›0.5 mg/kg rectal if no IV access (pediatric)
›Alternative for pre-hospital management
›Midazolam IM
›0.2 mg/kg IM maximum 10 mg if no IV access
›Second-line antiepileptic drugs
›Levetiracetam IV
›60 mg/kg IV over 15 minutes (pediatric) maximum 4500 mg
›1000 to 3000 mg IV (adult) over 15 minutes
›Preferred second-line: minimal drug interactions, no hepatic metabolism required
›Fosphenytoin IV
›20 mg phenytoin equivalents per kg IV (pediatric and adult)
›Maximum rate 3 mg PE/kg/min in children, 150 mg PE/min in adults
›Monitor for hypotension and cardiac arrhythmia during infusion
›Valproate IV
›40 mg/kg IV over 5 to 10 minutes (pediatric)
›Avoid in liver disease
›Refractory status epilepticus
›Continuous midazolam infusion
›0.1 to 0.2 mg/kg bolus then 0.05 to 0.5 mg/kg/hour
›Titrate to burst suppression if needed
›Continuous EEG monitoring during refractory status management
›Propofol infusion option in adults
›1 to 5 mg/kg/hour IV
›Avoid prolonged high-dose in children (propofol infusion syndrome risk)
›Maintenance antiepileptic therapy
›Duration of AED therapy after hospital discharge
›Guided by neurology based on EEG findings and seizure burden
›Epileptiform discharges on EEG predict long-term epilepsy
Antiviral and antimicrobial therapy
›Empiric acyclovir
›Pediatric dosing
›10 to 15 mg/kg IV every 8 hours
›Infuse over 1 hour
›Renal dose adjustment for creatinine clearance less than 50 ml/min
›Adult dosing
›10 mg/kg IV every 8 hours
›Continue until HSV PCR from CSF confirmed negative
›Rationale
›No activity against LACV but HSE exclusion mandates treatment
›Do not delay pending serologic confirmation
›Empiric bacterial coverage
›Ceftriaxone IV
›100 mg/kg/day divided every 12 to 24 hours IV (pediatric) maximum 4 g/day
›2 g IV every 12 hours (adult)
›Vancomycin IV if pneumococcal meningitis suspected
›60 mg/kg/day divided every 6 hours IV (pediatric)
›25 to 30 mg/kg/day IV in divided doses (adult) with AUC monitoring
›Discontinue when bacterial meningitis excluded
›Ribavirin consideration
›In vitro inhibition of LACV demonstrated
›Used as compassionate therapy in severe cases
›No definitive efficacy data: randomized trial initiated but incomplete
›Not standard of care: consider with specialist guidance in refractory disease
›Elevated ICP measures
›Head of bed elevation 30 degrees
›Neutral neck position to promote venous drainage
›Osmotic therapy
›Mannitol 0.5 to 1 g/kg IV over 15 to 30 minutes
›Repeat every 4 to 6 hours as needed
›Target serum osmolality less than 320 mOsm/kg
›Hypertonic saline 3%
›5 to 10 ml/kg IV bolus over 15 to 30 minutes (pediatric)
›Preferred if hyponatremia coexists
›Target sodium 145 to 155 mmol/l in ICP crisis
›Avoid hypotonic fluids
›Worsen cerebral edema
›ICP monitoring
›Consider in patients with GCS <= 8 unresponsive to initial measures
›Neurosurgery consultation for placement
›Sodium correction
›Mild hyponatremia (sodium 125 to 135 mmol/l)
›Fluid restriction to two-thirds maintenance
›Serial sodium monitoring q6 to 8 hours
›Severe hyponatremia (sodium less than 125 mmol/l) or symptomatic
›Hypertonic saline 3% 5 ml/kg IV over 30 minutes
›Target sodium rise 3 to 5 mmol/l initial correction
›Maximum correction 10 to 12 mmol/l per 24 hours to avoid osmotic demyelination
›SIADH management
›Fluid restriction primary approach
›Avoid excessive free water
›Antipyretic therapy
›Acetaminophen
›15 mg/kg PO or PR every 4 to 6 hours (pediatric) maximum 75 mg/kg/day
›650 to 1000 mg PO every 4 to 6 hours (adult)
›Ibuprofen (if not contraindicated)
›10 mg/kg PO every 6 to 8 hours (pediatric)
›Rising temperature during hospitalization independently associated with worsening
›Aggressive temperature control priority