Lack of narrow therapeutic index awareness leading to increased risk of acute phenytoin toxicity in a child with traumatic brain injury

Phenytoin is a commonly prescribed antiepileptic medication in the pediatric age group for multiple indications. It has very narrow therapeutic range with well known side-effects. A careful dose dispensing of utmost importance while administering medications index especially groups variable weight bands. Multiple dosage formulations like tablets/syrups varying strength ranging from 30-300mg are available market just small difference color coding on labels making it prone to iatrogenic errors leading toxicity.