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Clinical Case 134: Frequent Fitter Farmacology

Larry is a 45 year old man who is well known to your ED.  He is a frequent flyer [see podcast with Dr Seth Trueger] and attends most weeks after having a seizure in public somewhere.

Larry has a background of a traumatic brain injury with a subdural haemorrhage 20 years ago.  This has left him with some mild cognitive impairment and a tendency to have seizures.  Larry has been “sleeping rough” on and off for the last 10 years.  He drink s a bit when he has the cash.  He is prescribed phenytoin 300 mg per day, although he has found it tough to keep up with this given his circumstances.

Larry has a “Management Plan” in his chart.  Typically he presents with the Ambos post-ictal, then he usually gets a bit aggressive until he has returned to normal level of consciousness.  Over the past few years he has had dozens of IV phenytoin loads in the ED and been sent either back out to the street or to the Obs ward on his usual oral doses.

Today Larry presents in his usual manner.  The ambulance was called when bystanders witnessed him have a generalised seizure in the carpark of the local shopping centre.  The fit lasted about a minute and by the time the Ambos arrived he was laying on his side. He has been incontinent and sustained a graze to his left face.

On route he has a normal set of Obs and a BSL is 6.0 mmol.   In the ED Larry is ‘arcing up’ and refusing any exam or attempts at IV access.  He smells of wine and is disoriented.   However, 5 minutes later Larry is more settled and aware of his surroundings and chatting to the nurses he knows.

We are worried that Larry might have another seizure – so an ampoule of midazolam is drawn up and kept nearby…

Traditionally Larry would now be dripped and receive ~ 1000 mg of IV phenytoin.  This would take 30 – 60 minutes to get in and then be watched in ED… but is there a better way?

Maybe.  After a bit of reading and this excellent post on ALIEM by my friend Bryan Hayes ( @PharmERToxGuy ) on the art or RAPID ORAL LOADING in the ED.  I think I will be changing my practice with all the Larrys in my ED.

He is how I think I will roll in the future where it seems appropriate to forgo the IVC:

  1. Consider giving a dose of longer-acting benzo [clonazepam or lorazepam] at ~ 1 mg to prevent the next seizure whilst we load.
  2. Give 500 mg of oral phenytoin ASAP after arrival
  3. Admit to Obs or observe in the ED – use this time to assess for other occult pathology or injury.
  4. Repeat 500 mg oral phenytoin at 2 hours
  5. Observe until the magical 4 hour mark…

At this point we are likely to be close to a therapeutic plasma level of phenytoin and have a bit of benzo on board to smooth out bumps.

I have tried it a few times without the initial benzo (Step 1) and had ‘failures’ with patient having a subsequent seizure whilst awaiting the second dose.  So I hope that adding the prophylactic clonazepam will help.

I hear that this is pretty effective in a few places around the world.

I would love to hear your practice and if you have any experience with “rapid oral loading” of phenytoin.

The bigger picture here is about finding a way to provide ongoing care to our most vulnerable patients.  These folk tend to get labelled as “hopeless cases” and it is easy to become cynical.  However, in my time kicking around the bush I have been surprised to see people overcome really impossible circumstances and get themselves into a place where they can take care of their health needs… after finding a roof and secure food supply.

So my teaching when it comes to dealing with the “non-compliant patient” is to start fresh and have a red-hot crack at making it as easy as possible for them to access and use the meds we prescribe.  This may mean thinking outside the box in terms of prescribing and dispensing meds.  Sometimes a bit of creativity can change the situation.

Let me know if you have strategies that help your rough-living folk get the care they need

Casey

Comments

  1. David Berger says:

    I’ve tried oral loading a number of times in our ED, Casey, and they’re often so drunk it’s just easier to give IV. Then you know it’s in and they are more quickly loaded. Plus, as you know, many of our clientele will have buzzed off by two hours anyway, which is also an argument for going straight to CT scan when there is any concern of head injury, rather than watch and wait.

    I’m not sure what the advantage is of oral loading.

  2. Patrick Linehan says:

    What’s the point of loading them up with phenytoin the ED if they aren’t going to take it when they leave? How much benefit is Larry getting from being prescribed phenytoin if he never takes it? It doesn’t sound like he is having status seizures that need phenytoin to be controlled. You could have a talk with him, and if he does not think it is doing him any good just stop it, and stick to loading him with a benzo when he gets to the ED. I have seen several patients with seizures in my ED who have decided not to take any anti-seizure medications at all because they kept having seizures anyway. They are out the door as soon as their post-ictal confusion has resolved.

    • Casey Parker says:

      Hi Patrick
      Agree -- It is a tricky area of ethics. Handing out a bottle of pills certainly won’t fix the base causes of Larrys inability to comply with the medicines. However, he does deserve the same standards of care as any other patient.
      In the ED it is easy to lose perspective on the patient’s world. Hence the last part of this post…
      He will never change this pattern without help. ED may not be the place to provide necessary supports.
      As mentioned- I have seen a few seriously chronic patients turn their lives around and become much healthier as a result. I think Larry deserves a chance to do same?

      • Hi Casey, here in Sweden we give Phenytoin to patients with status but it’s not part of our practice to load stable patients either orally or IV. So I wonder: What would be the rationale? To prevent recurrent seizures in the coming hours? Is there any evidence behind the practice?
        Thanks for a great podcast and blog!

        //Martin

      • Patrick Linehan says:

        Suppose Larry is your local bank manager, morally upright and full of rectitude. He has been prescribed phenytoin for his seizures and takes it faithfully, yet a couple times a month he has a seizure and is brought to the ED and due to some unknown metabolic abnormality his phenytoin levels are low. After a couple of years of being loaded with dilantin each time he turns to you and says, “Doc, do I have to keep taking phenytoin? It really doesn’t seem to be helping me.” Are you going to say to him “No, this is the only drug for you and this is the only way of treating you, we are going to keep this up forever.”?

        Or might you say, let’s try something different?

  3. I have recommended an oral loading strategy of phenytoin for patients in our emergency department with some good success. It really is dependent on the patient population, and the typical patient that I have provided this recommendation is one who is relatively stable who has missed a few doses due to non-compliance issues and/or is subtherapeutic (based on measured serum concentration), and in these patients, it may be a time-saving and cost-effective approach.

    On our blog, we also covered the pharmacokinetic properties of several other antiepileptic agents and the current evidence surrounding the feasibility to utilize a rapid oral loading strategy for these agents: http://empharmd.blogspot.com/2014/08/empower-episode-4-rapid-oral-loading-of.html (#FOAMed FTW).

    Thanks,
    Nadia Awad (@Nadia_EMPharmD)
    Emergency Medicine PharmD

  4. I think it’s great to re-think your approach to these kind of cases. It’s easy to do the same thing when they have presented 100 times before.
    I guess the oral loading approach is a little more patient centred and has the potential to fast track things if they go well. Some of our patients have literally been canulated a hundred times so I can see some advantage there. I’m surprised by how little our intoxicated patients tend to vomit in ED. Obvious this would set up for failure. Would you reconsider if the patient had a history of staticus?
    The more tricky question is your last one. How do we help these people? I like the idea of ‘street nurse’ for our troubled cases. That might improve compliance but wouldn’t fix the alcohol issue.

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