Loading Dose Of Phenytoin Research Articles

Evaluation of phenytoin loading doses in overweight patients using actual versus adjusted body weight

Background and ObjectivesThe appropriate loading dose strategy for phenytoin/fosphenytoin in overweight patients is unknown. A small pharmacokinetic study indicated that overweight patients have a higher volume of distribution and potentially would benefit from using adjusted body weight (AdjBW) instead of actual body weight (ABW) to calculate the loading dose. The purpose of this study was to determine the optimal loading dose strategy of phenytoin in patients whose ABW is greater than 120% of their ideal body weight (IBW) using either ABW or AdjBW for calculation of the loading dose. MethodsThis was a single center, retrospective study which included patients who received a loading dose of phenytoin of at least 10 mg/kg based on ABW, had a phenytoin level drawn <6 h after the end of the dose, and weighed ≥120% of their IBW. Patients were excluded if they received intramuscular phenytoin or fosphenytoin or were prescribed phenytoin prior to the loading dose. Patients were divided into two groups, those who were dosed using their AdjBW versus those dosed using ABW. The primary outcome was achievement of therapeutic phenytoin level of 10–20 mcg/mL. Secondary outcomes included achievement of a subtherapeutic or supratherapeutic level. ResultsA total of 195 patients (128 in AdjBW group and 67 in ABW group) met criteria for inclusion. Patients in the AdjBW group weighed more (96.2 kg vs. 91.2 kg, p = 0.04) and received a lower dose in milligrams (1364 vs. 1760, p < 0.0001) and in mg/kg of ABW (14.2 vs. 19.3, p < 0.0001). The primary outcome was achieved in 74% of patients in the AdjBW group and 57% of patients in the ABW group (p = 0.02). Patients in the ABW group were more likely to have a supratherapeutic level (43% vs. 22%, p = 0.003), although adverse reactions did not differ between the groups. DiscussionPatients weighing >120% of their IBW (average body mass index 33.5 kg/m2) who received a 20 mg/kg loading dose based on AdjBW were more likely to achieve a therapeutic phenytoin concentration compared to those dosed based on ABW. Further research is needed to correlate this finding with clinical outcomes, such as resolution of status epilepticus.

Efficacy of phenytoin for 7 days versus 21 days as prophylactic anticonvulsant in traumatic brain injury patients - A comparative study.

Post traumatic seizures (PTS) are very common after traumatic brain injury and occur more common in severe form of injury. Prophylactic treatment with phenytoin has been found to be effective however till now no uniform internationally agreed guideline is available for the duration of anticonvulsant prophylaxis for traumatic brain injury patients. 100 patients of either sex between age group of 18-65 years who have suffered intracranial injury identified by CT scan, admitted in Trauma ICU were enrolled in this prospective randomized single blinded clinical study. Group 1 (n = 50) received 7 days prophylactic anticonvulsant therapy with phenytoin and Group 2 (n = 50) received for 21 days. The primary end point was the occurrence of seizures, which were classified as early (occurring from time of drug loading to day 7) or late (occurring on day 8 or later after loading of drug). Patients were also assessed for the possible adverse side effects of phenytoin. Out of 100 patients, 90 completed the study successfully as 5 patients from each group expired during the duration of the study. On comparing the frequency of seizure from 1st to 7th day after loading dose of phenytoin between two groups, out of 45 patient, 2 (4.4%) developed seizure in group 1 and 3 (6.7%) developed seizure in group 2 and found to be statistically insignificant (P = 0.645). On comparing the frequency of seizure from 1st to 21st day after loading dose of phenytoin between two groups, out of 45 patient, 4 (8.9%) developed seizure in groups 1 and 3 (11.1%) developed seizure in group 2 and found to be statistically insignificant (P = 0.725). A 21-day prophylactic anticonvulsant therapy with phenytoin was not more effective than a 7-day prophylactic therapy with phenytoin to reduce the frequency of seizure in a TBI patient in trauma ICU and was also associated with more adverse side effects that were insignificant.

