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Nervous

Encephalitis

Herpes simplex encephalitis (HSE) High-yield Verified · Sep 2026

Encephalitis is inflammation of the brain parenchyma, most often caused by a virus (herpes simplex virus, arboviruses such as West Nile, enteroviruses) or by an autoimmune antibody attack such as anti-NMDA receptor encephalitis, producing fever, headache, altered mental status, seizures and focal neurologic deficits.

Encephalitis inflames the brain parenchyma; the patient is confused, not just stiff-necked. Herpes simplex virus favors the temporal lobes — memory, speech and personality change, seizures — and kills most untreated patients, so every suspected case gets empiric IV acyclovir as soon as possible. Image first if pressure may be high, then lumbar puncture with HSV PCR. Acyclovir must run over at least an hour with good hydration. West Nile has no antiviral; autoimmune encephalitis needs immunotherapy and a tumor search.

What’s going wrong in the body

The normal physiology, where it fails, and why the body’s compensation backfires.

01 Virus or antibodies inflame the brain tissue itself

"Viral encephalitis is an inflammation of the brain parenchyma caused by a virus. It is the most common type of encephalitis and often coexists with viral meningitis." "Encephalitis can also be autoimmune when antibodies can attack brain cells." "Viruses are the most prevalent identified cause, accounting for about 70% of confirmed cases of encephalitis" — yet "The etiology of many cases of encephalitis remains unknown despite extensive workup."

How viruses reach the brain. "Viruses invade the host at a site outside the CNS and replicate. Most then reach the spinal cord and brain hematogenously. HSV, rabies, and herpes zoster virus are important exceptions to this. They travel to the CNS from nerve endings in a retrograde manner." Mosquito-borne arboviruses such as West Nile enter through a bite.

The injury. "Once in the brain, the virus and the host’s inflammatory response disrupt neural cell function." NINDS: "Inflammation itself can cause a wide range of symptoms and, in extreme cases, can lead to brain damage, stroke, or even death." Brain swelling raises intracranial pressure: "Elevated ICP is associated with poor prognosis."

Viruses reaching the brain through the blood or along nerves, or autoantibodies, inflame the brain parenchyma — causing confusion, seizures, focal deficits and swelling that can raise intracranial pressure.

02 Herpes simplex — the most common sporadic, treatable cause

[HSV] "HSV-1 is the most common cause of life-threatening sporadic encephalitis across the globe and does not exhibit any seasonal variation." After a first oral infection, the virus is "conveyed in a retrograde manner to the cell bodies, where it takes up latent residency"; most HSV encephalitis comes from "reactivation of or reinfection with HSV-1," reaching the brain "via the trigeminal or olfactory nerves."

Why the symptoms look psychiatric. "Herpes simplex encephalitis usually affects the temporal lobes and the adjacent limbic systems." NINDS: brain damage is usually in "the frontal lobes (leading to behavioral and personality changes) and temporal lobes (leading to memory and speech problems)." "Neuronal cell destruction results from both direct injury caused by the virus and cell injury due to an overactivated immune system." "Behavioral or personality changes are often misdiagnosed as psychiatric disorders."

Why speed matters. "Up to 70% of patients die without treatment, and mortality is 20% to 30% even with appropriate treatment." "A large retrospective study showed a delay in initiating acyclovir for more than 48 hours as one of the factors associated with poor outcomes." So "all patients with suspected encephalitis should be started empirically on acyclovir as soon as possible."

Suspected encephalitis: stabilize, start IV acyclovir at once, image first if pressure may be raised, then lumbar puncture with HSV PCR; an early negative PCR may need repeating.

03 West Nile and autoimmune (anti-NMDA receptor) encephalitis

[West Nile] "An estimated 80% of human WNV infections are subclinical or asymptomatic." "Less than 1% of infected patients develop neuroinvasive disease, which typically manifests as meningitis, encephalitis, or acute flaccid myelitis. Risk of neuroinvasive disease is higher among older individuals and those with immunocompromising conditions." WNV encephalitis "often manifests with fever, altered mental status, and movement disorders such as tremors, myoclonus, parkinsonism, and cerebellar ataxia." There is no antiviral — management "involves supportive care as there are no current antiviral treatment options."

