p p r o x i m a t e l y 400,000 p a t i e n t s w i t h s e i z u r e s k g individual, F o s p h e n y t o i n c a n b e i n f u s e d at a m a x -
A r e q u i r e t r e a t m e n t in e m e r g e n c y d e p a r t m e n t s
e a c h year. 1 T h u s far, p h e n y t o i n (Dilantin) h a s b e e n
o n e of t h e c o r n e r s t o n e s of s e i z u r e therapy. Un-
fortunately, t h e r e are s e v e r a l c o m p l i c a t i o n s a s s o c i a t -
e d w i t h t h e a d m i n i s t r a t i o n of p a r e n t e r a l p h e n y t o i n ,
r e l a t e d to its p r o p y l e n e glycol a n d e t h a n o l b a s e . T h e
h i g h l y alkaline p H of 12 is r e s p o n s i b l e for painful infu-
sions, local v e n o u s irritation (phlebitis), i n c o m p a t i b i l -
i t i e s w i t h m o s t IV s o l u t i o n s o t h e r t h a n n o r m a l saline
solution, a n d if infiltration occurs, skin s l o u g h i n g a n d
t i s s u e n e c r o s i s , z In addition, h y p o t e n s i o n , c a r d i a c
d y s r h y t h m i a s , a n d c a r d i o v a s c u l a r c o l l a p s e are p o s s i -
ble if p h e n y t o i n is i n f u s e d at a r a t e g r e a t e r t h a n 50
mg/min.
F o s p h e n y t o i n (Cerebyx), a r e c e n t l y r e l e a s e d pro-
d r u g formulation of p h e n y t o i n , c o n v e r t s to p h e n y t o i n
in t h e body; therefore it h a s t h e s a m e t h e r a p e u t i c
a c t i o n as p h e n y t o i n . It b i n d s to p l a s m a p r o t e i n s b u t
r a p i d l y e n t e r s all t i s s u e s w h e r e it b i n d s to p r o t e i n s
a n d p h o s p h o l i p i d s . B e c a u s e f o s p h e n y t o i n delivers
p h e n y t o i n in a w a t e r - s o l u b l e form, m a n y of t h e infu-
s i o n - r e l a t e d a n d c a r d i o v a s c u l a r c o m p l i c a t i o n s are
e l i m i n a t e d . 3 In addition, f o s p h e n y t o i n ' s lower p H of
8.5 to 8.8 allows for c o m p a t i b i l i t y w i t h m o s t IV solu-
tions, d o e s n o t r e q u i r e t h e u s e of a filter in a d m i n i s -
tration, a n d c a n b e i n f u s e d at a faster rate.
Dosing and administration
F o s p h e n y t o i n is biologically b i o e q u i v a l e n t to p h e n y -
toin; t h e r e f o r e t h e e f f i c a c y r e m a i n s t h e s a m e .
F o s p h e n y t o i n d o s i n g is also e q u i v a l e n t to t h a t of
p h e n y t o i n . A s t a n d a r d l o a d i n g d o s e of f o s p h e n y t o i n
is 15 to 20 m g / k g , or a b o u t 1200 to 1600 m g for a n 80
Kathleen Bradbury-Golas is a clinical nurse specialist, Critical Care
and Medical-Surgical Department, Somers Point, New Jersey.
Linda Carson is a staff nurse, Emergency Department, Shore
Memorial Hospital, Somers Point, New Jersey.
For reprints, write Kathleen Bradbury-Golas, RN, MSN, CNS, C,
CCRN, 14 Avalon Woods Court, Swainton, NJ 08210.
J Emerg Nurs 1996;22:431-2.
Copyright 9 1996 by the Emergency Nurses Association.
