›Empiric antimicrobials
›Acyclovir IV
›Initiate immediately if encephalitis suspected
›Dose 10 mg per kg IV every 8 hours
›Use ideal body weight for obesity
›Renal adjustment required
›Hydration to reduce nephrotoxicity
›Isotonic fluids if not contraindicated
›Duration
›HSV confirmed 14 to 21 days
›If initial HSV PCR negative but high suspicion then repeat PCR 24 to 48 hours
›Empiric bacterial meningitis coverage when not excluded
›Ceftriaxone IV 2 g every 12 hours
›If meningococcal risk continue droplet precautions until 24 hours effective therapy
›Vancomycin IV weight based dosing
›Target trough per local protocol
›Ampicillin IV 2 g every 4 hours
›Add if age 50 or older
›Add if immunocompromised
›Listeria coverage
›If severe beta lactam allergy then alternative per local antibiogram
›Dexamethasone for suspected pneumococcal meningitis
›Initiate with or before first antibiotic dose
›Dose 10 mg IV every 6 hours for 4 days
›Stop if non pneumococcal etiology confirmed
›Seizure management
›Benzodiazepine first line for active seizure
›Lorazepam IV 0.1 mg per kg
›Maximum 4 mg per dose
›Repeat once if needed
›Midazolam IM 10 mg if no IV access
›Second line antiseizure medication
›Levetiracetam IV 60 mg per kg loading
›Maximum 4500 mg
›Maintenance 1000 to 1500 mg every 12 hours
›Valproate IV 40 mg per kg loading
›Maximum 3000 mg
›Avoid in pregnancy and severe liver disease
›Fosphenytoin IV 20 mg PE per kg loading
›Cardiac monitoring
›Refractory status epilepticus pathway
›Continuous EEG
›ICU sedation protocol per local guideline
Intracranial pressure and cerebral edema
›Intracranial pressure and cerebral edema
›Supportive measures
›Head elevation 30 degrees
›Normocapnia target PaCO2 35 to 40 mmHg
›Normoxia target PaO2 80 mmHg or higher
›Normoglycemia target 4 to 10 mmol/L
›Hyperosmolar therapy if herniation concern
›Mannitol IV 0.5 to 1 g per kg
›Avoid hypotension
›Monitor osmolality
›Hypertonic saline 3 percent IV 2 mL per kg bolus
›Sodium monitoring
›Avoid rapid correction in chronic hyponatremia
›Neurosurgery involvement triggers
›Mass lesion
›Hydrocephalus
›Refractory elevated ICP
Autoimmune encephalitis immunotherapy
›Autoimmune encephalitis immunotherapy
›First line immunotherapy after exclusion of uncontrolled infection
›Methylprednisolone IV 1 g daily for 3 to 5 days
›Glucose monitoring
›GI prophylaxis if high risk
›IVIG 0.4 g per kg daily for 5 days
›Thrombosis risk assessment
›Renal function monitoring
›Plasma exchange 5 to 7 exchanges
›Central access planning
›Second line therapies specialist directed
›Rituximab
›Cyclophosphamide
›Tumor screening and treatment
›Ovarian teratoma evaluation
›Age appropriate malignancy screening
›Supportive care
›Fever management
›Acetaminophen dosing per weight
›Cooling measures if severe hyperthermia
›Delirium and agitation
›Lowest effective sedation
›Avoid anticholinergic burden
›VTE prophylaxis
›Mechanical until bleeding risk clarified
›Pharmacologic per inpatient protocol when safe
›Nutrition and aspiration prevention
›Swallow assessment if extubated and dysphagic
›Renal protection
›Avoid nephrotoxins with acyclovir