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    This clinical guideline provides recommendations for the assessment and management of acute encephalitis syndrome (AES). Major criteria for AES include fever with reduced conscious level/altered mental status for over 24 hours plus seizures, abnormal movements, behavioral changes or sleep pattern changes. Initial assessments should include vital signs, seizures, intracranial pressure, blood tests and imaging if available. Infectious etiologies like HSV and influenza are treated with antivirals. Bacterial infections receive antibiotics. Para-infectious conditions like ADEM may require steroids. Refractory or suspected autoimmune encephalitis warrants specialty consultation. Annexes provide treatment algorithms, measures to reduce intracranial pressure, antiviral dosages and

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    This clinical guideline provides recommendations for the assessment and management of acute encephalitis syndrome (AES). Major criteria for AES include fever with reduced conscious level/altered mental status for over 24 hours plus seizures, abnormal movements, behavioral changes or sleep pattern changes. Initial assessments should include vital signs, seizures, intracranial pressure, blood tests and imaging if available. Infectious etiologies like HSV and influenza are treated with antivirals. Bacterial infections receive antibiotics. Para-infectious conditions like ADEM may require steroids. Refractory or suspected autoimmune encephalitis warrants specialty consultation. Annexes provide treatment algorithms, measures to reduce intracranial pressure, antiviral dosages and

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    This clinical guideline provides recommendations for the assessment and management of acute encephalitis syndrome (AES). Major criteria for AES include fever with reduced conscious level/altered mental status for over 24 hours plus seizures, abnormal movements, behavioral changes or sleep pattern changes. Initial assessments should include vital signs, seizures, intracranial pressure, blood tests and imaging if available. Infectious etiologies like HSV and influenza are treated with antivirals. Bacterial infections receive antibiotics. Para-infectious conditions like ADEM may require steroids. Refractory or suspected autoimmune encephalitis warrants specialty consultation. Annexes provide treatment algorithms, measures to reduce intracranial pressure, antiviral dosages and

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    5 views4 pages

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    This clinical guideline provides recommendations for the assessment and management of acute encephalitis syndrome (AES). Major criteria for AES include fever with reduced conscious level/altered mental status for over 24 hours plus seizures, abnormal movements, behavioral changes or sleep pattern changes. Initial assessments should include vital signs, seizures, intracranial pressure, blood tests and imaging if available. Infectious etiologies like HSV and influenza are treated with antivirals. Bacterial infections receive antibiotics. Para-infectious conditions like ADEM may require steroids. Refractory or suspected autoimmune encephalitis warrants specialty consultation. Annexes provide treatment algorithms, measures to reduce intracranial pressure, antiviral dosages and

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    of 4

    Clinical Guideline for Acute Encephalitis Syndrome (AES)

    (Version 1)(4-8-2023)

    Major criteria: Fever with reduced conscious level/ altered mental status
    >24 hours plus
    One of the following minor criteria:
    - Seizures/abnormal movement/behavioural problems/change in sleep
    pattern

    Assess ABC, active seizures, raised ICP Annex A & B

    Blood: FBC, CRP, Blood C&S, U&E, RBS, *Ca & *Mg, Dengue/ JE serology, MP
    Nasopharyngeal swab for influenza/Covid -19 viruses, rectal swab for enteroviruses
    CSF (if patient’s condition is favourable): RE, Gram & ZN stain, viral PCR (if available),
    (Store 2-3 ml of extra CSF in sterile container for further antibodies testing at 2-8˚C)
    Neuroimaging: CT/MR brain (if available)

