Acute Encephalopathy Management

Initial Assessment and Stabilization

The American Association for the Study of Liver Diseases recommends positioning patients with head elevated at 30 degrees to help reduce intracranial pressure 2, 3
Patients with declining level of consciousness require urgent assessment by ICU staff for airway protection and ventilatory support, as recommended by the Infectious Diseases Society of America 1
Obtain immediate neurological specialist opinion and manage in a setting where clinical neurological review can be obtained within 24 hours, according to the Journal of Infection guidelines 1
Perform neuroimaging (CT or MRI) to exclude other causes of altered mental status such as intracranial hemorrhage, as suggested by the Hepatology society 2

For Grade I-II Encephalopathy, consider transfer to specialized facility based on underlying cause, and avoid sedation if possible; use short-acting benzodiazepines in small doses only for unmanageable agitation, as recommended by the Hepatology society 2
For Grade III-IV Encephalopathy, intubate for airway protection, and consider propofol for sedation in small doses, as suggested by the Hepatology society 2, 3

For viral encephalitis, administer aciclovir 10 mg/kg IV every 8 hours (adjust for renal function), as recommended by the Infectious Diseases Society of America 1
For hepatic encephalopathy, administer vitamin K, fresh frozen plasma only for invasive procedures or active bleeding, as suggested by the Hepatology society 2
For parasitic causes, such as Toxoplasma gondii, pyrimethamine plus either sulfadiazine or clindamycin is recommended, according to the Clinical Infectious Diseases society 5, 6

Ensure access to neuroimaging (MRI and CT) and neurophysiology (EEG) within 24 hours, as recommended by the Journal of Infection guidelines 1
Monitor for and promptly treat infections, and follow glucose, potassium, magnesium, and phosphate levels closely, as suggested by the Hepatology society 2
Consider nutrition through enteral feedings when possible, or total parenteral nutrition, as recommended by the Hepatology society 2