eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Phenytoin: Follow-up

Author: Charlene A Miller, MD, Consulting Staff, Department of Emergency Medicine, Oakwood Hospital Medical Center
Coauthor(s): Daniel M Joyce, MD, Consulting Staff, Department of Emergency Medicine, Saint Vincent's and Saint Mary's Medical
Contributor Information and Disclosures

Updated: Jul 15, 2009

Follow-up

Further Inpatient Care

  • Many patients with moderate toxicity require inpatient care because they are unable to ambulate from the severe ataxia or unable to eat secondary to the nausea.
    • Maintain adequate IV hydration.
    • These patients should be out of bed only with assistance because they are at high risk of falling and sustaining serious injuries.
  • Patients with the evidence of cardiac toxicity and ECG changes should be admitted to monitored settings
  • Numerous, repeat phenytoin levels are not required because symptoms and clinical signs allow determination of toxicity.
  • In chronic nonintentional overdoses, pay specific attention to the patient's pharmacopeia to determine if the toxicity was iatrogenic.

Further Outpatient Care

  • For nonintentional overdoses, individuals with mild toxicity may be treated as outpatients if they are not so ataxic that risk of self-injury is a concern and if they are capable of maintaining adequate hydration despite their nausea. In these instances, carefully review their medications and correct any wrong dosages or drug interactions.

Complications

  • The most common complications involve undiagnosed injuries sustained as a result of the phenytoin-induced ataxia.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose a phenytoin hypersensitivity reaction, thus not stopping further phenytoin ingestion
  • Failure to realize that signs and symptoms may progress as the free phenytoin penetrates the CNS, thereby discharging a patient with a deteriorating clinical picture
  • Prescribing a new drug that causes adverse pharmacokinetic reaction with a stable dose of phenytoin, thus leading to signs and symptoms of toxicity
  • Failure to diagnose traumatic injury in patients who are ataxic and suffer from fall
  • Aspiration pneumonia after administration of multiple doses of activated charcoal in patients with altered mental status

Special Concerns

  • Phenytoin toxicity may manifest itself in a variety of clinical symptoms and syndromes.
    • Because many clinicians are unfamiliar with subtle presentations of these syndromes, many cases of chronic toxicity may go unrecognized, with resultant serious consequences.
    • Phenytoin hypersensitivity is not a typical hypersensitivity reaction.
    • It may present as one of many different syndromes, such as lymphoma, hepatitis, or Stevens-Johnson syndrome.
    • It may include a wide variety of symptoms, such as fever, rash, arthralgias, or lymphadenopathy.
  • Because phenytoin toxicity may take many forms, consider the possibility of a phenytoin hypersensitivity reaction in any patient receiving phenytoin who has unusual symptoms. This is especially important if the patient presents with the triad of fever, rash, and lymphadenopathy.
 


More on Toxicity, Phenytoin

Overview: Toxicity, Phenytoin
Differential Diagnoses & Workup: Toxicity, Phenytoin
Treatment & Medication: Toxicity, Phenytoin
Follow-up: Toxicity, Phenytoin
References
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References

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Further Reading

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Keywords

phenytoin toxicity, phenytoin poisoning, phenytoin exposure, anticonvulsant drug, seizure disorder, phenytoin overdose, elevated phenytoin levels, status epilepticus, phenytoin ingestion, seizure treatment, treatment of seizure

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Contributor Information and Disclosures

Author

Charlene A Miller, MD, Consulting Staff, Department of Emergency Medicine, Oakwood Hospital Medical Center
Charlene A Miller, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel M Joyce, MD, Consulting Staff, Department of Emergency Medicine, Saint Vincent's and Saint Mary's Medical
Daniel M Joyce, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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