothesis that adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine. METHODS: This randomized, double-blind, placebo-controlled trial was conducted in the emergency department of an academic tertiary care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of 100 adult patients who received 10 mg of intravenous prochlorperazine for the treatment of nausea/vomiting or headache. Subjects were randomly assigned to receive a 2-minute infusion of prochlorperazine with either 50 mg of diphenhydramine or placebo. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. To measure the influence of treatment on sedation, the subjects noted, on a 100-mm visual analog scale, their degree of sedation before and after treatment. RESULTS: Akathisia developed in 18 (36%) of 50 subjects in the control group and in 7 (14%) of 50 subjects in the diphenhydramine group, a 61% relative reduction. The addition of adjunct diphenhydramine resulted in an absolute reduction of 22% in the incidence of akathisia (95% confidence interval [CI] 6% to 38%; P = .01). The odds ratio for akathisia with the use of adjuvant diphenhydramine was 0.39 (95% CI 0.18 to 0.85). Mean sedation scores increased 12 mm after infusion of prochlorperazine alone (95% CI 3 to 21 mm) compared with a 33-mm increase after infusion of prochlorperazine with adjuvant diphenhydramine (95% CI 24 to 42 mm). The 12-mm difference between the groups was statistically significant (95% CI 9 to 34 mm, P < .001). CONCLUSION: Adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine and is associated with an increase in sedation.
Publication Types:
* Clinical Trial
* Randomized Controlled Trial
Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes.
Cicek M, Karcioglu O, Parlak I, Ozturk V, Duman O, Serinken M, Guryay M.
Department of Emergency Medicine, Dokuz Eylul University Medical School, Izmir, Turkey. Department of Neurology, Dokuz Eylul University Medical School.
STUDY OBJECTIVE: To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED). METHODS: All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief. RESULTS: Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003). CONCLUSION: These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes.
PMID: 15107371 [PubMed - in process]
- Joined
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con't
Headache. 2003 Jul-Aug;43(7):729-33. Related Articles, Links
Sumatriptan plus metoclopramide in triptan-nonresponsive migraineurs.
Schulman EA, Dermott KF.
Center for Headache Management, Ambulatory Care Pavilion, Suite 533, One Medical Center Boulevard, Upland, PA 19013, USA.
OBJECTIVES: We evaluated the effectiveness of combination treatment using sumatriptan plus metoclopramide versus sumatriptan alone for the treatment of acute migraine. The patients who were treated had failed to respond to triptans in the past despite adequate doses on at least 2 separate trials of the same triptan or 2 trials involving different triptans. BACKGROUND: There is limited evidence that dopaminergic antagonists may benefit the migraineur by relieving migraine pain and associated symptoms. The exact mechanism of action in migraine is unknown. The postulated action is the inhibition of dopaminergic overactivity. A dopaminergic antagonist, metoclopramide, may improve the efficacy of a 5-HT1B/1D agonist, sumatriptan. METHODS: In this double-blind, randomized, crossover study, 16 adult migraineurs fulfilling International Headache Society (IHS) criteria for migraine with or without aura who had failed to receive adequate relief from triptans treated one migraine with each treatment: sumatriptan 50 mg plus metoclopramide 10 mg or sumatriptan 50 mg plus placebo to match metoclopramide. Patients treated their migraines when they were moderate or severe in intensity and recorded pain severity and symptoms prior to treatment and 30, 60, 90, and 120 minutes and 24 hours after treatment. RESULTS: Thirteen women and 3 men (mean age, 40 years) completed the study; ie, treated 2 migraines (a total of 32 migraines), one attack with each treatment. Meaningful relief was attained in 10 (63%) of 16 migraines treated with the combination of sumatriptan 50 mg plus metoclopramide 10 mg compared with 5 (31%) of 16 migraines treated with sumatriptan 50 mg plus placebo. Headache response (moderate or severe to mild or no pain at 2 hours) was achieved in 7 (44%) of 16 migraines with the combination of sumatriptan 50 mg plus metoclopramide 10 mg compared with 5 (31%) of 16 migraines treated with sumatriptan 50 mg plus placebo. There did not appear to be a difference between treatment groups with respect to associated symptoms. The combination of sumatriptan 50 mg plus metoclopramide 10 mg was well tolerated. CONCLUSIONS: Combining sumatriptan with metoclopramide provided relief in some migraineurs who failed to achieve adequate relief with a triptan alone. It remains unknown whether initiating therapy when pain was mild or using a higher dose of sumatriptan (ie, 100 mg) would have provided additional benefit. Further studies are indicated.
Ann Emerg Med. 2001 Dec;38(6):621-7. Related Articles, Links
Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache.
Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ.
Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA. [email protected]
STUDY OBJECTIVE: We test the hypothesis that intravenous magnesium sulfate is an effective adjunctive medication for treatment of acute migraine. METHODS: In this randomized, double-blind, placebo-controlled trial, adults presenting to 2 urban emergency departments with headache meeting International Headache Society criteria for acute migraine received either 20 mg of intravenous metoclopramide plus 2 g of intravenous magnesium sulfate or 20 mg of intravenous metoclopramide plus a placebo of intravenous saline solution at 15-minute intervals for a maximum of 3 doses or until pain relief occurred. At 0, 15, 30, and 45 minutes, patients recorded pain intensity using a standard visual analog scale (VAS). The primary study end point was the between-group difference in pain improvement when initial and final VAS scores were compared. RESULTS: Of 44 patients enrolled (21 randomized to metoclopramide plus magnesium and 23 to metoclopramide plus placebo), 42 (95%) were women. Baseline features were comparable in both groups. Each group experienced a more than 50-mm improvement in VAS score during the study. However, this improvement was smaller in the magnesium group for the primary end point (16-mm difference favoring placebo [95% confidence interval (CI) -2 to 34 mm]), as was the proportion with normal functional status at their final rating (36% absolute difference also favoring placebo [95% CI 7% to 65%]). Using a 50% reduction in pain to dichotomize VAS scores, the number needed to harm with magnesium plus metoclopramide versus metoclopramide alone is 4 patients (95% CI 2 to 36). CONCLUSION: Although this result was unexpected, our data suggest that the addition of magnesium to metoclopramide may attenuate the effectiveness of metoclopramide in relieving migraine. Countertherapeutic cerebral vasodilatation caused by magnesium is a plausible, although unproven, explanation for this finding. Because of the preponderance of women in our trial, these data may not be generalizable to men.
Publication Types:
* Clinical Trial
* Randomized Controlled Trial
Am J Emerg Med. 2003 May;21(3):173-5. Related Articles, Links
A prospective double-blind study of nasal sumatriptan versus IV ketorolac in migraine.
Meredith JT, Wait S, Brewer KL.
The Brody School of Medicine at East Carolina University, Department of Emergency Medicine, Division of Research, Physician's Quadrangle, Building M, Greenville, NC 27858, USA.
We conducted a study to compare the efficacy in migraine headache of nasal sumatriptan and intravenous ketorolac. The study was a prospective, double-blind study done with a convenience sample of 29 patients presenting to the emergency department (ED) with acute migraine. Patients received either 20 mg of nasal sumatriptan or 30 mg of intravenous ketorolac. Patients scored the severity of their headache on a 100-mm visual analog scale (VAS) of pain prior to medication, and again 1 hour after medication. Differences between initial and 1-hour scores were analyzed. Before treatment, no difference existed between the groups in the intensity of headache. One hour after medication, the sumatriptan group had a decrease in pain score of 22.937 mm and the ketorolac group a decrease of 71.462 mm on the VAS. The decrease in pain score with ketorolac was significantly greater than that with sumatriptan (P < 0.001). The study therefore showed that both sumatriptan and ketorolac effectively reduced the pain associated with acute migraine headache, but that intravenous ketorolac produced a greater reduction in pain than did nasal sumatriptan.