[Anti-NMDAR] Encephalitis "occurs when the immune system makes antibodies that mistakenly attack proteins on the surface of nerve cells called NMDA (N-methyl-D-aspartate) receptors." It can follow an "underlying ovarian teratoma" or HSV encephalitis. "Females develop anti-NMDAR encephalitis approximately 4 times more frequently than males." It "now surpasses any individual viral cause of encephalitis in young persons."

Its course. "Adults more commonly present with psychiatric symptoms, whereas children frequently exhibit movement disorders or seizures as initial manifestations." Later come "oro-lingual dyskinesias with lip-smacking, tongue protrusion, and jaw movements" and "Significant autonomic dysfunction, including labile blood pressure and heart rate, cardiac arrhythmias, temperature instability, and central hypoventilation." Treatment should start "rather than waiting for definitive antibody results."

West Nile encephalitis is treated supportively and prevented by avoiding mosquito bites; anti-NMDA receptor encephalitis, often linked to a teratoma or prior HSV encephalitis, is treated with immunotherapy and tumor removal.

Causes & risk factors

Modifiable factors are teaching targets — the patient can act on them.

Herpes simplex virus — HSV-1 in most adults ("HSV-2 constituting less than 10% of infections"); newborns can acquire HSV-2 at birth Arboviruses (West Nile and others) — mosquito or tick bites in summer; West Nile also by transfusion or organ transplant modifiable Enteroviruses — "usually occurs in the summer and fall" Autoimmune — anti-NMDA receptor — young women, ovarian teratoma, after HSV encephalitis Weakened immunity — HIV, immunosuppressant drugs, chemotherapy; certain biologics raise HSV encephalitis risk Missed routine vaccines — measles, mumps, polio, rabies, rubella and varicella can cause encephalitis modifiable

Signs & symptoms

Each finding tied to the mechanism that produces it — and the triage it calls for.

Fever, headache, confusion or altered level of consciousness Report immediately
Why: "The most common sign and symptoms are fever, headache, seizures, and altered mental status." Anyone suspected of encephalitis "should immediately contact a doctor or go to the hospital."
[HSV] Personality or behavior change, memory loss, aphasia, hallucinations Report immediately
Why: Temporal- and frontal-lobe inflammation — "psychiatric features, memory deficits, and aphasia." Often "misdiagnosed as psychiatric disorders." Altered mentation lasting more than 24 hours with fever or focal signs is typical.
Seizures Report immediately
Why: Inflamed cortex; "the medial temporal and hippocampal regions affected by herpes simplex encephalitis are highly epileptogenic." Status epilepticus is a short-term complication.
Focal deficits — hemiparesis, cranial nerve palsy, visual field loss, ataxia, papilledema Report immediately
Why: Localized brain injury; papilledema signals raised pressure — "Lumbar puncture is contraindicated in the presence of brain shift, herniation, or any other signs of increased intracranial pressure."
Stiff neck (sometimes absent)
Why: Coexisting meningeal inflammation — but in HSV encephalitis "meningismus is present less than half the time," so its absence does not exclude encephalitis.
Infant: fever, lethargy, poor feeding, vomiting, body stiffness, unusual irritability or crying, bulging fontanel Report immediately
Why: NINDS: "Encephalitis can be dangerous in infants." Newborn HSV encephalitis usually appears in the first weeks of life — lethargy, irritability, tremors, seizures, poor feeding.
[West Nile] New limb weakness, flaccid paralysis or trouble breathing Report immediately
Why: Acute flaccid myelitis "can cause limb weakness, paralysis, areflexia, cranial neuropathies, and neuromuscular respiratory failure."
[Anti-NMDAR] Rapid psychiatric change in a young woman, then abnormal mouth movements, labile BP and heart rate Report immediately
Why: "The rapid onset of symptoms contrasts with the slower progression typically observed in primary psychiatric disorders." Then "Significant autonomic dysfunction, including labile blood pressure and heart rate, cardiac arrhythmias, temperature instability, and central hypoventilation" — watch vital signs and breathing closely.
[Acyclovir] New or worse confusion, tremor, hallucinations in an older or renally impaired patient Hold & notify
Why: Possible drug neurotoxicity rather than disease progression — "Approximately 1% of patients receiving intravenous acyclovir have manifested encephalopathic changes"; it needs provider evaluation, never an assumption.
Fatigue and weakness lingering for weeks after West Nile fever or meningitis late Expected
Why: Expected slow recovery — "fatigue, malaise, and weakness can linger for weeks or months."