Phenytoin induced Steven Johnson syndrome

Phenytoin is an anticonvulsant and Hydantoin, it is mainly used in the management o Seizures, and it stabilizes the neuronal membranes and decreases seizure activity by increasing efflux or reducing the influx of sodium ions across cell membranes in the motor cortex during the generation of nerve impulses. It is available in the market in the form of oral and intravenous forms, a loading dose of Phenytoin for the management of seizures is 10-20 mg, divided into 2-3 doses. Stevens-Johnson syndrome is a rare and serious adverse effect of the skin along with the membranes of the mucous. It is caused by specific Drugs or Viral Infections. We have performed causality assessment by using the WHO and NARANJO'S ADR rating scale. It will seem, it is a Probable ADR, and severity assessed it confers a Type-A ADR, and it should be in Probably Preventable. So being a Reliable Clinical Pharmacist, we recommend to all health care professionals be aware of adverse drug reactions, and Desirable vigilance is necessitated toward safe and effective management for specific patients, strictly observe the patients in sequence anticipate Dangerous Adverse events.

Successful treatment of refractory status epileptics with a single dose of IV ketamine in a Saudi child - a case report

Background: Status epileptics are classically defined as seizures that are continuous for 30 minutes or longer or repetitive seizures between which the patient does not regain consciousness. This study reports a case of a boy with a 2-hour seizure. Case Presentation: We present the case of a 7-year-old boy, who is known to have tuberous sclerosis (TSC2 gene mutation). On the day of presentation, the seizure had started with aura (epigastric pain with weakness in the face), then started to seize in a form left focal jerky movement with generalization associated with rolling up of the eyes, and lasted for 5 minutes; it was aborted clinically by lorazepam 0.1 mg/kg IV. However, the electroencephalography (EEG) showed subclinical seizure. The patient received a loading dose of phenytoin, 20 mg/kg IV, with no changes in the EEG; then Keppra (three doses) with a total of 40 mg/kg IV was given, but subclinical seizure still persisted. The patient was given one dose of Ketamine IV of 1 mg/kg, which resulted in complete cessation of the seizure activity within 3 minutes after injection, which was confirmed by prolonged EEG monitoring. The total duration of the seizure was 2 hours. Conclusion: Ketamine can be considered as a third-line drug in refractory status epilepticus.

Evaluation of Intravenous Phenytoin and Fosphenytoin Loading Doses: Influence of Obesity and Sex.

Recommended loading doses (LDs) of phenytoin and fosphenytoin range from 10 to 25 mg/kg. Few studies have examined the LD requirements in male versus female patients and in patients who are obese. To examine the influence of obesity and sex on phenytoin LDs. This was a retrospective cohort study comparing free phenytoin or fosphenytoin serum concentrations following LDs in male versus female and nonobese versus obese patients. An equation used for determining LDs in obese patients was evaluated. There were 141 nonobese and 54 obese patients. When adjusted for total body weight, the obese cohort received a smaller LD than the nonobese cohort (17 mg/kg, interquartile range [IQR] = 14.9-20.0, vs 20 mg/kg, IQR = 18.6-20.0, respectively; P < 0.001). There was no difference between the 2 cohorts in the measured free phenytoin concentration following the LD (obese: 1.7 µg/mL [IQR = 1.4-2.0]; nonobese: 1.8 µg/mL [IQR = 1.5-2.1]; P = 0.16). In the obese cohort, men received a significantly lower weight-based phenytoin dose compared with women (15 mg/kg [IQR = 14.0-19.2], vs 19.9 mg/kg [IQR = 15.0-20.0], respectively; P = 0.008). Postload free phenytoin concentrations were similar between the 2 groups (male: 1.6 µg/mL [IQR = 1.2-2.1]; female: 1.7 µg/mL [IQR = 1.4-2.0]; P = 0.24). Conclusion and Relevance: Phenytoin and fosphenytoin LDs of at least 15 mg/kg of actual body weight are more likely to lead to desired free phenytoin concentrations. Obese female patients need a larger weight-based dose than male patients to achieve similar postload phenytoin concentrations.

