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Phenytoin (commonly known by the brand name Dilantin® ) has been used since the 1930’s as an anticonvulsant and is still a first-line drug used for some seizure disorders. Many overdoses with phenytoin are reported to poison centers, but fatalities are rare.
Absorption of oral doses of phenytoin is often erratic and delayed. It’s not unusual to see gastrointestinal absorption continue for several days. Phenytoin is highly protein bound and rapidly distributed to all tissues. Therapeutic levels are 10-20 mcg/mL.. Labs routinely test for total phenytoin; however, only free or unbound phenytoin is responsible for clinical effects. More than 95% of the drug is metabolized by the liver. The half-life of phenytoin is 6-24 hours with therapeutic doses but is prolonged in overdoses, to 20-60 hours.
Acute phenytoin toxicity produces mainly neurologic symptoms that may persist for days to a week or more. Phenytoin concentrations greater than 15-20 mcg/mL are associated with horizontal and/or vertical nystagmus, ataxia is seen with levels greater than 30 mcg/mL , and slurred speech, confusion and lethargy appear at levels greater than 40-50 mcg/mL. Large overdoses may also result in tremor, delirium, hyperreflexia, dyskinesias, hallucinations, and coma. Nausea and vomiting can occur following phenytoin ingestions because of the large amount of undissolved drug in the stomach. Respiratory depression rarely occurs. High doses of intravenous phenytoin or rapid infusions can result in hypotension, bradycardia and dysrhythmias due to myocardial conduction depression. These cardiovascular effects are thought to be due to the propylene glycol diluent in the parenteral form of phenytoin. Cardiovascular toxicity following oral overdoses has not been reported; therefore, patients who ingest large amounts of phenytoin do not need cardiac monitoring.
Treatment consists of supportive care and activated charcoal. Repeat doses of charcoal are often recommended to prevent further absorption of any drug that persists in the GI tract. Ataxic patients should be observed closely and steps taken to prevent falls. Because of its erratic absorption, phenytoin levels should be repeated every six hours after an acute overdose.
See Also - these poisoning and overdose segments on the Nursing Show:
For those of you who deal with pediatric or adolescent patients, you know that kids don’t need extra help getting injured sometimes. However, what about when they are involved in sports?
A recent article at WebMD talks about a recent study published in the Journal of Athletic Trainers April 2008 issue, where they looked at the riskiest high school sports activities. Not surprisingly, Football topped the list for both competition and practice related injuries. Following on football’s heels were, girls and boys soccer for competition related injuries and wrestling and boys soccer for practice related injuries.
When you talk to these young athletes, stress to them the importance to rest and let their injuries heal before returning to practice and make sure they know about the importance of proper stretching before practice and games, as well as the use of protective gear associated with their sport. I interviewed a Dr. Mike of the Pediacast about sports injuries on the MedicCast Podcast. Check out that episode for his take on sports injuries in kids.
I like the article I found recently on rural telemedicine. It talks about linking patients in remote areas of the country and even the world with health care specialists and testing that will open up incredible possibilities for these people.
Imagine a patient who may have an internal bleed. Local health care is unable to adequately assess the patient locally. Do you transport the patient by ground for hours to a specialty center only to find that they didn’t need to go there? This technology offers these borderline patients a chance to be “seen” by doctors who are located elsewhere (perhaps around the world), and have the assessing team on location be guided in their assessment by the specialist.
Nurses or local doctors act as the eyes and ears of the specialist, transmit data, video, or audio files to the distant location and have a better chance at saving the patient the need for extended costs of specialty care and transport if they don’t need it. It also offers diagnostic tools to catch problems that might be missed.
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If you are involved in education or corporate communications, you won’t want to miss all of the fantastic speakers and information sessions at this year’s expo. Stay tuned here at the MedicCast, I have a special badge for you to use to register and help out the show here by doing so.
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A recent U.S. Supreme Court decision may have a significant impact on the future of major medical device and pharmaceutical lawsuits. The Court decided that a lawsuit against Medtronic, Inc. was improper based on the fact that the FDA oversight for acceptable adverse effect and outcome rates should not be second guessed in the courts.
Supporters of the Court’s decision say that the pace of lawsuits against medical device manufacturers was fast approaching the point that they were stifling innovation in the marketplace. Detractors argue that the current tort system provides oversight and discovery of industry cover-ups. They might be right considering the recent revelations I discussed regarding drug companies covering up adverse reactions and effectiveness studies in favor of making money in higher sales.
This protection may be extended to include pharmaceutical companies since the Supreme Court is scheduled to hear a case in October concerning Wyeth Pharmaceuticals and a lawsuit against one of their products.
Researchers at Children’s Hospital of Philadelphia (CHOP) conducted a study of preventative health screenings of children in the first years of life and how those screenings were affected by continuity of care. In this case continuity of care referred to having the same medical provider perform assessments and care during the first six months of life.
The study focused on the children most at risk for preventable and treatable diseases like lead poisoning and tuberculosis exposure. Children in urban, low income families were more likely to have a variety of providers assessing them over the early months and years of life. Without a clear understanding of baseline responses that a provider might establish over a series of well and sick child visits (is the child normally irritable, has the child been developmentally appropriate, etc.), the child is more likely to have preventable conditions assessed and correctly diagnosed early.
For those of us who deal with these at risk populations, early recognition and treatment is key to preventing long term negative outcomes. When dealing with the parents of these children, stress to them the importance of returning to the same clinics and even to the same nurse, nurse practitioner, or physician’s assistant if not to the same doctor.
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