Category: Paeds

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)

Stages

  1. Dark purple Pale blue discolouration occurs around or distal to injection site 2-12hrs after administration. (In our case approx 30 min)
  2. Discolouration and Oedema progresses around site and into fingers, hand and forearm over the next 12-16 hours
  3. 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

Croup

Quick Ref Guide

Document Severity @ discharge:  Remember sometimes well children that it is appropriate to discharge can deteriorate. So ensure the reason for your decision is well documented, and the patient is safety netted.

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Bronchiolitis

Quick Ref Guide

 

Background

  • Bronchiolitis is seasonal (winter) viral lower respiratory tract infection
  • Affects children under 2 years – 1 in 3 infants will develop bronchiolitis
  • 2-3 % all infants with bronchiolitis will require admission to hospital
  • Causes: RSV, rhinovirus, adenovirus, influenza, parainfluenza

Read more

Asthma – Paeds

Quick Ref Guide

Asthma is common and potentially fatal.

  • Severity – Severe or Life threatening – think RESUS
  • Treatment within 30 min – bronchodilators and steroids should bee given within 30min
  • 2hrs Observation after Neb – better after a neb don’t just send home they may deteriorate when it wears off.
  • Discharge advice sheet – print off from this guide, remember to check inhaler technique and consider a spacer

PDF:asthma pead

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

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