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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 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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