the iNFANT is truly a design enigma, it is simple yet complicated, amazing yet frustrating, beautiful yet disgusting. And due to a unique production method, each iNFANT has its own variations and special features. Read more
Category: Paeds
RCEM CPD Conference Day 3
REALISTIC EMERGENCY MEDICINE 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
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
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
Quick-Wee method
Have you ever wanted an infant to PU faster?
Gentle suprapubic cutaneous stimulation with gauze soaked in cold fluid (the Quick-Wee method) led to a clinically and statistically significant increase in voiding and successful urine collection within five minutes for infants aged 1-12 months
An ideal job to be given to parents/carers
SUDIC – Sudden Unexpected Death In Child
Occasionally children (<18 yrs) unfortunately will either die in ED or be brought in dead, this is obviously a terrible time for the child’s family and for staff. Despite this there are several important things we must do. Read more