Airway and ventilatory management

Severely lethargic or stuporous/comatose patients should be electively intubated and mechanically ventilated to protect the airways from aspiration, assure optimal oxygenation, and prevent retention of carbon dioxide. Hypercarbia can result in cerebral hyperemia, aggravation of elevated ICP, and abrupt clinical deterioration in the marginally compensated patient. Hasty intubation under crisis conditions is a common but often preventable contributor to morbidity. Use of short-acting sedative premedication, oronasal topical anesthesia, adequate preoxygenation, and gentle laryngoscopic technique may prevent surges in ICP during the process of intubation. Nasotracheal intubation may be the route of choice in some cases.

Agitation and disordered ventilation secondary to bilateral cerebral or brainstem involvement (particularly Cheyne-Stokes respiration, episodic hyperventilation) are common in viral encephalitis, particularly herpes simplex encephalitis and rabies. However, pharmacological suppression of abnormal breathing patterns or behavior should not generally not be practised unless there is compromised gas exchange or increased work of breathing represents a significant physiological stress in an individual patient. Too liberal use of sedatives will obviously result in sacrifice of the neurological examination and should be undertaken only with appropriate justification, and then with caution. In non-intubated patents with severe agitation that threatens patient safety or the provision of care, short-term use of haloperidol, administered intravenously, is a particularly useful strategy because this agent generally does not suppress respiratory drive and has little adverse effect on hemodynamics.

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