Variation in seizure prophylaxis in severe pediatric traumatic brain injury.
OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.
Medical Student Research Training Program, University of Washington School of Medicine.
Paige J
PJ
Ostahowski
Departments of 2 Epidemiology.
Nithya
N
Kannan
Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois.
Mark S
MS
Wainwright
Pediatrics.
Qian
Q
Qiu
Department of Pediatrics, Harbor-UCLA and Los Angeles BioMedical Research Institute, Torrance.
Richard B
RB
Mink
Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio; and.
Jonathan I
JI
Groner
Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania.
Michael J
MJ
Bell
Department of Neurosurgery and.|Division of Pediatric Neurology, Mattel Children's Hospital, UCLA, Los Angeles, California.
Christopher C
CC
Giza
Psychiatry and Behavioral Sciences.
Douglas F
DF
Zatzick
Neurological Surgery.|Global Health Medicine.
Richard G
RG
Ellenbogen
Industrial and Systems Engineering.
Linda Ng
LN
Boyle
School of Nursing, University of Washington, Seattle, Washington.
Pamela H
PH
Mitchell
Neurological Surgery.|Anesthesiology & Pain Medicine, and.
Monica S
MS
Vavilala
D000367:Age Factors; D000927:Anticonvulsants / Q000627:therapeutic use*; D001921:Brain / Q000000981:diagnostic imaging / Q000187:drug effects / Q000503:physiopathology; D000070642:Brain Injuries, Traumatic / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D002648:Child; D004569:Electroencephalography; D005260:Female; D015600:Glasgow Coma Scale; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D010672:Phenytoin / Q000031:analogs & derivatives / Q000627:therapeutic use; D012189:Retrospective Studies; D012640:Seizures / Q000517:prevention & control*; D013997:Time Factors; D014193:Trauma Centers; D014481:United States
D000927:Anticonvulsants; D010672:Phenytoin; C043114:fosphenytoin
AIS = Abbreviated Injury Scale; ED = emergency department; EEG = encephalography; ICU = intensive care unit; ISS = Injury Severity Score; OR = operating room; PEGASUS = Pediatric Guideline Adherence and Outcomes; PICU = pediatric ICU; TBI = traumatic brain injury; antiepileptic medications; epilepsy; pediatrics; seizures; trauma; traumatic brain injury