0099-1767/96 $5.00 + 0 18/62/76730
i m u m r a t e of 150 m g / m i n . This m e a n s t h a t a n initial
d o s e c a n b e g i v e n over a p p r o x i m a t e l y 8 to 10 min-
u t e s ( b a s e d on an 80 k g person) c o m p a r e d w i t h t h e
20 to 30 m i n u t e s t y p i c a l l y r e q u i r e d for a s t a n d a r d
d o s e of p h e n y t o i n . 1
In addition, f o s p h e n y t o i n
c a n be a d m i n i s t e r e d
intramuscularly.
In addition, f o s p h e n y t o i n c a n b e a d m i n i s t e r e d
i n t r a m u s c u l a r l y if IV a c c e s s is n o t o b t a i n e d or if a
t e m p o r a r y s u b s t i t u t e for oral p h e n y t o i n is required.
In controlled trials, f o s p h e n y t o i n w a s a d m i n i s t e r e d
i n t r a m u s c u l a r l y a s a s i n g l e daily dose, w i t h either
one or t w o injection sites. T h e m a n u f a c t u r e r reports
t h a t i n j e c t i o n s of 5 to 20 ml at a s i n g l e s i t e w e r e well
t o l e r a t e d b y t h e p a t i e n t s p a r t i c i p a t i n g in t h e s e tri-
als. 4 I n t r a m u s c u l a r i n j e c t i o n is n o t r e c o m m e n d e d
with phenytoin. 5
F o s p h e n y t o i n is s u p p l i e d in 2 mI (150 mg) a n d 10
ml (750 mg) vials a n d m u s t b e refrigerated until used.
If a d m i x e d in a d v a n c e , f o s p h e n y t o i n is stable for 8
hours at room t e m p e r a t u r e or 24 hours if refrigerated. 1
F o s p h e n y t o i n can b e m i x e d for injection to a c o n c e n -
tration r a n g i n g from 2.5 to 20 mg/ml. For example, it
c a n b e m i x e d in 50 to 400 ml of 5% d e x t r o s e in w a t e r
or normal saline solution d e p e n d i n g on t h e n e e d e d
concentration. Filtering is n o t r e q u i r e d as w i t h p h e n y -
toin. P h e n y t o i n is s t a b l e at room t e m p e r a t u r e w h e n
n o t mixed; however, it c a n n o t b e p r e m i x e d b e c a u s e of
its lack of solubility a n d resultant precipitation.
Standard laboratory chromatographic assays
u s e d to m e a s u r e p h e n y t o i n also are u s e d to a s c e r t a i n
t h e r a p e u t i c levels of f o s p h e n y t o i n . However, a 2- to
4-hour w a i t i n g p e r i o d is r e c o m m e n d e d after fos-
p h e n y t o i n infusion for g r e a t e s t a c c u r a c y .
October 1996 431
JOURNAL OF EMERGENCYNURSING/Bradbury-Golasand Carson

Table 1
Comparison of phenytoin and fosphenytoin 1"~
Phenytoin Fosphenytoin
Propylene glycol/ethanol base No propylene glycol/ethanol base; water-soluble
pH of 12 pH 8.5 to 8.8
Compatible with NSS only; precipitation can occur Compatible with common IV solutions; no precipitation
IV filter required No filter required
IM injection not recommended Well absorbed IM
Maximum IV rate of 50 mg/min IV rate of 150 mg/min
Cardiac monitoring required Cardiac monitoring required (IV only)
Side effects Side effects
Pain and burning at IV infusion site Minimal infusion complications
Vein irritation Paresthesia
Potential necrosis Pruritis
Hypotension Infrequent hypotension
Dysrhythmias Infrequent dysrhythmias
Potential cardiac arrest Infrequent cardiac arrests
Stability Stability
Unmixed: Stable at room temperature Unmixed: Stable without refrigeration for 48 hours
Premixed: Unable to premix because of rapid precipitation Premixed: Stable with refrigeration for 24 hours
Therapeutic levels: Wait 1 to 2 hours before Therapeutic levels: Wait 2 to 4 hours before
obtaining blood specimen obtaining blood specimen

NSS, Normal saline solution; IM, intramuscular.

