I have been involved in the resuscitation of a 15month old child with a suspected reaction to Phenytoin. We are still conducting our review, so I will stick to just a few essential points. This child went into status epilepticus a few days post-op after correction of craniosynostosis. History of one febrile seizure in the past, selflimiting. No other history of note. 20mg Diazepam i.v. did not stop the seizures. Rapid sequence intubation followed. A CT scan showed no surgical cause and the child was taken to ITU where a phenytoin loading dose was administered. Shortly afterwards develops bradycardia around 70 and Sao2 in the low 70%s. Hypoxia was assumed to be the cause of the bradycardia, but 100% O2 did not improve HR or Sats, chest fine on auscultation, easy to bag. Atropine no effect, then asystolie. CPR was commenced immediately. We went through all the reversible causes of cardiac arrest and settled on Phenytoin as the most likely culprit for toxicity. Advice from pharmacy was that there is no known treatment for Phenytoin. I remembered having read that Intralipid has been used in other cases of drug toxicicty and we felt we had nothing to loose. The first bolus was given after the 6th cycle of CPR/adrenaline. This was the first time any electrical acticity was observed on the ECG for a few seconds, a second bolus was then given and the infusion started. Sodium Bic was also given at this point. After the 12th cycle of CPR/adrenaline external pacing was attempted and led to an immediate response, good output, rapid improvement in colour and saturation. Twenty minutes later spontaneous sinus rhythm returned. The child was cooled for two days, extubated a day after that and has left hospital with no apparent deficit.
Hi Eva, Thanks for posting this most interesting, intriguing and VERY SCARY case. Asystole in a 15 month old is pretty much at the top of my 'things I never want to see' list. YOu must be congratulated for solving the puzzle and establishing a plan that ultimately proved successful. I await your further details since I imagine it will take a while to sort things out. Do you have hard copy of ECG traces during the initial period thru the first lipid bolus? What was the interval between the lipid and the successful pacing? 1-5 minutes, or 30 minutes? would you consider writing this up? Thanks again for posting. Pls also post at www.lipidregistry.org Guy
This child went into status epilepticus a few days post-op after correction of craniosynostosis. History of one febrile seizure in the past, selflimiting. No other history of note. 20mg Diazepam i.v. did not stop the seizures. Rapid sequence intubation followed. A CT scan showed no surgical cause and the child was taken to ITU where a phenytoin loading dose was administered. Shortly afterwards develops bradycardia around 70 and Sao2 in the low 70%s. Hypoxia was assumed to be the cause of the bradycardia, but 100% O2 did not improve HR or Sats, chest fine on auscultation, easy to bag. Atropine no effect, then asystolie. CPR was commenced immediately. We went through all the reversible causes of cardiac arrest and settled on Phenytoin as the most likely culprit for toxicity. Advice from pharmacy was that there is no known treatment for Phenytoin. I remembered having read that Intralipid has been used in other cases of drug toxicicty and we felt we had nothing to loose. The first bolus was given after the 6th cycle of CPR/adrenaline. This was the first time any electrical acticity was observed on the ECG for a few seconds, a second bolus was then given and the infusion started. Sodium Bic was also given at this point. After the 12th cycle of CPR/adrenaline external pacing was attempted and led to an immediate response, good output, rapid improvement in colour and saturation. Twenty minutes later spontaneous sinus rhythm returned. The child was cooled for two days, extubated a day after that and has left hospital with no apparent deficit.