Intraoperative Seizures Detected as Increased Bispectral Index Values during Posterior Fossa Surgeries

AbstractWe present a case series of four cerebellopontine angle surgeries with intraoperative detection seizure activity. The cases discussed follow the uniform anesthetic protocol of maintenance with infusion of propofol, fentanyl and dexmedetomidine excluding muscle relaxant, targeted to maintain bispectral index (BIS) in the range of 40 to 60. The cases experienced either of the two scenarios: (I) Unexplained increased or widely varying BIS values associated with increases in BIS electromyography (EMG) and motor manifestation of seizure activity in limbs. (2) Varying BIS values with EMG activation of facial nerve monitoring without motor manifestation in limbs. A common theme noticed in all these cases was the utilisation of tranexamic acid in cumulative doses of 25 to 30 mg/kg and amelioration of the seizure activity with a loading dose of phenytoin (15 mg/kg). A hypothesis is being presented linking intraoperative seizures with a combination of tranexamic acid utilisation.

IV fosphenytoin in obese patients: Dosing strategies, safety, and efficacy.

Previous studies evaluated the disposition of IV phenytoin loading doses and found that obese patients had increased drug distribution into excess body weight, larger volumes of distribution, and longer half-lives when compared to their nonobese counterparts. We assess the safety and efficacy of fosphenytoin loading doses in patients with different body mass indices (BMIs). A retrospective chart review was conducted in 410 patients who received fosphenytoin. Patients were divided into 2 groups: BMI <30 (nonobese) and BMI ≥30 (obese). Patient demographics, fosphenytoin dose administered in mg/kg body weight, renal and liver function tests, fosphenytoin drug levels, and pre- and post-fosphenytoin administration vital signs were collected to assess for adverse events. Necessity of additional antiepileptic loading doses was used as a surrogate for clinical efficacy. The median dose of fosphenytoin administered was 19 mg/kg (interquartile range 15-20). The most frequently encountered adverse event was hypotension, which occurred in 39% of the cohort. Using a Bonferroni adjustment for multiple comparisons, there were no differences in adverse events between the 2 groups. The need for additional antiepileptic loading doses was not different between the 2 groups (p = 0.07). The incidence of adverse events and the need for repeat loading antiepileptic medications was similar between the 2 groups. From our findings, the patients in our study did not receive empiric loading dose adjustments and the current method of loading fosphenytoin achieves similar outcomes, regardless of the patient's BMI.

Comparing paediatric intravenous phenytoin doses using physiologically based pharmacokinetic (PBPK) modelling software

PurposeTo use a physiologically based pharmacokinetic (PBPK) modelling system to predict the serum levels achieved by two different intravenous loading doses of phenytoin. MethodsA phenytoin pharmacokinetic model was used in the Simcyp™ population-based ADME simulator, simulating 100 children age 2–10 years receiving intravenous phenytoin (18 and 20mg/kg). Visual checks were used to evaluate the predictive performance of the candidate model. ResultsLoading with doses of 18mg/kg, blood levels were sub-therapeutic in 22/100 (concentration at 2h post infusion (C2h) <10μg/mL), therapeutic in 62/100 (C2h 10–20μg/mL), and supra-therapeutic in 16/100 (C2h>20μg/mL). Loading with 20mg/kg, the percentages were 15, 59, and 26, respectively. Increasing from 18 to 20mg/kg increased the mean C2h from 16.0 to 17.9μg/mL, and the mean AUC from 145 to 162μg/mL/h. A C2h>30μg/mL was predicted in 4% and 8% of children in the 18 and 20mg/kg doses, with 3% predicted to have a C2h>40μg/mL following either dose. For maintenance doses, a 1st dose of 2.5 or 5mg/kg (intravenous) given at 12h (after either 18 or 20mg/kg loading) gives the highest percentages of 10–20μg/mL serum concentrations. For sub-therapeutic concentrations following intravenous loading (20mg/kg), a 1st maintenance dose (intravenous) of 10mg/kg will achieve therapeutic concentrations in 93%. ConclusionUse of PBPK modelling suggests that children receiving the 20mg/kg intravenous loading dose are at slightly increased risk of supra-therapeutic blood levels. Ideally, therapeutic drug monitoring is required to monitor serum concentrations, although the dose regime suggested by the BNFc appear appropriate.

