What is the appropriate acute management for a patient with viral meningitis presenting with seizures?

Management of Viral Meningitis with Seizures

In a patient with viral meningitis presenting with seizures, immediately stabilize airway/breathing/circulation, treat seizures promptly with anticonvulsants, defer lumbar puncture until seizures are controlled, maintain euvolemia with crystalloid fluids, and provide supportive care—antibiotics are NOT indicated for confirmed viral meningitis but should be given empirically if bacterial meningitis cannot be excluded.

Initial Stabilization and Assessment

• Airway, breathing, and circulation must be stabilized immediately as the first priority 1
• Document Glasgow Coma Scale (GCS) score immediately for prognostic value and to monitor changes 1
• Consider intubation if GCS falls below 12 to protect the airway 2
• Obtain blood cultures within 1 hour of arrival 1
• Calculate National Early Warning Score (NEWS): aggregate score ≥5-6 or single parameter score of 3 prompts urgent senior review; score ≥7 requires critical care assessment 1

Seizure Management - Critical Priority

Seizures occur in approximately 15% of patients with meningitis and are associated with worse outcomes, therefore anticonvulsant treatment must be started promptly even when seizures are suspected but not proven 1

• Start anticonvulsant therapy immediately upon recognition of seizure activity 1
• Patients with suspected or proven status epilepticus (including non-convulsive/subtle motor status), such as those with fluctuating GCS off sedation or subtle abnormal movements, should have electroencephalogram (EEG) monitoring 1
• Continuous or uncontrolled seizures are an absolute contraindication to lumbar puncture until controlled 1

Lumbar Puncture Timing - Key Decision Point

The patient's clinical condition precludes LP when there are continued seizures, rapidly deteriorating GCS, or cardiac/respiratory compromise 1

Defer LP if any of the following are present:

• Continuous or uncontrolled seizures 1
• GCS ≤12 1
• Focal neurological signs 1
• Papilloedema 1
• Respiratory or cardiac compromise 1

When LP is deferred:

• Review the decision at 12 hours and regularly thereafter 1
• Perform LP as soon as the patient's condition stabilizes and seizures are controlled 1

Antibiotic Decision - Critical Distinction

This is where viral versus bacterial meningitis distinction becomes crucial:

If bacterial meningitis CANNOT be excluded:

• Give empiric antibiotics immediately after blood cultures, within the first hour 1
• Standard empiric therapy: ceftriaxone 2g IV every 12 hours PLUS vancomycin 15-20 mg/kg IV every 8-12 hours 3
• Add ampicillin 2g IV every 4 hours if patient is ≥60 years or immunocompromised (for Listeria coverage) 3
• Dexamethasone 10mg IV every 6 hours should be given immediately before or simultaneously with first antibiotic dose 3

If viral meningitis is confirmed:

• Antibiotics are NOT indicated for viral meningitis 4, 5
• Viral meningitis requires supportive care and is generally self-limited with good prognosis 5, 6
• Consider acyclovir if herpes simplex virus is suspected 4, 6

Fluid Management - Avoid Common Pitfall

Patients should be kept euvolemic to maintain normal hemodynamic parameters; fluid restriction is NOT recommended 1, 3

• When intravenous fluid therapy is required, crystalloids are the initial fluid of choice 1, 3
• Fluid restriction in an attempt to reduce cerebral edema is explicitly not recommended and may worsen outcomes 1, 3
• Maintain mean arterial pressure (MAP) ≥65 mmHg to ensure adequate cerebral perfusion 1, 3

Supportive Measures for Raised Intracranial Pressure

Control of raised intracranial pressure is essential to prevent mortality 1

• Achieve normal to elevated MAP 1
• Head elevation 1
• Avoid hyperthermia and hyponatremia 1
• Maintain normocarbia and normoglycemia 1
• Control venous pressure 1
• Routine use of ICP monitoring is not recommended 1

Monitoring and Escalation

Patients with meningitis can deteriorate rapidly despite initially reassuring vital signs 1, 7

• Monitor GCS serially; any drop of ≥2 points requires immediate critical care transfer 7
• Monitor for signs of impaired perfusion: delayed capillary refill time, dusky or cold extremities, decreased urine output 7
• Transfer to critical care is mandatory for: uncontrolled seizures, GCS ≤12 or drop of ≥2 points, cardiovascular instability, or respiratory compromise 7

Common Pitfalls to Avoid

• Never perform LP during active or uncontrolled seizures—this risks cerebral herniation 1
• Never restrict fluids in meningitis patients—this does not reduce cerebral edema and may worsen outcomes 1, 3
• Never delay anticonvulsant treatment waiting for diagnostic confirmation—seizures worsen outcomes and should be treated immediately 1
• Do not rely solely on blood pressure as patients can maintain normal blood pressure until sudden cardiovascular collapse 7
• Consult infectious disease specialists early as there is observational evidence that outcomes are improved with specialist management 1