S i d e effects
Side effects of f o s p h e n y t o i n are similar to those of
p h e n y t o i n b u t far less frequent. There also m a y b e
t r a n s i e n t p a r e s t h e s i a a n d pruritis, primarily in t h e
p e r i n e a l area, w h i c h usually resolves s p o n t a n e o u s l y
after c o m p l e t i o n of t h e infusion. The i n t e n s i t y of the
p a r e s t h e s i a a n d pruritis is rate related. With IV
a d m i n i s t r a t i o n t h e rate c a n b e d e c r e a s e d to r e d u c e
t h e effects. More s e r i o u s side effects i n c l u d i n g
h y p o t e n s i o n , d y s r h y t h m i a s , a n d cardiac arrest have
b e e n reported. However, the i n c i d e n c e of t h e s e side
effects is lower for f o s p h e n y t o i n t h a n w i t h p h e n y t o i n .
Table 1 outlines a c o m p a r i s o n of p h e n y t o i n a n d fos-
phenytoin.
N u r s i n g care a n d m o n i t o r i n g Of t h e p a t i e n t
r e c e i v i n g IV f o s p h e n y t o i n is u n c h a n g e d from t h a t of
p a r e n t e r a l p h e n y t o i n . C o n t i n u o u s cardiac m o n i t o r i n g
is r e c o m m e n d e d d u r i n g IV infusion of p h e n y t o i n or
f o s p h e n y t o i n . However, p a t i e n t s c a n b e g i v e n both
l o a d i n g a n d m a i n t e n a n c e doses of IM fosphenytoin,
w h i c h does n o t r e q u i r e cardiac monitoring. N u r s i n g
t i m e is d e c r e a s e d b e c a u s e of t h e shorter p r e p a r a t i o n
time, shorter i n f u s i o n time, a n d the i n f r e q u e n c y of
a d v e r s e d r u g reactions. Initiation of oral p h e n y t o i n
r e m a i n s u n c h a n g e d o n c e the p a t i e n t ' s c o n d i t i o n has
stabilized.
Clinical trials for f o s p h e n y t o i n u s e h a v e n o t b e e n
c o n d u c t e d for children y o u n g e r t h a n 5 years of age;
therefore f o s p h e n y t o i n does n o t have a n a p p r o v e d
i n d i c a t i o n i n this group. 1
F o s p h e n y t o i n is more e x p e n s i v e t h a n p h e n y t o i n .
P h e n y t o i n costs a p p r o x i m a t e l y $2 to $3 for a n aver-
age l o a d i n g dose, w h e r e a s fosphenytoin, currently
b e i n g priced, is e x p e c t e d to cost in the r a n g e of $60
to $100 for a n a v e r a g e l o a d i n g dose. However,
d e c r e a s e d p r e p a r a t i o n time, d e c r e a s e d complica-
tions, i m p r o v e d compatibility, a n d equal efficacy
m a k e f o s p h e n y t o i n a feasible alternative to s t a n d a r d
parenteral p h e n y t o i n .
References
1. Wilder BJ, editor. Advances in anticonvulsants: new
directions in acute seizure therapy [seminar]. Gainesville
(FL): Southern Clinical Neurological Society, 1995.
2. Lehne R. Pharmacology for nursing care. Philadelphia:
WB Saunders, 1994:233.
3. Bebin M, Bleck T. New anticonvulsant drugs. Drugs
1994;48:157-60.
4. Parke-Davis. Cerebyx: Package insert [draft]. Morris
Plains (NJ): The Manufacturer, 1996.
5. Physicians' desk reference. Monvale (NJ): Medical
Economics Data Production, 1995.
Contributions to this column may be sent to J a n e t
H icks Keen, RN, MS, CCRN, CEN, 9090 OM
Southwick Pass, Alpharetta, GA 30202; phone
(770) 343-9512.

432 Volume 22, Number 5