Question about seizures at extubation in TBI patients

[rnfostermom, BSN, RN]

I have observed that a number of our TBI patients have begun seizing upon extubation. The patients had moderate to severe TBIs but not had prior observed seizure activity. They had tolerated the weaning of their sedation (we use fentanyl, versed and precedex), and had done well with vent support weaning trials. ICPs and sodiums had been stable for a number of days. Seizure prophylaxis meds on board. No VAPs or other infections. In the instances I'm aware of, the seizures began within several minutes of extubation and in some instances required reintubation soon afterward.

I'm curious if there could be a specific cause we are missing in preparation for extubation of these kids. Obviously weaning the sedation meds likely reduced the seizure threshold and the experience is stressful. But could there be another reason? For example, the need to take spontaneous breaths without the extra PEEP support? I just spent the morning searching on the internet and finding not very much. I did find one article about gas emboli but am waiting to receive access to read it.

I'm just a plain bedside nurse, not a doctor (obviously), and I don't know much other than what I've observed. I know it's way beyond my pay grade to question this stuff, but after spending a very long time with families caring for their children -- who seemed to be doing well -- to have this setback is frustrating and incredibly discouraging!

Does anyone have any ideas? Observed any therapy changes at their institution? Know of any research? Care to commiserate?

[NotReady4PrimeTime, RN]

Please don't ever apologize and call yourself "just a nurse" when you seek more information and a better understanding of something you're observing. This career of ours requires... no - DEMANDS life-long learning. And we all want to provide the best care possible to the children and families who come into our world.

Having said all that, I haven't observed this phenomenon in our TBI kids and I'm at a total loss as to the underlying reasons for it. It does present quite a puzzle. Does it cross the age spectrum? Or is it seen more in one age category more than others? Do they continue to have seizures after that initial post-extubation seizure? Current evidence argues against routine use of anticonvulsants post TBI unless seizures have been present because studies have shown that long-term seizure disorders post TBI aren't all that common. There's a very good Medscape article on post-traumatic seizure and post-traumatic epilepsy that you might find answers some of your questions... or maybe create more. Medscape: Medscape Access