Impact of a phenytoin loading dose program in the emergency department.

The use of a combined physician-and pharmacist-directed phenytoin loading dose program in an emergency department (ED) was evaluated. This single-center, observational, preimplementation-postimplementation study evaluated adult patients who received a phenytoin loading dose in the ED. The primary outcome compared the proportion of optimal phenytoin loading doses in the preimplementation and postimplementation groups. The postimplementation group was further stratified into pharmacist- and prescriber-dosing groups. Other outcomes evaluated included the numbers of appropriate serum phenytoin concentrations measured, adverse drug reactions (ADRs), and recurrence of seizures within 24 hours of loading dose administration in the preimplementation and postimplementation groups. There was no difference in the proportion of optimal phenytoin loading doses between the preimplementation and postimplementation groups (50% versus 62%, respectively; p=0.19). When stratified by individual groups, the rate of optimal phenytoin loading doses increased by 64% in the postimplementation pharmacist group (50% versus 82%, p=0.007), while the rate in the prescriber-dosing group remained relatively unchanged (50% versus 49%, p=0.91). The number of appropriate serum phenytoin concentrations significantly improved in the postimplementation versus preimplementation group (65% versus 40%, p=0.025). Rates of ADRs and recurrence of seizures did not differ across the study groups. No change in the percentage of optimal phenytoin loading doses in the ED was observed after implementation of a combined pharmacist- and physician- dosing program. When stratified into pharmacist or prescriber dosing, the pharmacist-led dosing program significantly improved the proportion of patients who received optimal phenytoin loading doses.

G335(P) Phenytoin dosing and serum concentrations in paediatric patients requiring 20 mg/kg intravenous loading dose

AimPhenytoin’s loading dose for refractory tonic-clonic seizures in children was changed from 18 mg/kg to 20 mg/kg in January 2011 to reduce the theoretical risk of miscalculation. Phenytoin has complex...

Phenytoin dosing and serum concentrations in paediatric patients requiring 20 mg/kg intravenous loading

IntroductionPhenytoin has complex pharmacokinetics. The intravenous loading dose of phenytoin for children in status epilepticus has recently been increased from 18 to 20 mg/kg. There are no data on the...

Rare case of phenytoin induced acute generalized exanthematous pustulosis with cerebellar syndrome

Acute generalized exanthematous pustulosis (AGEP) is a rare drug induced cutaneous hypersensitivity reaction characterized by sudden onset of fever with sterile pustules overlying an erythematous skin occurring all over the body. The offending drugs are usually B-lactams and macrolides. Among anticonvulsants carbamazepine and Phenobarbital are commonly associated with AGEP. Only one case of phenytoin induced AGEP has been reported in literature. We present a rare case of AGEP with cerebellar syndrome occurring after receiving loading dose of phenytoin.

Psychogenic non-epileptic seizures in a second-trimester pregnant woman with a previous child loss.