Publication Types:
* Clinical Trial
Randomized Controlled Trial
TREATMENT AND ETIOLOGY OF HEADACHE IN THE ED
Inhalation of High-flow Oxygens as a Treatment for Migraine Headache in the Emergency Department
Robert Stambaugh, John Sisson and Charles Erdman
Naval Medical Center Portsmouth: Portsmouth, VA
ABSTRACT
Objective: Migraine headache is a common complaint in the Emergency Department. We hypothesized that inhalation of one hundred percent oxygen for thirty minutes would cause a clinically significant (25%) reduction of pain for patients with migraine headache. Methods: This study was a prospective, randomized, controlled, double-blinded trial using high-flow inhaled oxygen as the treatment group and inhaled air as the control group. It was conducted between December 2001 and April 2002 in the ED of a military hospital. A convenience sample was enrolled into the study using a computer generated randomization scheme. Inclusion criteria were all patients 18 to 65 years old with a previous diagnosis of migraine headaches who presented to the ED complaining of a "typical migraine headache". Exclusion criteria included: patients triaged as "urgent" or "emergent", patients with altered mental status, febrile patients, and patients with COPD. A visual analog scale (VAS) was used to rate headache pain before and after treatment. The change in pain score as measured by the VAS (in mm) was assessed by a two factor repeated measures analysis of variance (ANOVA). Change in VAS from before intervention to after intervention between the Air and Oxygen groups was the test of interest. Analysis of covariance (ANCOVA) was also used to compare VAS scores after intervention adjusted for VAS scores before intervention. Results: Forty-six patients completed the study, with 23 in each group. The Air group recorded a mean pain level of 84.7mm +/- 13.2mm SD on the VAS before intervention and 81.3mm +/- 15.3mm SD after intervention. The Oxygen group showed a mean of 76.1mm +/- 15.5 SD prior to intervention and a mean of 60.4mm +/- 29.4mm SD after intervention. The Oxygen group had, on average a 21% decrease in pain compared to a 4% decrease for the Air Group (p = 0.031 by ANCOVA). Conclusion: Inhalation of high-flow oxygen caused a statistically significant reduction in the pain of migraine headache.
Headache. 2003 Jul-Aug;43(7):729-33. Related Articles, Links
Sumatriptan plus metoclopramide in triptan-nonresponsive migraineurs.
Schulman EA, Dermott KF.
Center for Headache Management, Ambulatory Care Pavilion, Suite 533, One Medical Center Boulevard, Upland, PA 19013, USA.
OBJECTIVES: We evaluated the effectiveness of combination treatment using sumatriptan plus metoclopramide versus sumatriptan alone for the treatment of acute migraine. The patients who were treated had failed to respond to triptans in the past despite adequate doses on at least 2 separate trials of the same triptan or 2 trials involving different triptans. BACKGROUND: There is limited evidence that dopaminergic antagonists may benefit the migraineur by relieving migraine pain and associated symptoms. The exact mechanism of action in migraine is unknown. The postulated action is the inhibition of dopaminergic overactivity. A dopaminergic antagonist, metoclopramide, may improve the efficacy of a 5-HT1B/1D agonist, sumatriptan. METHODS: In this double-blind, randomized, crossover study, 16 adult migraineurs fulfilling International Headache Society (IHS) criteria for migraine with or without aura who had failed to receive adequate relief from triptans treated one migraine with each treatment: sumatriptan 50 mg plus metoclopramide 10 mg or sumatriptan 50 mg plus placebo to match metoclopramide. Patients treated their migraines when they were moderate or severe in intensity and recorded pain severity and symptoms prior to treatment and 30, 60, 90, and 120 minutes and 24 hours after treatment. RESULTS: Thirteen women and 3 men (mean age, 40 years) completed the study; ie, treated 2 migraines (a total of 32 migraines), one attack with each treatment. Meaningful relief was attained in 10 (63%) of 16 migraines treated with the combination of sumatriptan 50 mg plus metoclopramide 10 mg compared with 5 (31%) of 16 migraines treated with sumatriptan 50 mg plus placebo. Headache response (moderate or severe to mild or no pain at 2 hours) was achieved in 7 (44%) of 16 migraines with the combination of sumatriptan 50 mg plus metoclopramide 10 mg compared with 5 (31%) of 16 migraines treated with sumatriptan 50 mg plus placebo. There did not appear to be a difference between treatment groups with respect to associated symptoms. The combination of sumatriptan 50 mg plus metoclopramide 10 mg was well tolerated. CONCLUSIONS: Combining sumatriptan with metoclopramide provided relief in some migraineurs who failed to achieve adequate relief with a triptan alone. It remains unknown whether initiating therapy when pain was mild or using a higher dose of sumatriptan (ie, 100 mg) would have provided additional benefit. Further studies are indicated.
