Resuscitation from prolonged cardiac arrest with high-dose intravenous magnesium sulfate

doi:10.1016/0736-4679(91)90220-A

The Journal of Emergency Medicine

Volume 9, Issue 6, November–December 1991, Pages 469-476

https://doi.org/10.1016/0736-4679(91)90220-A Get rights and content

Abstract

We present evidence of resuscitation from prolonged (70-min) cardiac arrest, temporally associated with administration of 8 g intravenous (IV) magnesium sulfate (MgSO₄). A patient undergoing liposuction surgery developed bradycardia and a fall in oxygen tension after reversal of general anesthesia with physostigmine. The electrocardiogram (ECG) rhythm degenerated to ventricular asystole, which was refractory to standard therapy, including multiple boluses of epinephrine, atropine, wide-open dopamine, and attempts at right heart pacing. External cardiopulmonary resuscitation (CPR) was continuously maintained with the patient intubated on 100% oxygen. Multiple electric countershocks (× 7) and lidocaine were also administered when ventricular tachycardia/ventricular fibrillation (VTNF) occurred, but without clinical success. Approximately one hour into the resuscitation, after all of the above occurred, 8 g IV MgSO₄ was given and countershock repeated. Whereas the 7 previous countershocks had resulted in unsuccessful conversion of VT/VF to a pulseless rhythm (END), the 8th countershock (applied immediately after two 4 g boluses of IV MgSO₄) resulted in a stable pulse and normal sinus rhythm developing within 4 minutes. The patient recovered without neurologic deficit.

References (47)

A. Tortolani et al.
In-hospital cardiopulmonary resuscitation: patient arrest and resuscitation factors associated with survival
Resuscitation
(1990)
L.T. Iseri et al.
Magnesium deficiency and cardiac disorders
Am J Med.
(1975)
B. Buky
Effects of magnesium on ventricular fibrillation due to hypothermia
Br J Anesthesia
(1970)
E.E. Harrison et al.
Use of calcium in electromechanical dissociation
Ann Emerg Med.
(1984)
H.A. Stueven et al.
Calcium chloride: reassessment of use in asystole
Ann Emerg Med.
(1984)
H. Stueven et al.
Effect of calcium chloride in refractory electromechanical dissociation
Ann Emerg Med.
(1984)
H. Zwerling
Does exogenous magnesium suppress myocardial irritability and tachycardia in the non-digitalized patient?
Am Heart J.
(1987)
B. Chipperfield et al.
Differences in metal content of the heart muscle in death from ischemic heart disease
Am Heart J.
(1978)
D.A. Cooley et al.
Ischemic contracture of the heart: “stone-heart”
Am J Cardiol.
(1972)
C.J. Johnson et al.
Myocardial tissue concentrations of magnesium and potassium in men dying suddenly from ischemic heart disease
Am J Clin Nutr.
(1979)

J.S. Pirolo et al.

Electromechanical dissociation. Pathologic explanations in 50 patients

Hum Pathol.

(1985)

P.D. Turlapaty et al.

Extracellular magnesium ions control calcium exchange and content of vascular smooth muscle

Eur J Pharmacol.

(1978)

M.L. Entman et al.

Phasic components of calcium binding and release by canine cardiac relaxing system (sarcoplasmic recticulum fragments)

J Mol Cell Cardiol.

(1972)

J. Vitale et al.

The effects of magnesium deficiency on oxidative phosphorylation

J Biol Chem.

(1957)

J.C. Pamintuan et al.

Comparative mechanisms of antiarrhythmic agents

Amer J. Cardiol.

(1970)

L.A. DiCarlo et al.

Effects of magnesium sulfate on cardiac conduction and refractoriness in humans

J Am Coll Cardiol.

(1986)

J. Freundlich

Paroxysmal ventricular tachycardia

American Heart J.

(1946)

B. Scaff et al.

Cardiopulmonary resuscitation at a community hospital with a family practice residency

J Fam Pract.

(1984)

S.E. Bedell et al.

Survival after cardiopulmonary resuscitation in the hospital

N Engl J Med.

(1983)

P.I. Polimeni et al.

Magnesium in heart muscle

Circ Res.

(1973)

L.T. Iseri et al.

Magnesium therapy for intractable ventricular arrhythmias in normomagnesemic patients

West J. Med.

(1983)

M.M. Scheinman et al.

Magnesium metabolism in patients undergoing cardiopulmonary bypass

Circulation

(1969)

R.W. Sullivan et al.