To the Editor: Psychogenic non-epileptic seizures (PNES), also known as non-epileptic attack disorder,1 are events that apparently simulate an epileptic seizure and are triggered essentially by emotion and psychological events of which a patient does not have control. These are not due to abnormal electrical discharges in the brain as in epilepsy. We report a case of PNES in a pregnant woman. Case report. Ms A, a 19-year-old woman who was 24 weeks pregnant, was transferred via life flight from a local hospital. She initially presented to the local hospital for complaints of headache, syncopal episodes with visual changes, and loss of consciousness for 1 day. Shortly after she arrived at the local hospital, she developed reduced sensation on the right side and decreased movement on left side of her body. During her evaluation, she developed tonic-clonic seizures for which a loading dose of phenytoin was given and she was intubated for airway protection and transferred to our facility. Electroencephalography (EEG) revealed no epileptiform activity. Magnetic resonance imaging and magnetic resonance venography of brain showed no abnormalities. Complete blood cell count, comprehensive metabolic panel results, lactic acid test findings, and results of blood gas analysis were within normal limits. Video EEG showed no epileptogenic activity. Ms A had past history of drop attacks since age 13 with a frequency of 1 or 2 attacks per year. During those attacks she would lose consciousness for less than a minute with no residual deficits. She discovered that these attacks or spells occurred in conjunction with an increase in stressors in her life. At the time of this presentation, she found herself threatened by her roommate and felt stress about her pregnancy because she had lost a child in the past. The true prevalence of PNES is unknown, but the estimated prevalence is 2 to 33 per 100,000.2 The prevalence of epilepsy is 0.5% to 1% in the general population; among the general population, intractable epilepsy accounts for 20% to 30%, of which 10%–20% is accounted for by PNES.3 PNES are more prevalent in females, who constitute up to 80% of cases.4 Although PNES is common in all age groups, patients usually present in their third decade. Several clinical signs help to distinguish these non-epileptic spells from epileptic seizures, including gradual onset, fluctuating course, side-to-side head movements, bilateral asynchronous movements, arching of back, stuttering, and violent thrashing movements.5 The duration of PNES may vary from less than 2 minutes to 150 minutes. Video EEG remains the gold standard for distinguishing PNES from epileptic seizure. PNES is often associated with psychiatric conditions such as major depressive disorders, anxiety or bipolar disorder,posttraumatic stress disorder, and borderline personality traits.6 PNES is more commonly seen in patients with epilepsy and also in patients with a family history of epilepsy.7 It can also be reflected as a manifestation of repressed psychological detriment in response to trauma, such as child and sexual abuse.8 There is no single strategy designed for the management of PNES. Treatment should include multidimensional approaches involving a neurologist, psychiatrist, psychotherapist, and primary care physician. The primary focus should be on addressing the underlying trigger. Psychotherapy, including cognitive-behavioral therapy, insight-oriented therapy, and mindfulness techniques, remains the mainstay of treatment.9 Treatment of comorbid conditions such as anxiety and depression results in a decrease in the incidence of PNES and an improvement in the overall prognosis.9

Phenytoin Loading Doses in Adult Critical Care Patients: Does Current Practice Achieve Adequate Drug Levels?

Phenytoin is regularly employed in the critically ill for prophylaxis against or treatment of seizure disorders. No prior studies have examined current dosing practices in an Australasian intensive care unit (ICU) setting. The aims of this study were to: a) describe the adequacy of contemporary dosing in respect to free and total serum phenytoin concentrations; b) identify factors associated with therapeutic drug concentrations; and c) examine the accuracy of predictive equations that estimate free concentrations in this setting. All patients receiving a loading dose of phenytoin in a tertiary-level ICU were eligible for enrolment; 53 patients were enrolled in the study. Serum samples to determine free and total phenytoin concentrations (measured by high performance liquid chromatography) were then drawn prior to the following dose. Free concentrations below the recommended target (<1 mg/l) were considered as suboptimal. The most common indication for phenytoin loading was traumatic brain injury (49%) and the mean administered dose was 14.5 (3.66) mg/kg. Twenty-six patients (49%) had suboptimal trough free concentrations, although this subgroup was significantly heavier and therefore received a lower per kilogram dose (12.8 [3.1] vs 16.3 [3.4] mg/kg, P=0.001). In multivariate analysis, larger weight adjusted doses (P=0.018), higher albumin concentration (P=0.034) and receiving phenytoin for an indication other than seizure (P=0.035), were associated with a greater likelihood of adequate concentrations. In conclusion, phenytoin dosing remains complex in critically ill patients, although lower per kilogram loading doses are strongly associated with free concentrations below the desired target.