Ann Emerg Med. 2001 Dec;38(6):621-7. Related Articles, Links
Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache.
Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ.
Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA. [email protected]
STUDY OBJECTIVE: We test the hypothesis that intravenous magnesium sulfate is an effective adjunctive medication for treatment of acute migraine. METHODS: In this randomized, double-blind, placebo-controlled trial, adults presenting to 2 urban emergency departments with headache meeting International Headache Society criteria for acute migraine received either 20 mg of intravenous metoclopramide plus 2 g of intravenous magnesium sulfate or 20 mg of intravenous metoclopramide plus a placebo of intravenous saline solution at 15-minute intervals for a maximum of 3 doses or until pain relief occurred. At 0, 15, 30, and 45 minutes, patients recorded pain intensity using a standard visual analog scale (VAS). The primary study end point was the between-group difference in pain improvement when initial and final VAS scores were compared. RESULTS: Of 44 patients enrolled (21 randomized to metoclopramide plus magnesium and 23 to metoclopramide plus placebo), 42 (95%) were women. Baseline features were comparable in both groups. Each group experienced a more than 50-mm improvement in VAS score during the study. However, this improvement was smaller in the magnesium group for the primary end point (16-mm difference favoring placebo [95% confidence interval (CI) -2 to 34 mm]), as was the proportion with normal functional status at their final rating (36% absolute difference also favoring placebo [95% CI 7% to 65%]). Using a 50% reduction in pain to dichotomize VAS scores, the number needed to harm with magnesium plus metoclopramide versus metoclopramide alone is 4 patients (95% CI 2 to 36). CONCLUSION: Although this result was unexpected, our data suggest that the addition of magnesium to metoclopramide may attenuate the effectiveness of metoclopramide in relieving migraine. Countertherapeutic cerebral vasodilatation caused by magnesium is a plausible, although unproven, explanation for this finding. Because of the preponderance of women in our trial, these data may not be generalizable to men.
Publication Types:
* Clinical Trial
* Randomized Controlled Trial
Am J Emerg Med. 2003 May;21(3):173-5. Related Articles, Links
A prospective double-blind study of nasal sumatriptan versus IV ketorolac in migraine.
Meredith JT, Wait S, Brewer KL.
The Brody School of Medicine at East Carolina University, Department of Emergency Medicine, Division of Research, Physician's Quadrangle, Building M, Greenville, NC 27858, USA.
We conducted a study to compare the efficacy in migraine headache of nasal sumatriptan and intravenous ketorolac. The study was a prospective, double-blind study done with a convenience sample of 29 patients presenting to the emergency department (ED) with acute migraine. Patients received either 20 mg of nasal sumatriptan or 30 mg of intravenous ketorolac. Patients scored the severity of their headache on a 100-mm visual analog scale (VAS) of pain prior to medication, and again 1 hour after medication. Differences between initial and 1-hour scores were analyzed. Before treatment, no difference existed between the groups in the intensity of headache. One hour after medication, the sumatriptan group had a decrease in pain score of 22.937 mm and the ketorolac group a decrease of 71.462 mm on the VAS. The decrease in pain score with ketorolac was significantly greater than that with sumatriptan (P < 0.001). The study therefore showed that both sumatriptan and ketorolac effectively reduced the pain associated with acute migraine headache, but that intravenous ketorolac produced a greater reduction in pain than did nasal sumatriptan.