    Infectious etiology: Para-infectious etiology: Suspect Autoimmune


    ▪ HSV: IV aciclovir 20 ADEM or ANEC or AHLE encephalitis:
    mg/kg 8 H x 21 days ▪ Multifocal, bilateral, ▪ Refractory seizure
    ▪ Influenza: consider asymmetric white matter ▪ Abnormal movement
    Oseltamivir (preferably within demyelination pattern in ▪ Change in personality or
    48 hr after onset of neuroimaging (+) behaviour
    symptoms) for 5-7 days. Refer ▪ Viral serology or PCR may ▪ Change in sleep pattern
    Annex C for dosage. or may not be (+) ▪ Speech reduction
    ▪ Bacteria: IV ceftriaxone ▪ CSF pleocytosis may be (+)
    80-100 mg/kg 1 or 2 divided in RE
    doses x 7-14 days ▪ Anti-MOG, Anti-
    ▪ Scrub typhus if cutaneous AQP4 antibodies may
    eschar positive (Annex D): be (+)
    ▪ Give IV methylprednisolone
    oral or IV azithromycin
    20-30 mg/kg x 5 days or IVIG
    10mg/kg/day x 5 days 2G/kg in 2-5 days (if Consult with Paed. Neurology team
    refractory or contraindicated to
    methylpred.)

    *Investigation: consider only when there is refractory seizure control despite adequate doses of anti-
    seizure medications

    Abbreviations: ADEM – acute disseminated encephalomyelitis; ANEC – acute necrotizing encephalitis of


    childhood; AHLE – acute hemorrhagic leukoencephalitis; Anti-MOG – anti myelin oligodendrocyte
    glycoprotein; anti-AQP4 – anti aquaporin 4

    Department of Medical Services, Ministry of Health, Myanmar


    Clinical Guideline for Acute Encephalitis Syndrome (AES)

    Annex A
    Algorithm for treatment of active seizures

    *Benzodiazepines Seizures
    PR Diazepam – 0.5 mg/kg #
    IM Midazolam – 0.2 mg/kg #
    Nasal Midazolam – 0.3 mg/kg # • Lateral Position
    Buccal Midazolam – 0.3 mg/kg # • O2
    IV Diazepam – 0.3 mg/kg • Suction if required
    IV Lorazepam – 0.1 mg/kg
    • Obtain IV access (as early as possible)
    # preferable if available
    • Blood Glucose Level

    Maximum doses for


    Benzodiazepine
    Unwitnessed onset/ >5 min duration
    Midazolam
    Child 1 mth-1 year – 2.5 mg
    Child 1-5 years – 5 mg
    Child 5-10 years – 7.5 mg
    *Benzodiazepines (First line)
    above 10 years – 10 mg
    Diazepam Wait for 5min
    Child 1 mth-2 year – 5 mg
    Child 2-5 years – 7.5 mg If ongoing seizure
    Child 5-12 years – 10 mg **Parenteral route
    **2nd dose of Benzodiazepines is preferable
    Lorazepam
    Child 1 mth-12 years – 4 mg Wait for 5min

    ***Use pheno if already ***Second line (go to third line if not available)
    on oral phenytoin and IV/IO Phenobarbitone 20 mg/kg over 20 min (OR)
    vice versa (if possible)
    IV/IO Phenytoin 20 mg/kg over 20 min (OR)
    IV Levetiracetam 40-50 mg over 5-20 min (dilute with 50-100 ml
    0.9% N/S or 5% dextrose, max. 9 mcg/kg/min)

    20 min after giving drug

    Third line (preferable should be in ICU)


    • IV diazepam infusion 100 mcg/kg/hr increasing to a maximum of 400 mcg/kg/hr (OR)
    • IV Midazolam 0.2 mg/kg bolus (at 2 mg/min; max 10 mg), followed by IV infusion of
    1 mcg/kg/minute (increased by 1 mcg/kg/minute every 15 minutes) until seizures
    controlled; max 9 mcg/kg/minute

    Rapid sequence induction of anaesthesia (RSI)


    • IV Atropine 0.02 mg/kg/dose (maximum 1 mg)
    • IV Suxamethonium 1-2 mg/kg/dose
    • IV Thiopentone 4 mg/kg/dose then 2-8 mg/kg/hour by continuous intravenous infusion

