CORRESPONDENCE
d i s e a s e u n d e r g o i n g v a r i o u s procedures and found significant respiratory depression in 4.2%. 4 Total dosage of meperidine used exceeded our guidelines in three of four patients with complications in his series. The mean dosage of meperidine was 2.6 mg/kg in those with complications. Although "prospective," no means or trends for the other 91 patients in this series were reported. In evaluating 2,340 children reported after IM MPC, 16 (0.7%) had serious complications (Table). We find that children with complications tend to have underlying disease (69%), higher doses of meperidine (56%), and transient respiratory depression (81%). As we stated, we were unable to comment on the development or prediction of serious side effects in our report because of the small number of study subjects. We agree that we must be more vigilant about providing satisfactory sedation when initial attempts seem insufficient. Although there are s o m e p r o m i s i n g agents available for comparison, IM MPC remains the m o s t c o m m o n outpatient sedative/analgesic agent combination used on children for laceration repair. 9 Complications may be reduced by avoiding MPC use in children with chronic illness, seizure disorders, abnormal mental status, and acute head injury. As alternative sedative/analgesic agents are examined fo r efficacy in the ED setting, investigators should have a safety profile comparable to that of IM MPC. Thomas E Terndrup, MD, FACEP Daniel J Dire, MD Celeste Madden, MD, FAAP Richard Cantor, MD, FAAP Denise Gavula, DO State University of New York Health Science Center Syracuse
152/1277
1. Terndzup TE~ Cantor RM, Madden CM: Intramuscular meperidine, promethazine, and chlorpromazine: Analysis of use and complications in 487 pediatric e m e r g e n c y d e p a r t m e n t patients. A n n Emerg Med 1989;18:528-833. 2. MeConachie IW, Day A, Morris P: Recovery from anaesthesia in children. Anaesthesia i989;44:986-990. 3. Smith C, Rowe RD, Vlad P: Sedation of children for cardiac catheterization with an ataractic mixture. Can Anes Soc J 1958~5:35-40. 4. Nahata MC r Clotz MA, Krogg EA: Adverse effects of meperidine~ promethazine, and chlorpromazine for sedation in pediatric patients. Clin Pediatr 1985;24: 558-560.
5. Benusis KP, Kapann D, Furuam LJ: Respiratory depression in a child following meperidine, promethazine, and chlorpromazine premedication: Report of a case. J Dent Child 1979j46:80-53. 6. Mitchell AA, Louik C, Laeourture P, et a]: Risks to children from computed tomographic scan premedication. JAMA i982;247:2385-2388. 7. Cohen GH, Casta A, Sapire DW, et al: Decorticate posture following 'cardiac cocktail': A transient complication of sedation for catheterization. Ped Cardiol 1982~2:251-253. 8. Pierluisi GJ, Terndrup TE: Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations. Pediatr Emerg Care 1989;5:211-215. 9. Hawk W, Crockett RK, Ochsenschlagei DW, et al: Conscious sedation of the pediatric patient for suturing: A survey. Ped Emerg Care 1990;6:84-88.
Magnesium Should Not Be Omitted When Managing Seizures in Pregnancy To the Editor: The article, "Emergency Department Approach to Managing Seizures in Pregnancy" by Jagoda and Riggio [January 1991;20:80-85], is practical and well researched except in one respect, namely the role of magnesium in pregnancy. The authors quote from the paper of V H a c h i n s k y (reference no. 76) that, " m a g n e s i u m should be relegated to the labs, clinical trials, or history." On the contrary, the role of
Annals of Emergency Medicine
magnesium is being more and more recognized as a potential factor in the reduction of the incident of toxemia, p r e m a t u r e delivery, and low birth weight. The musculoskeletal system of the developing fetus extracts not only calcium but also large a m o u n t s of magnesium from the maternal circulation, predisposing the pregnant w o m a n to m a g n e s i u m deficiency, particularly if her diet is low in magnesium. Admittedly there is suffic i e n t m a g n e s i u m in the average American diet, but not every pregnant woman follows a well-rounded diet for many reasons. At this period of clarification of the role of magnesium in pregnancy, it would be a mistake to relegate its use to history when history itself has already proved its usefulness. True, magnesium cannot be considered a good anticonvulsant, but it is also well known that its depletion lowers the seizure threshold, a condition correctable by m a g n e s i u m supplementation; this condition should not be neglected even if anticonvulsants are given. When eclampsia is treated with near-toxic and tocolytic doses of m a g n e s i u m it is p r o b a b l y too much magnesium too late. M a g n e s i u m is a safe and cheap drug that in moderate doses has no downside risks in the absence of renal failure and has no teratogenic effects at all. It seems advisable to correct m a g n e s i u m deficiency during pregnancy, particularly if seizure disorder or toxemia is present. Magnesium should not be omitted from the treatment of eclampsia or eclamptic seizures.