Incidence of shoulder injuries after generalized tonic–clonic seizure admitted to intensive care

The observation of amisdiagnosed bilateral posterior fracture-dislocation followingGTCS, promptedustoevaluatetheincidenceofshoulderinjuriesinpatients admitted with seizures to our intensive care unit (ICU).A 46 year-old woman without significant past medical historywas admitted to the emergency room following a first seizureepisode. After a series of seven consecutive GTCS with return ofconsciousness between seizures, she was transferred to our ICU.Upon admission the patient was confused (Glasgow coma scale of14/15), her temperature 37 8C, and arterial pressure 140/80 mmHg. Clinical examinationdid not reveal any focal neurologic deficitor meningism. The rest of the physical exam was normal with theexception ofbilateralshoulderpain.Cerebro-spinalfluidandbrainCT scan were unremarkable. Chest X-ray performed in bed wasnormal. Therewerenopulmonaryorbonyabnormalities(althoughthe gleno-humeral joints were not captured). The seizures weresuccessfully controlled with a loading dose of phenytoin. Therewas no acute seizure recurrence and the patient was dischargedhome two days later with an appointment for a follow-up visitwith a neurologist. As shoulder pains and functional disabilitypersisted, however, shoulder X-rays were performed and revealedbilateral

Seizure-like Symptoms in a 2-day-old Term Female

A 2-day-old term female infant was noted to have lip smacking, eye twitching, and abnormal “jerking” left arm and leg movements. A loading dose of phenobarbital was given, but the episodes progressed to generalized clonic movements associated with apneas and desaturations requiring intermittent bag mask ventilation. A repeat dose of phenobarbital and a loading dose of phenytoin were given. A sepsis workup including complete blood cell count and blood culture was performed. A lumbar puncture was planned but was deferred because of the infant’s acutely deteriorating status. She was started on empiric antibiotics and acyclovir before ventilation for transfer to a tertiary referral hospital for further evaluation and management. Soon after arrival, a confluent erythematous rash presenting in a linear pattern was noted on the legs and lower trunk (Figs 1 and 2). Figure 1. Development of rash at 44 hours after birth. Figure 2. Leg rash presents in a linear pattern. ### Prenatal History: ### Birth History: Initial examination revealed a nondysmorphic, appropriate-for-gestational-age infant intubated and sedated on a ventilator. Anterior fontanelle noted to be full but soft. On neurological examination, infant was noted to have generalized hypertonia, increased deep tendon reflexes, and bilateral ankle clonus. Rash, as seen in figures, was nonvesicular in nature. Infant continued to have intermittent seizure activity associated with vital sign …

