Treatment of Severe Dengue with CNS Involvement and Encephalopathy (Convulsion / Coma)
Severe dengue can present with unusual neurological manifestations, including signs and symptoms of central nervous system involvement such as convulsion and/or coma — a clinical picture requiring a distinct management approach focused on airway protection, intracranial pressure control, and metabolic stabilisation.
Clinical Scenario
Some severe dengue patients develop encephalopathy with CNS involvement. Most of those presenting with encephalopathy have features consistent with hepatic encephalopathy. The scenario is characterised by altered consciousness, convulsions, or coma alongside the haematological changes of severe dengue.
Key Clinical Goal
A central therapeutic target in this setting is maintenance of blood sugar within a defined narrow range, alongside stabilisation of the airway and intracranial environment.
Approach Overview (Partial)
The protocol centres on supportive measures directed at airway management and reduction of intracranial pressure, including specific fluid strategy, positional measures, and early consideration of ventilatory support. Pharmacological interventions to address seizure control and metabolic derangements are also part of the approach.
The full stepwise regimen — including sequencing, agents, targets, and supporting interventions — is in the complete protocol.
References
- Some severe dengue patients present unusual manifestations with signs and symptoms of central nervous system (CNS) involvement, such as convulsion and/or coma.
- Most of the patients with encephalopathy report hepatic encephalopathy.
- Maintain adequate airway oxygenation with oxygen therapy.
- Give minimal IV fluid to maintain adequate intravascular volume; ideally the total IV fluid should not be > 80% fluid maintenance.
- Positioning of the patient must be with the head up by 30 degrees.
- Early intubation to avoid hypercarbia and to protect the airway.
- May consider steroid to reduce ICP and dexamethasone 0.15 mg/kg/dose IV to be administered every 6–8 h.
- Give lactulose 5–10 mL every 6 h for induction of osmotic diarrhoea.
- Maintain blood sugar level at 80–100 mg/dL%. Recommend glucose infusion rate is anywhere between 4–6 mg/kg/h.
- Vitamin K1 IV administration; 3 mg for < 1-year-old, 5 mg for < 5-year-old and 10 mg for > 5-year-old and adult patients.
- Anticonvulsants should be given for control of seizures: phenobarbital, dilantin and diazepam IV as indicated.
- Transfuse blood, preferably freshly packed red cells, as indicated.
- H2-blockers or proton pump inhibitor may be given to alleviate gastrointestinal bleeding.
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