Toxicity, Phenytoin Treatment & Management

  • Author: Charlene A Miller, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Nov 4, 2010
 

Prehospital Care

The usual measures of airway maintenance, breathing assessment, and circulatory support are indicated.

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Emergency Department Care

Support airway, breathing, and circulation.[6]

Obtain IV access, provide supplemental oxygen, and place on a cardiac monitor.

Consider the risks versus the benefits of orogastric lavage; it rarely offers any advantage over activated charcoal and cathartic use.

Administer multiple dose activated charcoal[7] every 2-6 hours until passage of charcoal stool, loss of bowel sounds, or improved clinical condition is observed. This may be difficult because nausea and emesis may complicate phenytoin toxicity. Activated charcoal may precipitate vomiting, aspiration pneumonia, or electrolyte disturbances.

While hemodialysis and hemoperfusion have traditionally been thought of as ineffective for phenytoin toxicity (given protein binding of phenytoin), recent cases and studies have suggested that hemodialysis may have a limited role in phenytoin toxicity.[8]

The treatment of hypotension secondary to IV infusion includes decreasing the rate of infusion, intravenous fluids, and, possibly, vasopressors.

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Consultations

Consult neurology department personnel for moderate-to-severe reactions caused by chronic therapy. Patients require close follow-up and changes in anticonvulsant medication.

Patients with serious complications (eg, dysrhythmias, hemodynamic instability, altered mental status, severe ataxia, coma, seizures) following a toxic exposure require hospital admission for further monitoring and treatment.[9]

Consultation of psychiatry department personnel for intentional overdoses is mandatory.

Consult a plastic surgeon for extravasation injuries.

Consult the regional poison control center or a local medical toxicologist (certified by the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations.

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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.

Specialty Editor Board

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.

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.

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.

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, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

  1. Craig S. Phenytoin poisoning. Neurocrit Care. 2005;3(2):161-70. [Medline].

  2. McCluggage LK, Voils SA, Bullock MR. Phenytoin toxicity due to genetic polymorphism. Neurocrit Care. 2009;10(2):222-4. [Medline].

  3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline]. [Full Text].

  4. Adams BD, Buckley NH, Kim JY, Tipps LB. Fosphenytoin may cause hemodynamically unstable bradydysrhythmias. J Emerg Med. Jan 2006;30(1):75-9. [Medline].

  5. Chokshi R, Openshaw J, Mehta NN, Mohler E 3rd. Purple glove syndrome following intravenous phenytoin administration. Vasc Med. Feb 2007;12(1):29-31. [Medline].

  6. Sen S, Ratnaraj N, Davies NA, Mookerjee RP, Cooper CE, Patsalos PN. Treatment of phenytoin toxicity by the molecular adsorbents recirculating system (MARS). Epilepsia. Feb 2003;44(2):265-7. [Medline].

  7. Dolgin JG, Nix DE, Sanchez J, Watson WA. Pharmacokinetic simulation of the effect of multiple-dose activated charcoal in phenytoin poisoning--report of two pediatric cases. DICP. Jun 1991;25(6):646-9. [Medline].

  8. Ghannoum M, Troyanov S, Ayoub P, Lavergne V, Hewlett T. Successful hemodialysis in a phenytoin overdose: case report and review of the literature. Clin Nephrol. Jul 2010;74(1):59-64. [Medline].

  9. De Schoenmakere G, De Waele J, Terryn W, Deweweire M, Verstraete A, Hoste E, et al. Phenytoin intoxication in critically ill patients. Am J Kidney Dis. Jan; 2005;45(1):189-92. [Medline].

  10. Carducci B, Hedges JR, Beal JC, et al. Emergency phenytoin loading by constant intravenous infusion. Ann Emerg Med. Nov 1984;13(11):1027-31. [Medline].

  11. Dela Cruz FG, Kanter MZ, Fischer JH, Leikin JB. Efficacy of individualized phenytoin sodium loading doses administered by intravenous infusion. Clin Pharm. Mar 1988;7(3):219-24. [Medline].

  12. Donovan PJ, Cline D. Phenytoin administration by constant intravenous infusion: selective rates of administration. Ann Emerg Med. Feb 1991;20(2):139-42. [Medline].

  13. Earnest MP, Marx JA, Drury LR. Complications of intravenous phenytoin for acute treatment of seizures. Recommendations for usage. JAMA. Feb 11 1983;249(6):762-5. [Medline].

  14. Goldfrank L, Flomenbaum NE, Lewin NA. Anticonvulsants -- phenytoin. In: Goldfrank's Toxicologic Emergencies. 5th ed. New York: McGraw-Hill; 1994:591-4.

  15. Goldfrank L, Flomenbaum NE, Lewis NA, eds. Goldfrank's Toxicologic Emergencies. New York: McGraw-Hill; 1998.

  16. Jones GL, Wimbish GH. Hydantoins in antiepileptic drugs. In: Handbook of Experimental Pharmacology. New York: Springer-Verlag; 1985:725-65.

  17. Levine M, Chang T. Therapeutic drug monitoring of phenytoin. In: Clinical Pharmacokinetics. Vol 19. 1990:341-58.

  18. Murphy JM, Motiwala R, Devinsky O. Phenytoin intoxication. South Med J. Oct 1991;84(10):1199-204. [Medline].

  19. Plenge KL. The toxicity of the major anticonvulsants. Ariz Med. Mar 1978;35(3):177-9. [Medline].

  20. Prosser TR, Lander RD. Phenytoin-induced hypersensitivity reactions. Clin Pharm. Sep 1987;6(9):728-34. [Medline].

  21. Ramsay RE, Hammond EJ, Perchalski RJ, Wilder BJ. Brain uptake of phenytoin, phenobarbital, and diazepam. Arch Neurol. Sep 1979;36(9):535-9. [Medline].

  22. Salem RB, Wilder BJ, Yost RL, et al. Rapid infusion of phenytoin sodium loading doses. Am J Hosp Pharm. Mar 1981;38(3):354-7. [Medline].

  23. Tintinalli J, Ruiz E, Krome R. Phenytoin toxicity. In: Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill; 1996:807-11.

  24. Watson WA, Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Youniss J, Reid N. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline]. [Full Text].

  25. Yaari Y, Selzer ME, Pincus JH. Phenytoin: mechanisms of its anticonvulsant action. Ann Neurol. Aug 1986;20(2):171-84. [Medline].

 
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