Diagnostic Dilemma of a Young Man With Fever and Headaches

A 23-year-old man was admitted to the hospital in the fall because of fever and headache. He had been well until 5 days earlier when he developed headaches associated with photophobia, neck pain, nausea, and vomiting. He had no significant medical history and took no medications. He lived with his parents in Seattle, Washington, and took classes at a local college. He had immigrated from China in 2007. The patient was alert and interactive. The temperature was 40.0°C, blood pressure was 161/92 mm Hg, pulse was 91 beats/min, and oxygen saturation was 100% on room air. His general examination revealed anicteric sclerae and no skin rash. Pain was noted with passive neck flexion. On neurologic examination, the patient was oriented with fluent speech and no dysarthria. Visual fields and extraocular movements were full. The remaining cranial nerve functions were intact. Muscle bulk and strength were normal. Sensation was preserved with no extinction detected. The tendon reflexes were equal at 2+, and plantar responses were flexor. There was no dysmetria on finger-to-nose testing. The gait was normal. Laboratory studies including a basic metabolic panel, liver function tests, coagulation studies, and urinalysis were notable only for a low sodium of 135 mEq/L (ref 136-145 mEq/L) and an elevated white blood cell count of 13 000/μL (ref 4.30-10.00 thousand/μL). Blood cultures were obtained. Chest radiograph revealed clear lungs and pleural spaces. Computed tomography (CT) of the head showed no abnormalities. The results of cerebrospinal fluid (CSF) analysis are shown in Table 1. Table 1. Cerebrospinal Fluid Analysis Dexamethasone, vancomycin, ceftriaxone, and acyclovir were started for possible bacterial or viral meningitis but discontinued once the blood cultures, CSF Gram stain and bacterial cultures, and viral polymerase chain reaction (PCR) tests were negative. Contrast-enhanced magnetic resonance imaging (MRI) of the brain was normal. The patient was discharged home after 3 days with a diagnosis of viral meningitis. Five days after initial discharge, the patient returned to the hospital with lethargy and confusion. His mother reported that he was less responsive, intermittently mumbling in response to questions, and requiring assistance with basic daily functions. The patient was drowsy and disoriented. The temperature was 38.2°C, blood pressure 119/90 mm Hg, and pulse 116 beats/minute. On examination, he exhibited neck stiffness, incoherent speech, and impaired comprehension. Serum sodium was 121 mEq/L and white blood cell count was 15 500/μL. Head CT showed mild dilatation of the third and lateral ventricles compared to the study 5 days before. Contrast-enhanced brain MRI demonstrated abnormal enhancement of the prepontine and interpeduncular cisterns (see Figure 1). Human immunodeficiency virus (HIV) test was negative. Repeat CSF analysis is shown in Table 1. Figure 1. Magnetic resonance scans of the brain. A, T1 fat-saturation postcontrast axial magnetic resonance image on initial presentation shows normal contrast enhancement. B, T1 postcontrast axial image 5 days later shows mild enhancement of the interpeduncular ... Antibiotics and antiviral medications were restarted. On hospital day 2, the patient had a witnessed convulsive seizure. Repeat head CT showed worsening hydrocephalus. An external ventricular drain was placed, and the patient was given a loading dose of phenytoin. The patient’s mother reported that the patient may have been exposed to an uncle with active pulmonary tuberculosis, leading to the initiation of antituberculous medications, including rifampin, isoniazid, pyrazinamide, and ethambutol. Three days after readmission, a presumptive mold grew in the CSF bacterial cultures. A rash was also noted on the patient’s right flank, consisting of plaques and papules with a central pearly pink color. A skin punch biopsy and additional laboratory studies were obtained, including antinuclear antibody (negative), rheumatoid factor (<13 IU/mL; negative), aspergillus galactomannan assay (0.114; negative), and Quantiferon-TB Gold (indeterminate). Upon further questioning, the patient’s mother reported the patient had spent 8 months in California 1½ years before. Liposomal amphotericin B was started. Six days after readmission, the results of 2 diagnostic tests were received.

Sertraline-Induced Hyponatremia and Seizures in Old Age

Sertraline-Induced Hyponatremia and Seizures in Old Age

Review article: Phenytoin use and efficacy in the ED

This article reviews the evidence regarding the use of phenytoin in adult and paediatric patients experiencing seizures in the ED in Australasia, including relevant pharmacokinetics, dosage, therapeutic drug monitoring and methods of administration. It summarizes current evidence regarding the use of phenytoin in a number of seizure types commonly seen in ED. A search of Medline, Embase and Cochrane was performed using appropriate keyword and MeSH headings. A loading dose of phenytoin should be given to phenytoin naïve patients for the emergency treatment of seizures; parenteral administration results in therapeutic concentration sooner than oral administration but is associated with more frequent and significant adverse effects. Diluting phenytoin is safe but there is limited evidence regarding adverse effects of diluted phenytoin; a filter is probably not needed. Free phenytoin concentrations correlate best with antiseizure efficacy. Phenytoin is used in the treatment of status epilepticus although evidence here is limited; it may also be given to prevent early post-traumatic seizures. It should not be given to treat or prevent eclamptic or alcohol-related seizures. There is insufficient evidence regarding its use in preventing febrile convulsions, treating or preventing seizures due to space occupying lesions or intracerebral haemorrhage and thrombosis. In conclusion, phenytoin is appropriate for treatment of some seizures seen in the ED; it is associated with significant adverse effects; trials are ongoing regarding the use of other anticonvulsants in the treatment of status epilepticus.

A Pressing Headache

A Pressing Headache