Clinical significance of hypomagnesemia in patients undergoing cardiopulmonary bypass

Circulation

(1969)

Cited by (29)

Drugs in Out-of-Hospital Cardiac Arrest
2018, Cardiology Clinics
Citation Excerpt :
The use of procainamide for cardiac arrest is not recommended, given the lack of data on its effectiveness.4 The use of magnesium as an antiarrhythmic in cardiac arrest has followed case reports of its use after prolonged downtimes with patient survival.42,43 Magnesium has also been used successfully as a treatment for terminating polymorphic VT with a prolonged QT interval (ie, torsades de pointes).44,45
The impact of the code drugs: Cardioactive medications in cardiac arrest resuscitation
2012, Emergency Medicine Clinics of North America
Citation Excerpt :
Tobey and colleagues25 reported the case of a 46-year-old man who suffered a VF arrest, received 62 minutes of ACLS care, and was successfully resuscitated on arrival in the emergency department when he received 4 g of IV magnesium sulfate (MgSO4). Craddock26 reports a similar case in which a 41-year-old woman experienced an asystolic cardiac arrest postoperatively and subsequent ROSC, which was temporally related to the administration of 8 g of IV MgSO4. Because of these 2 dramatic case reports, Fatovich and colleagues27 conducted the MAGIC (Magnesium in Cardiac Arrest) trial to determine if high-dose magnesium was associated with increased survival from out-of-hospital cardiac arrest.
Part 8: Advanced life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
2010, Resuscitation
Citation Excerpt :
The presence of a low plasma magnesium concentration was associated with poor prognosis in cardiac arrest patients in three studies (LOE 5).724–726 The use of magnesium in cardiac arrest was supported by five case series (LOE 4)727–731; however, five RCTs (LOE 1)219–222,732 and a systematic review (LOE 1)733 found no benefit from the use of magnesium in cardiac arrest. No studies were identified that specifically addressed the treatment of cardiac arrest caused by hypocalcaemia or hypercalcaemia.
Update in Pediatric Resuscitation
2009, Advances in Pediatrics
Citation Excerpt :
Similar to calcium, magnesium administration is recommended in specific circumstances, such as hypomagnesemia or torsades de pointes VT [77]. Case reports have suggested an improvement in survival among adult cardiac arrest patients given magnesium [103,104] but randomized control trials in in-hospital [105] and out-of-hospital [106] arrest populations showed no improvement in outcomes. Insufficient pediatric or adult evidence exists to recommend for or against its use during cardiac arrest [77].
Magnesium in cardiopulmonary resuscitation: Critical review
2008, Resuscitation
Citation Excerpt :
Although local coronary vasodilation may improve myocardial blood flow, systemic vasodilation following rapid or high-dose Mg administration reduces aortic diastolic pressure and coronary perfusion pressure, and if the reduction in aortic diastolic pressure is excessive, may decrease resuscitation rates. Despite these concerns, several case reports suggested an association between the administration of IV Mg and survival in patients with refractory or prolonged cardiac arrest.18,19 However, the role of Mg in or immediately after cardiac arrest in adults or children has not been systematically studied.
Although many different drugs and interventions have been studied in cardiac arrest to improve survival rates and neurological outcome, the results are still very poor. Magnesium (Mg) has important electrophysiological effects and normal concentrations are required to maintain regular cardiac conduction, rhythm and vascular tone, but its role in improving survival rates and neurological outcome in victims of cardiac arrest is not completely understood. We conducted a systematic review to identify evidence regarding the role of Mg in cardiac arrest. Specifically, we looked for data to answer if survival rates and neurological outcome are related to the administration of Mg either during CPR or following return of spontaneous circulation. We found that there are very few data available about the role of Mg in the treatment of cardiac arrest. Although two non-randomised and one animal study reported promising results, the lack of high quality studies makes it impossible to recommend for or against the administration of Mg during or early after resuscitation to improve outcome.
The use of anti-arrhythmic agents in cardiopulmonary resuscitation
2000, Bailliere's Best Practice and Research in Clinical Anaesthesiology
Cardiac arrest is a major cause of unexpected sudden death in adults. In the majority of cases an arrhythmia is the primary cause. A multitude of agents have been used in the treatment of ventricular fibrillation and asystole during cardiac arrest. At present there is no evidence to indicate that any of these agents ultimately improve the final outcome in humans. Prevention, competent basic life support and rapid defibrillation for patients in ventricular fibrillation remain the mainstays of treatment for cardiac arrest.

View all citing articles on Scopus

View full text

Selected topicResuscitation from prolonged cardiac arrest with high-dose intravenous magnesium sulfate

Abstract

Resuscitation

Am J Med.

Br J Anesthesia

Ann Emerg Med.

Ann Emerg Med.

Ann Emerg Med.

Am Heart J.

Am Heart J.

Am J Cardiol.

Am J Clin Nutr.

Hum Pathol.

Eur J Pharmacol.

J Mol Cell Cardiol.

J Biol Chem.

Amer J. Cardiol.

J Am Coll Cardiol.

American Heart J.

Cardiopulmonary resuscitation at a community hospital with a family practice residency

J Fam Pract.

Survival after cardiopulmonary resuscitation in the hospital

N Engl J Med.

Magnesium in heart muscle

Circ Res.

Magnesium therapy for intractable ventricular arrhythmias in normomagnesemic patients

West J. Med.

Magnesium metabolism in patients undergoing cardiopulmonary bypass

Circulation

Clinical significance of hypomagnesemia in patients undergoing cardiopulmonary bypass

Circulation

Selected topic
Resuscitation from prolonged cardiac arrest with high-dose intravenous magnesium sulfate