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

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

• 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