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



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