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Related Experiment Videos

Iatrogenic magnesium overdose: two case reports

R J Vissers1, R Purssell

  • 1Department of Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

The Journal of Emergency Medicine
|March 1, 1996
PubMed
Summary

Two patients suffered cardiac arrest from accidental 20g intravenous magnesium sulfate overdose during alcohol withdrawal treatment. While both were resuscitated, one died, highlighting medication safety risks.

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Area of Science:

  • Clinical Medicine
  • Pharmacology
  • Toxicology

Background:

  • Magnesium sulfate is commonly used for conditions like alcohol withdrawal.
  • Iatrogenic magnesium overdose is rare, especially without renal impairment.

Observation:

  • Two patients received a 10-fold overdose of intravenous magnesium sulfate (20g instead of 2g).
  • Both patients experienced cardiac arrest following the overdose.
  • Successful resuscitation was achieved in both cases.

Findings:

  • Hypermagnesemia can lead to severe, life-threatening complications including cardiac conduction delays, asystole, apnea, and coma.
  • One patient recovered fully, while the other succumbed to complications three days later.
  • A previous case report documented a fatal iatrogenic magnesium overdose.

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Implications:

  • The study underscores the critical need for meticulous attention to drug dosages and units of measurement in intravenous magnesium therapy.
  • Standardizing medication orders and labels is crucial to prevent administration errors.
  • This case series emphasizes the potential for severe adverse events, including fatality, from medication errors in clinical practice.