Publication Types:
* Clinical Trial
Randomized Controlled Trial
TREATMENT AND ETIOLOGY OF HEADACHE IN THE ED
Inhalation of High-flow Oxygens as a Treatment for Migraine Headache in the Emergency Department
Robert Stambaugh, John Sisson and Charles Erdman
Naval Medical Center Portsmouth: Portsmouth, VA
ABSTRACT
Objective: Migraine headache is a common complaint in the Emergency Department. We hypothesized that inhalation of one hundred percent oxygen for thirty minutes would cause a clinically significant (25%) reduction of pain for patients with migraine headache. Methods: This study was a prospective, randomized, controlled, double-blinded trial using high-flow inhaled oxygen as the treatment group and inhaled air as the control group. It was conducted between December 2001 and April 2002 in the ED of a military hospital. A convenience sample was enrolled into the study using a computer generated randomization scheme. Inclusion criteria were all patients 18 to 65 years old with a previous diagnosis of migraine headaches who presented to the ED complaining of a "typical migraine headache". Exclusion criteria included: patients triaged as "urgent" or "emergent", patients with altered mental status, febrile patients, and patients with COPD. A visual analog scale (VAS) was used to rate headache pain before and after treatment. The change in pain score as measured by the VAS (in mm) was assessed by a two factor repeated measures analysis of variance (ANOVA). Change in VAS from before intervention to after intervention between the Air and Oxygen groups was the test of interest. Analysis of covariance (ANCOVA) was also used to compare VAS scores after intervention adjusted for VAS scores before intervention. Results: Forty-six patients completed the study, with 23 in each group. The Air group recorded a mean pain level of 84.7mm +/- 13.2mm SD on the VAS before intervention and 81.3mm +/- 15.3mm SD after intervention. The Oxygen group showed a mean of 76.1mm +/- 15.5 SD prior to intervention and a mean of 60.4mm +/- 29.4mm SD after intervention. The Oxygen group had, on average a 21% decrease in pain compared to a 4% decrease for the Air Group (p = 0.031 by ANCOVA). Conclusion: Inhalation of high-flow oxygen caused a statistically significant reduction in the pain of migraine headache.
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Yer right. I usually do a Reglan/Benadryl, and if that doesn't work, or only gives slight improvement, give a gram of Mag. I've actually had almost 100% relief of patients with headaches that need no further workup.
Q, DO
Q, DO
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Very cool. Of course, I think that Tylenol is a worthy addition.
Now, of course, somebody will come up with a study that shows that the headache cocktail is no more effective than IV reglan.
We don't give IV antiemetics in our ER. (why? don't ask) so I haven't had any problems with Reglan/Compazine/Phenergan. Does the IV form work better/faster?
If you can post EBM on that topic it would be way cool...
Now, of course, somebody will come up with a study that shows that the headache cocktail is no more effective than IV reglan.
We don't give IV antiemetics in our ER. (why? don't ask) so I haven't had any problems with Reglan/Compazine/Phenergan. Does the IV form work better/faster?
If you can post EBM on that topic it would be way cool...
So this is what we have in the way of EBM for Mg and Headache(Pubmed search for clinical trials with key words Magnesium AND [Headache OR Migraine]). Since headache treatments have a ridiculously high placebo effect a randomized placebo controlled study is essential
1: Wang F, Van Den Eeden SK, Ackerson LM, Salk SE, Reince RH, Elin RJ. Related Articles, Links
Abstract Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a randomized, double-blind, placebo-controlled trial.
Headache. 2003 Jun;43(6):601-10.
PMID: 12786918 [PubMed - indexed for MEDLINE]
2: Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Related Articles, Links
Abstract Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache.
Ann Emerg Med. 2001 Dec;38(6):621-7.
PMID: 11719739 [PubMed - indexed for MEDLINE]
3: Ginder S, Oatman B, Pollack M. Related Articles, Links
Abstract A prospective study of i.v. magnesium and i.v. prochlorperazine in the treatment of headaches.