Diagnostics

Test In this disorder Normal
CT or MRI before lumbar puncture Imaging helps "exclude increased intracranial pressure and the risk of uncal herniation prior to performing an LP." MRI "is more than 90% sensitive in detecting abnormalities with herpes simplex encephalitis"; CT "often shows no abnormalities in early infection." Exclude raised ICP / shift; MRI shows temporal-lobe changes in HSV —
CSF HSV-1/HSV-2 PCR "Amplified polymerase chain reaction (PCR) should be performed for HSV-1 and HSV-2 and has a sensitivity and specificity of 96% and 99%, respectively." An early negative PCR in a high-suspicion patient "should be repeated"; StatPearls, citing the 2008 IDSA guideline, advises continuing acyclovir meanwhile. Positive in HSV encephalitis —
CSF analysis About "10% of patients will have normal CSF studies." In West Nile, neutrophils "may predominate early." Lymphocytic pleocytosis, elevated protein, normal glucose; RBCs possible in HSV —
EEG "EEG (electroencephalography) can identify abnormal brain waves by monitoring electrical activity in the brain." Frequently abnormal in HSV encephalitis —
[West Nile] Virus-specific IgM / PCR (CSF and serum) Consider WNV "in any person with an acute febrile or neurologic illness who has had recent exposure to mosquitoes, blood transfusion, or organ transplantation." Positive CDC —
[Anti-NMDAR] CSF anti-NMDAR IgG; pelvic ultrasound CSF antibody testing is "the gold-standard diagnostic evaluation"; "Transvaginal ultrasonography represents the most important screening test for young women." Exclude infection first. Antibody positive; look for ovarian teratoma —
[Acyclovir] Serum creatinine, BUN, urine output StatPearls: "Dose adjustment of acyclovir for ideal body weight and baseline renal function is imperative"; label: in older adults "it may be useful to monitor renal function." Stable renal function FDA label (acyclovir injection) —

Complications

Black-box warning — most severe: ■ [HSV] Death without prompt treatment Report immediately
"Up to 70% of patients die without treatment, and mortality is 20% to 30% even with appropriate treatment" (StatPearls). NINDS: HSV encephalitis "is the single most important cause of fatal encephalitis"; "More than half of untreated cases are fatal."
Warning: Cerebral edema, raised ICP, status epilepticus Report immediately
"Short-term complications include cerebral edema, status epilepticus, increased intracranial pressure, aspiration pneumonitis, cerebral venous thrombosis, cerebral infarction, and diabetes insipidus."
ICU care for "frequent neurologic checks, airway monitoring, hemodynamic instability, and blood pressure titration."
Warning: [Acyclovir] Acute kidney injury Hold & notify
"Acute kidney injury (AKI) is the most significant adverse effects of parenteral acyclovir administration." Crystals precipitate if solubility is exceeded "or if the drug is administered by bolus injection"; dehydration, kidney disease and other nephrotoxic drugs raise the risk.
Infuse over at least 1 hour, keep the patient hydrated, and monitor creatinine and urine output.
Caution: Long-term brain injury and epilepsy
After HSV encephalitis, "About 70% of patients report long-term behavioral and cognitive issues." "The most common long term complication after viral encephalitis is seizures that may occur in 10-20% of patients over several decades."
Caution: Autoimmune encephalitis after HSV Hold & notify
"Autoimmune encephalitis is thought to occur in up to 27% of cases within 3 months after HSV encephalitis" (StatPearls HSE); StatPearls anti-NMDAR notes recurrence "within 2 to 3 weeks following HSV encephalitis frequently reflects secondary anti-NMDAR encephalitis rather than recurrent viral infection."
Warning: [West Nile] Neuroinvasive disease outcome
"The overall fatality in patients with WNV neuroinvasive disease is approximately 10%. Long-term neurologic sequelae are common among survivors." "Mortality is ~20% for patients aged ≥70 years compared with ~2% for people <50 years."

