Very few of us come to work intent on doing harm. However, despite that we all keep making mistakes. Most of them pass unnoticed and do little harm, although we are all aware the times they don’t, and it is not only the patient that suffers. Read more
Category: Learning
Are You CO Aware?
With the onset of colder weather, many households in the UK are turning on their heating for the first time in months. Heating appliances need chimneys and flues to work safely – and these can block up over the summer months. So autumn is traditionally the period when people get poisoned by carbon monoxide (although it can happen any time of the year!)
Carbon monoxide (CO) is produced when anything containing carbon burns or smoulders. For practical purposes, this means the burning of any kind of fuel, commonly:
- Gas
- Coal
- Wood/Paper/Card
- Oil/Petrol/Diesel – (All UK cars have a ‘catalytic converter’ in the exhaust system, which converts carbon monoxide (CO) to carbon Dioxide (CO2), which is less poisonous. However, these converters need to warmed up – a cold car produces fatal amounts of CO in the exhaust)
CO is very poisonous. Exposure to as little as 300 parts per million (that’s just 0.03%) can prove fatal.
Morton’s Neuroma
Morton’s Neuroma is a painful condition resulting from the fibrous thickening of the plantar interdigital nerve of the foot.
Often described as feeling like there is a pebble in the shoe, this is is a chronic condition not associated with acute trauma. It is gradual in onset but may present as acutely painful.
Paronychia
- Infection in the skin fold (or paronychium) to lateral edge of the nail (of the finger or toe, but most commonly finger).
- Leads to a pus filled abscess.
- Can result in cellulitis of the digit, and any other complications usually seen with this.
- Is often very painful.
- Common in nail biting.
Metastatic Spinal Cord Compression (MSCC)
You need to be a bit more suspicious and have a lower threshold for investigation than in patients without Known, Suspected OR Previous Malignancy Read more
Purple Glove Syndrome – Case
Is a rare complication of I.V. Phenytoin, which presents with a triad of: Pain, Oedema & Discolouration, typically in the hand.
In our case a child presented in status epilepticus, having received rectal diazepam from the ambulance crew, then 0.1mg/kg lorazepam in the ED, followed by 20mg/kg I.V. Phenytoin over 30 min, via a 24g cannula in back of the hand.
After intubation the patients thumb, index and middle fingers were all noted to be purple. Radial pulse was weak however, we saw good flow on ultrasound doppler in the ED. The patient had no cardiovascular Hx or FHx.
What the literature says
Mechanism (poorly understood)
- Phenytoin is highly Alkaline and may induce vasoconstriction and thrombus, resulting in leakage into the extravascular tissue.
- Phenytoin may precipitated when it mixes with acidic blood (More common in status patients rather than prophylaxis)
- I.V. Canulation may cause small tears promoting extravasation (In our case the cannula required repositioning on insertion)
Prevention
- Phenytoin infusion rate should be the lesser of 1-3mg/kg/min OR under 50mg/min (In our case the infusion rate was 22mg/min, less than 1mg/kg/min)
- Smaller hand veins should be avoided (As in our case, most reports in literature involve the use of hand veins)
- Use 20G cannula or larger (This is ideal for adults and older children)
- Ensure filter used with phenytoin infusions
Stages
- Dark purple – Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
- Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
- Healing, starts at the periphery moving towards the injection site – most patients have a full recovery over 72hrs (few cases of necrosis requiring amputation have been reported
Treating
- Stop giving phenytoin
- Dry Warm Heat (moist heat my contribute to skin breakdown)
- Elevate
- Analgesia
- Regular neuromuscular assessments
- Avoid Cold (this will worsen the vasoconstriction)
- GTN patches have also been used in several of the cases but efficacy is unknown
Learning Points
- Avoid Hand veins for I.V. Phenytoin (this seems to be a contributing factor form the evidence, be it due to small size or more frequent injury of the vein though need to reposition?)
- Avoid Cannulas that required repositioning (increase chance of leaking)
- Use a big cannula (easier said than done in a fitting child)
References
- Purple glove syndrome following intravenous phenytoin administration
- Incidence and clinical consequence of the purple glove syndrome in patients receiving intravenous phenytoin
- Purple Glove Syndrome – Patient advisory
- Phenytoin-Induced Purple Glove Syndrome: A Case Report and Review of the Literature
- Purple glove syndrome: A looming threat
- Purple glove syndrome following intravenous phenytoin administration
- PURPLE GLOVE SYNDROME IS NOT ALWAYS PURPLE AT THE INITIAL PRESENTATION: A Case Report and Literature Review
- Tissue necrosis of hand caused by phenytoin extravasation: An unusual occurrence
The Wheezy Kid <5yrs
Which of theses fit best?
1. Choose a condition (Click the circle)
2. Assess Severity
3. Treat
Viral Induced Wheeze
Quick Ref Guide
Background
- Viral respiratory infections are the most common cause of wheezing in infants and young children
- Risk factors include exposure to tobacco smoke and reduced lung function
- Although treatment is broadly like treatment for asthma there are some differences
Tick Bites
Though less common locally than in some areas, tick bites pre and post removal do offer some concern to patients.
Alprostadil
To maintain or restore patency of the ductus arteriosus
Only to be used in infants who are ventilated or where ventilation is immediately available
DO NOT DELAY IN STARTING Alprostadil if: there is clinical
suspicion of duct dependent CHD while waiting for paediatric cardiology opinion OR echocardiogram, even when in-house echo facilities are present.
PDF: Alprostidil