J Emerg Med. 2000 Apr;18(3):311-5.
PMID: 10729668 [PubMed - indexed for MEDLINE]
4: Peikert A, Wilimzig C, Kohne-Volland R. Related Articles, Links
Abstract Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study.
Cephalalgia. 1996 Jun;16(4):257-63.
PMID: 8792038 [PubMed - indexed for MEDLINE]
5: Mauskop A, Altura BT, Cracco RQ, Altura BM. Related Articles, Links
Abstract Intravenous magnesium sulfate rapidly alleviates headaches of various types.
Headache. 1996 Mar;36(3):154-60.
PMID: 8984087 [PubMed - indexed for MEDLINE]
6: Taubert K. Related Articles, Links
Abstract [Magnesium in migraine. Results of a multicenter pilot study]
Fortschr Med. 1994 Aug 30;112(24):328-30. German.
PMID: 7959501 [PubMed - indexed for MEDLINE]
7: Facchinetti F, Sances G, Borella P, Genazzani AR, Nappi G. Related Articles, Links
Abstract Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium.
Headache. 1991 May;31(5):298-301.
PMID: 1860787 [PubMed - indexed for MEDLINE]
What it comes down to is four randomized trials of Mg as PROPHYLAXIS for migraine which show variable but generally positive results. One randomized comparison of Mg to Compazine which showed compazine kicking Mg's ass. One nonrandomized, poorly controlled, small study with a grab bag of head ache types which showed 80% relief with Mg (no placebo group). And one randomized controlled trial of reglan+Mg vs reglan+placebo which showed Mg made one drug that we know works, reglan, less effective.
There are lots of things done in medicine because somebody thought it was a good idea and the old guys swear its always worked great for them so it becomes self-perpetuating. This is one of those ideas that appears to actually be harmful when we look at the evidence. Based on available evidence I can't see why you would give Mg to your headache patients and don't say, "because it works" because it pretty clearly doesn't
1: Wang F, Van Den Eeden SK, Ackerson LM, Salk SE, Reince RH, Elin RJ. Related Articles, Links
Abstract Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a randomized, double-blind, placebo-controlled trial.
Headache. 2003 Jun;43(6):601-10.
PMID: 12786918 [PubMed - indexed for MEDLINE]
2: Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Related Articles, Links
Abstract Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache.
Ann Emerg Med. 2001 Dec;38(6):621-7.
PMID: 11719739 [PubMed - indexed for MEDLINE]
3: Ginder S, Oatman B, Pollack M. Related Articles, Links
Abstract A prospective study of i.v. magnesium and i.v. prochlorperazine in the treatment of headaches.
J Emerg Med. 2000 Apr;18(3):311-5.
PMID: 10729668 [PubMed - indexed for MEDLINE]
4: Peikert A, Wilimzig C, Kohne-Volland R. Related Articles, Links
Abstract Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study.
Cephalalgia. 1996 Jun;16(4):257-63.
PMID: 8792038 [PubMed - indexed for MEDLINE]
5: Mauskop A, Altura BT, Cracco RQ, Altura BM. Related Articles, Links
Abstract Intravenous magnesium sulfate rapidly alleviates headaches of various types.
Headache. 1996 Mar;36(3):154-60.
PMID: 8984087 [PubMed - indexed for MEDLINE]
6: Taubert K. Related Articles, Links
Abstract [Magnesium in migraine. Results of a multicenter pilot study]
Fortschr Med. 1994 Aug 30;112(24):328-30. German.
PMID: 7959501 [PubMed - indexed for MEDLINE]
7: Facchinetti F, Sances G, Borella P, Genazzani AR, Nappi G. Related Articles, Links
Abstract Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium.
Headache. 1991 May;31(5):298-301.
PMID: 1860787 [PubMed - indexed for MEDLINE]
What it comes down to is four randomized trials of Mg as PROPHYLAXIS for migraine which show variable but generally positive results. One randomized comparison of Mg to Compazine which showed compazine kicking Mg's ass. One nonrandomized, poorly controlled, small study with a grab bag of head ache types which showed 80% relief with Mg (no placebo group). And one randomized controlled trial of reglan+Mg vs reglan+placebo which showed Mg made one drug that we know works, reglan, less effective.