    Department of Medical Services, Ministry of Health, Myanmar 2


    Clinical Guideline for Acute Encephalitis Syndrome (AES)

    Annex B

    Summary of measures to reduce intracranial pressure


    ➢ Assessment and management of ABC’s
    • Ensure oxygenation- Normoxia (PaO2>60 mmHg, SpO2>92%)
    • Ensure adequate circulating volume- Normovolaemia
    • Maintain normal BP
    ➢ Identify the signs of impending brain herniation and treat immediately
    ➢ Early intubation if; GCS <8, Evidence of herniation, Apnoea, inability to maintain
    airway
    ➢ Short term hyperventilation using bag ventilation: Target PaCO2: 30–35 mm Hg
    (suitable for acute, sharp increases in ICP or signs of impending herniation)
    ➢ If present, inform ICU team and transfer as soon as possible
    ➢ Treatment of underlying cause including surgery
    ➢ Head in neutral position with mild head elevation of 15–30° (Ensure that the child is
    euvolemic)
    ➢ Mannitol: 0.5-1.5g/kg (2.5-7.5 mL/kg of 20% solution) every 4-6 hour as per
    requirement, up to 72 h
    ➢ Hypertonic 3% Saline infusion:
    • Preferable in presence of Hypotension, Hypovolemia, Renal failure
    • Dose: 10ml/kg bolus followed by 0.1–1 ml/kg/hr infusion, Target Na+−145–
    155 mEq/L
    ➢ Steroids
    • Especially intracranial SOL with perilesional oedema
    • Dexamethasone IV - 1-1.5 mg/kg/day 4 divided doses; Max- 16 mg/day
    ➢ Acetazolamide: Hydrocephalous, benign intracranial hypertension
    ➢ Adequate sedation and analgesia
    ➢ Prevention and treatment of seizures
    ➢ Avoid noxious stimuli
    ➢ Control fever: antipyretics, cooling measures
    ➢ Maintenance IV Fluids: Only isotonic or hypertonic fluids (Ringer lactate, 0.9% Saline,
    5% D in 0.9% NS), No Hypotonic fluids
    ➢ Maintain blood sugar: 80–120 mg/dL
    ➢ Maintain Hb concentration around 10 g/dl, to help cerebral oxygen delivery
    ➢ Refractory raised ICP:
    • Heavy sedation and paralysis
    • Barbiturate coma
    • Hypothermia
    • Decompressive craniectomy

    Monitoring

    ➢ Monitor continuously for all vital parameters (temperature, HR, RR, BP, MABP, CFT), and
    level of consciousness, neurological status, herniation signs, oxygenation (SpO2) and PaCO2,
    hourly.
    ➢ Assess adequacy of sedation and analgesia, input and output and bowel sounds.
    ➢ After a dose of mannitol, monitor the urine output hourly.
    ➢ Random blood sugar should be monitored at least every 6 h. If hypoglycaemia/
    hyperglycaemia, monitor blood sugar every 1–2 h.
    ➢ Serum sodium should be monitored every 6-8 h, if 3% saline is used.
    ➢ EEG (if facility and specialist is available) should be monitored to look for non-convulsive
    seizure if child is comatose.

    Department of Medical Services, Ministry of Health, Myanmar 3


    Clinical Guideline for Acute Encephalitis Syndrome (AES)

    Annex C

    Dosage of Oseltamivir

    Ref: https://www.cdc.gov/flu/pdf/professionals/antivirals/antiviral-dosage-duration.pdf

    Cutaneous eschar in scrub typhus (Annex D)

    Ref: Am. J. Trop. Med. Hyg., 95(6), 2016, pp. 1223–1224 doi:10.4269/ajtmh.16-0583

    This guideline was developed by Clinical Management Committee on Vaccine Preventable Diseases, Ministry of
    Health, Myanmar.
    Contact- [email protected]
    Department of Medical Services, Ministry of Health, Myanmar 4

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