Introduction NICE recommends phenytoin as second line agent for CSE, but compared with newer iv agents, there are potential problems with following treatment protocols effectively, reliably and safely.

Aim To assess local adherence to NICE guidelines and the frequency of phenytoin-related complications.

Method We identified 45 hospital episodes with a discharge coding of CSE between July 2011 and March 2014. All lasted >5 minutes and were refractory to benzodiazepines.

Results Identifying appropriate CSE guidelines via intranet was problematic. 41 patients received phenytoin: protocol breaches occurred for choice of second line agent (4/41), cardiac monitoring (3/41) and loading dose (28/41). Hypotension developed in 2 cases.

Conclusion Phenytoin was not administered per protocol in most cases. Accurate loading caused most breaches and related to calculating dose by weight. This could lead to ineffective or excessive dosing. Although infrequent (8%), cardiac monitoring breaches were concerning because of the potential risks. Both of these issues may reflect problems with signposting to guidelines, rather than Phenytoin use per se. We aim to reaudit after improving this signposting.