York R C, Coleridge S T
Emergency Medicine Service, Walter Reed Army Medical Center, Washington, DC.
Am J Emerg Med. 1988 May;6(3):255-9. doi: 10.1016/0735-6757(88)90012-5.
Two patients, aged 44 and 68 years, presented with generalized seizures either witnessed or highly suspected. Both patients had laboratory-proven subtherapeutic anticonvulsant serum levels. The patients differed with regard to risk; one patient had existing cardiopulmonary disease, and the other was free of such risk factors except liver disease. An apparently appropriate dose of intravenous phenytoin was initiated in each case, and the patients were monitored appropriately and given supplemental oxygen. Bradycardia, hypotension, respiratory distress, and, ultimately, cardiopulmonary arrest occurred in both. The criteria proposed by Earnest et al. should be implemented for each seizure case that requires a decision on the urgent need for therapeutic anticonvulsant levels, whether by mechanical infusion, manual intravenous push, or oral loading. The mechanical infusion is the easiest method to standardize and monitor. The manual intravenous push has a greater possibility of inadvertent overdosage during some small time frame, as well as more local symptoms by some reports. Record et al. have recommended oral loading in selected patients. Careful consideration must be made of the choice of environment in which intravenous loading is done (e.g., emergency department, intensive care unit), as dictated by patient parameters, nursing staff levels, and planned disposition. The crucial factors contributing to the deterioration of both patients in the two cases presented were the concentration of phenytoin manually infused and the possibility that their high-risk status made them poor candidates for manual intravenous phenytoin. Dose and a hypersensitivity reaction were doubtful factors in these cases.
两名患者，年龄分别为44岁和68岁，出现了有目击或高度怀疑的全身性癫痫发作。两名患者的抗惊厥血清水平经实验室证实均低于治疗剂量。这两名患者在风险方面存在差异；一名患者患有现有的心肺疾病，另一名患者除了肝病外没有此类风险因素。在每种情况下均开始使用明显合适剂量的静脉注射苯妥英钠，并对患者进行适当监测并给予补充氧气。两名患者均出现心动过缓、低血压、呼吸窘迫，并最终发生心肺骤停。对于每一例需要就紧急达到治疗性抗惊厥水平做出决策的癫痫病例，无论是通过机械输注、手动静脉推注还是口服负荷给药，都应采用厄内斯特等人提出的标准。机械输注是最容易标准化和监测的方法。手动静脉推注在某些短时间内有更大的意外过量给药可能性，而且有报告称会出现更多局部症状。罗克德等人建议在选定患者中采用口服负荷给药。必须根据患者参数、护理人员水平和计划的处置方式，仔细考虑进行静脉负荷给药的环境选择（例如急诊科、重症监护病房）。在这两例病例中导致两名患者病情恶化的关键因素是手动输注的苯妥英钠浓度，以及他们的高风险状态使他们不适合进行手动静脉注射苯妥英钠。在这些病例中，剂量和过敏反应是可疑因素。
