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TREATMENT OF NEUROLOGICAL CAUSES OF SECONDARY CEREBRAL DAMAGE

Continuous EEG monitoring should be used to detect electroencephalographic seizures without concomitant clinical manifestations and to determine if some clinical manifestations are epileptic. Electroencephalographic seizures with and without concomitant clinical manifestations should be treated. The antiepileptic drug of choice is phenobarbital. Diazepam, lorazepam, phosphenytoin, and valproic acid may also be used. The only contraindication for complete electroencephalographic and electroclinical seizure control is if the systemic effects of high antiepileptic drugs are deemed unacceptable. Brain swelling is managed by fluid restriction and placing the patient's head midline and mildly elevated. The use of mannitol and diuretics may offer some benefit but are not routinely used. Mannitol 0.25 g/kg intravenously (onset of action in 15 minutes) may be given every 6 hours during the first day.

TREATMENT OF THE PRIMARY INSULT

Treatment of the primary insult may be carried out on the basis of a firm diagnosis or on suspicion. Treatment of comatose neonates with a firm diagnosis was briefly discussed under each etiology. The need for empirical treatment arises when the suspected primary insult warrants immediate treatment and its confirmation requires a potentially dangerous procedure, transportation, or a laboratory test whose results will not be immediately available.
Meningitis is diagnosed by performing a lumbar puncture. A lumbar puncture is not a risk-free procedure. Transtentorial herniation or clinical deterioration without apparent herniation may occur after lumbar puncture in patients with open fontanels. They appear to be related to forceful flexion of the neck during the lumbar puncture rather than to the extraction of the cerebrospinal fluid.

 

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de Louvois, 1991 Rowley, 1990  Weisman, 1983