Medications for this condition

Why each class is prescribed here — every card links to its full pharmacology page.

Antivirals First-line
Immune / Anti-infective · acyclovir

IV acyclovir — empiric for every suspected encephalitis. "Patients presenting with clinical features consistent with acute encephalitis should receive empiric intravenous acyclovir while awaiting HSV polymerase chain reaction (PCR) results." The label indication is "the treatment of herpes simplex encephalitis." Safety: "intended for intravenous infusion only, and should not be administered topically, intramuscularly, orally, subcutaneously, or in the eye"; "Intravenous infusions must be given over a period of at least 1 hour to reduce the risk of renal tubular damage"; "must be accompanied by adequate hydration"; concentration "approximately 7 mg/mL or lower." Watch creatinine, neurotoxicity (lethargy, tremors, confusion, hallucinations) and infusion-site phlebitis ("approximately 9%" — the drug is alkaline). Dose uses ideal body weight in obesity. No antiviral treats West Nile — acyclovir is continued only if HSV is not excluded.
Anticonvulsants
Nervous · phenytoin

Seizures. NINDS: "Anticonvulsants can stop or prevent seizures." StatPearls: "Seizures may need to be managed with valproic acid or phenytoin. For status epilepticus, one may require benzodiazepines." Seizures are also the most common long-term complication.

Beyond medications

  • ABCs and ICU-level monitoring — "Emergency management strategies include assessing the airway, breathing, and circulation." Patients "may require intensive care for frequent neurologic exams and/or respiratory support."
  • Raised ICP — serial ICP monitoring; "steroids and mannitol can be given to relieve increased ICP" (limited data). NINDS: "Corticosteroids can reduce brain swelling." In HSV encephalitis, adjuvant corticosteroids "continues to be controversial."
  • Symptom relief — "acetaminophen to relieve a fever or a headache"; a sedative if "irritable or restless"; "artificial respiration" for breathing difficulty (NINDS).
  • Autoimmune encephalitis — "First-line therapy includes rapid initiation of immunomodulatory and immunosuppressive treatment with corticosteroids, intravenous immunoglobulin (IVIG), and plasmapheresis (PLEX), combined with tumor resection when an underlying neoplasm has been identified." "Approximately 50% of patients respond to first-line therapy alone."
  • Rehabilitation — "comprehensive rehabilitation should include cognitive rehabilitation and physical, speech, and occupational therapy if brain function is severely affected."
  • Isolation — for HSV encephalitis "Prophylactic treatment of close contacts and isolation precautions are not indicated"; some other forms spread through saliva, nasal discharge, feces or respiratory secretions — follow infection-control policy for the organism.

Nursing considerations

The RN-specific layer — each action paired with the reason it matters.