Joseph K Kiraly, MD, FACEP Emergency Department Danbury Hospital Danbury, Connecticut
20:11 November 1991
d i s e a s e u n d e r g o i n g v a r i o u s procedures and found significant respiratory depression in 4.2%. 4 Total dosage of meperidine used exceeded our guidelines in three of four patients with complications in his series. The mean dosage of meperidine was 2.6 mg/kg in those with complications. Although "prospective," no means or trends for the other 91 patients in this series were reported. In evaluating 2,340 children reported after IM MPC, 16 (0.7%) had serious complications (Table). We find that children with complications tend to have underlying disease (69%), higher doses of meperidine (56%), and transient respiratory depression (81%). As we stated, we were unable to comment on the development or prediction of serious side effects in our report because of the small number of study subjects. We agree that we must be more vigilant about providing satisfactory sedation when initial attempts seem insufficient. Although there are s o m e p r o m i s i n g agents available for comparison, IM MPC remains the m o s t c o m m o n outpatient sedative/analgesic agent combination used on children for laceration repair. 9 Complications may be reduced by avoiding MPC use in children with chronic illness, seizure disorders, abnormal mental status, and acute head injury. As alternative sedative/analgesic agents are examined fo r efficacy in the ED setting, investigators should have a safety profile comparable to that of IM MPC. Thomas E Terndrup, MD, FACEP Daniel J Dire, MD Celeste Madden, MD, FAAP Richard Cantor, MD, FAAP Denise Gavula, DO State University of New York Health Science Center Syracuse
152/1277
1. Terndzup TE~ Cantor RM, Madden CM: Intramuscular meperidine, promethazine, and chlorpromazine: Analysis of use and complications in 487 pediatric e m e r g e n c y d e p a r t m e n t patients. A n n Emerg Med 1989;18:528-833. 2. MeConachie IW, Day A, Morris P: Recovery from anaesthesia in children. Anaesthesia i989;44:986-990. 3. Smith C, Rowe RD, Vlad P: Sedation of children for cardiac catheterization with an ataractic mixture. Can Anes Soc J 1958~5:35-40. 4. Nahata MC r Clotz MA, Krogg EA: Adverse effects of meperidine~ promethazine, and chlorpromazine for sedation in pediatric patients. Clin Pediatr 1985;24: 558-560.
5. Benusis KP, Kapann D, Furuam LJ: Respiratory depression in a child following meperidine, promethazine, and chlorpromazine premedication: Report of a case. J Dent Child 1979j46:80-53. 6. Mitchell AA, Louik C, Laeourture P, et a]: Risks to children from computed tomographic scan premedication. JAMA i982;247:2385-2388. 7. Cohen GH, Casta A, Sapire DW, et al: Decorticate posture following 'cardiac cocktail': A transient complication of sedation for catheterization. Ped Cardiol 1982~2:251-253. 8. Pierluisi GJ, Terndrup TE: Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations. Pediatr Emerg Care 1989;5:211-215. 9. Hawk W, Crockett RK, Ochsenschlagei DW, et al: Conscious sedation of the pediatric patient for suturing: A survey. Ped Emerg Care 1990;6:84-88.
Magnesium Should Not Be Omitted When Managing Seizures in Pregnancy To the Editor: The article, "Emergency Department Approach to Managing Seizures in Pregnancy" by Jagoda and Riggio [January 1991;20:80-85], is practical and well researched except in one respect, namely the role of magnesium in pregnancy. The authors quote from the paper of V H a c h i n s k y (reference no. 76) that, " m a g n e s i u m should be relegated to the labs, clinical trials, or history." On the contrary, the role of
Annals of Emergency Medicine
magnesium is being more and more recognized as a potential factor in the reduction of the incident of toxemia, p r e m a t u r e delivery, and low birth weight. The musculoskeletal system of the developing fetus extracts not only calcium but also large a m o u n t s of magnesium from the maternal circulation, predisposing the pregnant w o m a n to m a g n e s i u m deficiency, particularly if her diet is low in magnesium. Admittedly there is suffic i e n t m a g n e s i u m in the average American diet, but not every pregnant woman follows a well-rounded diet for many reasons. At this period of clarification of the role of magnesium in pregnancy, it would be a mistake to relegate its use to history when history itself has already proved its usefulness. True, magnesium cannot be considered a good anticonvulsant, but it is also well known that its depletion lowers the seizure threshold, a condition correctable by m a g n e s i u m supplementation; this condition should not be neglected even if anticonvulsants are given. When eclampsia is treated with near-toxic and tocolytic doses of m a g n e s i u m it is p r o b a b l y too much magnesium too late. M a g n e s i u m is a safe and cheap drug that in moderate doses has no downside risks in the absence of renal failure and has no teratogenic effects at all. It seems advisable to correct m a g n e s i u m deficiency during pregnancy, particularly if seizure disorder or toxemia is present. Magnesium should not be omitted from the treatment of eclampsia or eclamptic seizures.
Joseph K Kiraly, MD, FACEP Emergency Department Danbury Hospital Danbury, Connecticut
20:11 November 1991