There are lots of things done in medicine because somebody thought it was a good idea and the old guys swear its always worked great for them so it becomes self-perpetuating. This is one of those ideas that appears to actually be harmful when we look at the evidence. Based on available evidence I can't see why you would give Mg to your headache patients and don't say, "because it works" because it pretty clearly doesn't
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To go back to the OP...
Am I the only one who still uses digital intubation as a method of last resort? I performed them fairly frequently "on the street" (great way to intubate the non-extricated pt. for on-scene airway control). In medical school did one on an anes./critical care rotation while the chief was going for the "difficult airway" cart. Got looked at sideways first, then was asked to inservice the residents on the technique (and got "high honors" - yes!). Maybe I've got freakishly long fingers (they don't look it...) but digital has always been my "backup" of choice (with paralytics on board).
Anyone else use this "old school" technique?
- H
Am I the only one who still uses digital intubation as a method of last resort? I performed them fairly frequently "on the street" (great way to intubate the non-extricated pt. for on-scene airway control). In medical school did one on an anes./critical care rotation while the chief was going for the "difficult airway" cart. Got looked at sideways first, then was asked to inservice the residents on the technique (and got "high honors" - yes!). Maybe I've got freakishly long fingers (they don't look it...) but digital has always been my "backup" of choice (with paralytics on board).
Anyone else use this "old school" technique?
- H
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i have practiced it a lot, but never had to use it. one of my partners used it successfully on a trauma code before extrication.
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Digital tubing is great but is really more applicable to the street. You need an obtunded patient who is sitting, can't be put supine and needs a tube. I won't stick my finger in a pt's mouth unless they're really down. In the ED they can be laid flat. This is the same reason we don't use nasal tubes too much. There's only a very limited group of pts for whom it's appropriate.
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docB said:
I've used it on supine pts. with good success. Oh well, I guess it is one of those "old habits that die hard".
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Interesting discussion. In my humble experience (12 years EMS paramedic, starting med school in August) I have run into situations were the Nitrogen wash out idea has worked quite well and by monitoring oxygen sats and capnography, I have been able to spend the time necessary (sometimes as many as five minutes) to ensure an adequate airway on a patient who really needed it. The thing to remember with much of the science of ventilation, oxygenation and airway control is that the research was done in the controled setting of the operating room by our good friends in anestheisa (whom I hope to join in about four years). Therefore, the data they report does not always translate in the emergency deparment/EMS environment. Every patient is different and some do take more time than we like to get them intubated.
Anyway, while we are on the subject of resuce airways has anyone heard of the eschman catheter? It is a yellow stylette like device that one can use on a difficult airway. It works quite well on the patient who is very anterior and most likely to really test one's airway skills. To use the device you vissualize the catheter as close to the glottic opening as you can then pass the tube over the catheter and due to the up shaped curve at the tip of the catheter the tube passes over the catheter and into the glottis. It works quite well and has saved my bacon (not to mention helped me ventilate a patient) more than once!
-Zach
TUCOM '08
Anyway, while we are on the subject of resuce airways has anyone heard of the eschman catheter? It is a yellow stylette like device that one can use on a difficult airway. It works quite well on the patient who is very anterior and most likely to really test one's airway skills. To use the device you vissualize the catheter as close to the glottic opening as you can then pass the tube over the catheter and due to the up shaped curve at the tip of the catheter the tube passes over the catheter and into the glottis. It works quite well and has saved my bacon (not to mention helped me ventilate a patient) more than once!
-Zach
TUCOM '08
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zreagle said:
I just did a search, and found out the Eschmann catheter is the gum bougie.
I've never used it or seen it used, but seen it around readily in the OR, and a gas buddy of mine swears by it.
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Apollyon said:
Gum bougies are way cool. An excellent, low tech, easy to use, save your ass device. We got to use them a lot during residency and I still swear by them.