Assessment
Perform frequent neurologic checks — level of consciousness, orientation, speech, pupils, limb strength — and report any decline at once.
Why: Encephalitis "can occur suddenly and progress rapidly"; ICU care is for "frequent neurologic checks, airway monitoring."
Watch for raised ICP (papilledema, falling level of consciousness) and tell the provider before any lumbar puncture.
Why: LP "is contraindicated in the presence of brain shift, herniation, or any other signs of increased intracranial pressure."
Ask about exposures: mosquitoes/ticks, travel, season, sick contacts, transfusion or transplant, immune status and vaccines.
Why: History guides the cause — West Nile after bites, transfusion or transplant; HSV has no season.
On acyclovir, monitor intake and output, creatinine/BUN, mental status and the IV site.
Why: AKI, neurotoxicity and phlebitis are the main acyclovir toxicities; "nurses will be best positioned to inform the rest of the healthcare team."
Interventions
Give the first dose of IV acyclovir promptly as ordered — do not hold it for CT, LP or PCR results.
Why: Delay beyond 48 hours predicts poor outcome; acyclovir is given "while awaiting HSV polymerase chain reaction (PCR) results."
Infuse acyclovir over at least 1 hour by IV only, diluted to label concentration; never IV push, IM or SC; keep the patient well hydrated.
Why: Bolus or concentrated drug precipitates crystals in the renal tubules; the alkaline drug causes phlebitis.
Institute seizure precautions and have anticonvulsants and airway equipment ready.
Why: HSV encephalitis is "highly epileptogenic"; status epilepticus is a known complication.
Treat fever and headache as ordered; keep the environment calm and safe for the confused or agitated patient.
Why: Acetaminophen relieves fever/headache; behavior change and hallucinations are common.
Patient and family teaching
Seek emergency care for fever with confusion, personality change, seizure or weakness — and for an infant with fever, lethargy, poor feeding, stiffness or a bulging soft spot.
Why: NINDS: seek "immediate, aggressive medical treatment"; encephalitis "can be dangerous in infants."
Prevent mosquito and tick bites: EPA-registered repellent (not too much on young children), long loose sleeves and pants, avoid dusk-to-dawn outdoor time, window screens, rid the yard of standing water.
Why: "No licensed vaccines or medicines are available to prevent West Nile virus disease."
Keep routine vaccines up to date; don't share utensils or glasses with someone who is ill; wash hands with soap and water.
Why: Measles, mumps, polio, rabies, rubella and varicella can cause encephalitis.
Expect slow recovery: memory, behavior and speech may take months; rehabilitation helps.
Why: Most HSV survivors have long-term cognitive or behavioral issues.

How a real nurse thinks

The clinical-judgment loop, worked for a typical presentation — reasoning, not reference.

  1. 1
    Recognize cues

    Fever and headache for days, now confusion, memory problems, word-finding difficulty and a seizure — without a stiff neck.

  2. 2
    Analyze cues

    This pattern is encephalitis until proven otherwise, and the temporal-lobe features (memory, speech) point to herpes simplex virus. Absent meningismus does not exclude it. Untreated HSV encephalitis kills most patients; delay beyond 48 hours worsens outcome. The seizure raises concern for rising intracranial pressure before any lumbar puncture.

  3. 3
    Prioritize

    Airway and seizure safety, then IV acyclovir immediately, then imaging before LP.

  4. 4
    Generate solutions

    Protect the airway and place seizure precautions; notify the provider for empiric acyclovir without waiting for CT or PCR; prepare for CT/MRI then LP with HSV PCR; hydrate and plan renal monitoring during acyclovir; admit for frequent neuro checks.

  5. 5
    Take action

    SBAR: 46-year-old with 4 days of fever and headache, new confusion, memory and speech difficulty, and a generalized seizure at 1620. Suspected encephalitis. Requesting IV acyclovir now, CT before LP, and seizure management. Acyclovir is hung as an infusion over 1 hour with IV fluids running.

  6. 6
    Evaluate

    CT shows no shift; LP follows and CSF shows lymphocytes, raised protein and normal glucose; HSV PCR returns positive and acyclovir continues. No further seizures; creatinine stays 0.9 on day 3 with good urine output, and her orientation slowly improves.

Scenario — you’re the nurse

Work each question before revealing the answer. Rationales explain the wrong options too.

Emergency department · 1600

A 46-year-old woman is brought in by her husband after 4 days of fever and headache. Since this morning she has been confused, keeps repeating questions and is struggling to find words. She has no rash and no recent travel. She takes no regular medications.

