- Mark Su, MD, MPH
Mark Su, MD, MPH
- Clinical Associate Professor of Emergency Medicine
- New York University School of Medicine
- Allon Amitai, MD
Allon Amitai, MD
- Attending Physician
- Kahuku Medical Center
- Section Editors
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
Phenytoin (eg, Dilantin) is an anticonvulsant medication used to treat many seizure disorders. It is also a Vaughan-Williams class IB antiarrhythmic agent, although it is now infrequently used for that indication.
Phenytoin toxicity is rarely fatal, but can cause neurologic symptoms ranging from nystagmus to ataxia to coma. Intravenous phenytoin administration may rarely be complicated by Purple Glove Syndrome.
The basic pharmacology, presentation, and management of phenytoin toxicity will be reviewed here. The clinical use of phenytoin to treat epilepsy and general issues concerning management of the poisoned patient are discussed elsewhere. A summary table to facilitate emergent management is provided (table 1). (See "Overview of the management of epilepsy in adults" and "General approach to drug poisoning in adults".)
Phenytoin toxicity is associated with few serious adverse events or fatalities. According to the 2011 Annual Report of the American Association of Poison Control Centers (AAPCC) National Poison Data System, 1971 single-substance phenytoin exposures resulted in only 46 major outcomes and one death . There were four reported fatalities in cases of multiple-substance exposures in which phenytoin or fosphenytoin was deemed contributory, but in none of these cases was phenytoin determined to be the primary cause of death. This low incidence of major outcomes and deaths is similar to that seen in previous years .
Fosphenytoin, a prodrug of phenytoin, is believed to have fewer adverse effects than phenytoin. However, there were 29 cases of cardiac events related to fosphenytoin infusion reported to the US Food and Drug Administration (FDA) between 1997 and 2002 . Ten of these resulted in death. Arrhythmias included bradycardia, high degree AV block, and sinus arrest. It is unclear how many of these dysrhythmias can be directly attributed to fosphenytoin, since many of these patients had significant preexisting cardiac pathology or were presumed to be in a state of cardiac stress from status epilepticus.
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- Chokshi R, Openshaw J, Mehta NN, Mohler E 3rd. Purple glove syndrome following intravenous phenytoin administration. Vasc Med 2007; 12:29.
- Scumpia AJ, Yahsou J, Cajina J, Cao C. Purple glove syndrome after intravenous phenytoin administration presenting in the emergency department. J Emerg Med 2013; 44:e281.
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- Chhabra P, Gupta N, Kaushik A. Compartment syndrome as a spectrum of purple glove syndrome following intravenous phenytoin administration in a young male: a case report and review of literature. Neurol India 2013; 61:419.
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- Barrueto, F, Jr, Nelson, LS. Antiepileptic Agents. In: Pediatric Toxicology: Diagnosis & Management of the Poisoned Child, Erickson, TB, Ahrens, WR, Aks, SE, et al (Eds), McGraw-Hill, New York 205. p.283.
- PHARMACOLOGY AND CELLULAR TOXICOLOGY
- CLINICAL FEATURES
- History and drug administration
- Physical examination
- Drug-induced hypersensitivity syndrome
- Skin and soft tissue
- DIFFERENTIAL DIAGNOSIS
- LABORATORY EVALUATION
- Specific testing
- General testing
- General approach
- Airway and breathing
- Decontamination and removal
- Antidotal therapy
- Hypersensitivity and skin reactions
- Monitoring and disposition
- PEDIATRIC CONSIDERATIONS
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS