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Immediate priorities
High-risk states
Depressed level of consciousness
GCS 12 or less
Rapidly progressive focal deficit
Herniation physiology
Unilateral fixed dilated pupil
Decerebrate or decorticate posturing
Septic shock
MAP less than 65 mmHg after fluids
Lactate 4 mmol/L or more
Initial stabilization
Airway risk
GCS 8 or less
Recurrent vomiting with altered mental status
Breathing targets
SpO2 94% or more
EtCO2 35 to 40 mmHg
Circulation targets
MAP 65 mmHg or more
Avoid hypotension
Rapid glucose check
Hypoglycemia correction
Hyperglycemia management
Early escalation triggers
ICU activation
Need for vasoactive support
Need for hyperosmolar therapy
Neurosurgery notification
Posterior fossa lesion suspected
Obstructive hydrocephalus suspected
Infectious diseases notification
Immunocompromised host
Multiple lesions on imaging
Intracranial pressure risk mitigation
ICP protection bundle
Head of bed 30 degrees
Neutral neck alignment
Avoid jugular compression
Analgesia and sedation strategy
Avoid agitation
Avoid hypotension
Temperature control
Treat fever
Avoid hyperthermia
Osmotherapy readiness
Hypertonic saline availability
Mannitol availability
Herniation management
If signs of herniation, immediate hyperosmolar bolus
Hypertonic saline 3% 2 mL/kg IV bolus
Mannitol 0.5 g/kg IV bolus
If impending herniation, brief hyperventilation
EtCO2 30 to 35 mmHg
Bridge to definitive therapy only
If refractory deterioration, emergent neurosurgical decompression pathway
External ventricular drain consideration
Decompressive procedure discussion
Imaging first strategy
Neuroimaging sequencing
Noncontrast CT head for unstable patient
Mass effect screening
Hydrocephalus screening
MRI brain with gadolinium for definitive characterization
Strong recommendation and high quality evidence
ESCMID guideline recommendation
Contrast CT head when MRI unavailable
Ring-enhancing lesion detection
Lower lesion characterization than MRI
Lumbar puncture avoidance
Contraindication pattern
Suspected mass effect
Posterior fossa lesion suspected
Risk rationale
Herniation risk
Possible abscess rupture into CSF spaces
Early antimicrobial timing logic
Antibiotic timing decision
If severe disease, immediate empiric IV antimicrobials
Altered mental status
Herniation physiology
If stable and aspiration within 24 hours, consider deferring antimicrobials
Conditional recommendation and low quality evidence
ESCMID guideline recommendation
If delay to neurosurgery, empiric coverage without delay
Culture yield tradeoff accepted
Outcome priority
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.