Neuro — oriented to self only; word-finding difficulty; no neck stiffness; pupils equal; moves all limbs
Vital signs — T 38.8 °C · HR 104 · BP 132/80 · RR 18 · SpO2 97% RA
Event — 2-minute generalized seizure at 1620, then drowsy
Labs — creatinine 0.9 mg/dL; glucose 110 mg/dL
History — husband says she ‘is not herself’; no mosquito exposure noted
Q1 Multiple choice
When should the nurse expect IV acyclovir to be started for this patient?
  1. A. After the CSF HSV PCR returns positive
  2. B. After the MRI confirms temporal-lobe changes
  3. C. Immediately, while tests are pending
  4. D. Only if the lumbar puncture shows red blood cells
Reveal answer & rationale
Answer: C
Suspected encephalitis gets "empiric intravenous acyclovir while awaiting HSV polymerase chain reaction (PCR) results" (C). Waiting for PCR (A), MRI (B) or CSF RBCs (D) delays treatment, and "a delay in initiating acyclovir for more than 48 hours" is associated with poor outcomes.
Q2 Select all that apply
Which actions are correct when giving IV acyclovir? Select all that apply.
  1. A. Infuse over at least 1 hour
  2. B. Ensure adequate hydration
  3. C. Give it by IV push to reach therapeutic levels faster
  4. D. Monitor creatinine and urine output
  5. E. Check the IV site for redness and swelling
  6. F. Give it intramuscularly if IV access is lost
Reveal answer & rationale
Answer: A, B, D, E
Label: infusions "must be given over a period of at least 1 hour" (A) and "must be accompanied by adequate hydration" (B); AKI is the most significant adverse effect (D); phlebitis occurs in about 9% (E). A bolus precipitates crystals in the kidney (C), and the drug "should not be administered … intramuscularly" (F).
Q3 Multiple choice
Why does the nurse expect a CT scan before the lumbar puncture in this patient?
  1. A. CT is the most sensitive test for HSV encephalitis
  2. B. To exclude raised intracranial pressure or brain shift that would make an LP dangerous
  3. C. Because acyclovir cannot be started until imaging is complete
  4. D. CT replaces the need for PCR
Reveal answer & rationale
Answer: B
Imaging helps "exclude increased intracranial pressure and the risk of uncal herniation prior to performing an LP"; LP "is contraindicated in the presence of brain shift, herniation" (B). MRI, not CT, is the more sensitive study (A); acyclovir should not wait (C); PCR is the diagnostic test (D).
Q4 Multiple choice
On day 5 an older roommate with kidney disease on acyclovir for shingles becomes newly confused with tremor. What is the best nursing action?
  1. A. Assume the infection is spreading and document only
  2. B. Report the change, noting possible acyclovir neurotoxicity, and check renal function results
  3. C. Increase the infusion rate to clear the infection faster
  4. D. Hold all fluids to protect the brain
Reveal answer & rationale
Answer: B
IV acyclovir can cause "encephalopathic changes characterized by either lethargy, obtundation, tremors, confusion, hallucinations"; neurotoxicity is strongly linked to renal impairment, and older adults need renal monitoring (B). Assuming disease progression (A) misses toxicity; faster infusion (C) raises crystal-nephropathy risk; withholding fluids (D) worsens kidney injury.
Q5 Select all that apply
Which teaching helps prevent West Nile encephalitis? Select all that apply.
  1. A. Use an EPA-registered insect repellent
  2. B. Wear long, loose-fitting sleeves and pants outdoors
  3. C. Get the West Nile vaccine each spring
  4. D. Avoid being outside between dusk and dawn when possible
  5. E. Use window and door screens
Reveal answer & rationale
Answer: A, B, D, E
CDC: repellent, long loose clothing, avoiding dusk-to-dawn outdoor time and screens prevent bites (A, B, D, E). "No licensed vaccines or medicines are available to prevent West Nile virus disease" (C).

Common questions

What causes encephalitis?
Common causes and risk factors include herpes simplex virus — hsv-1 in most adults ("hsv-2 constituting less than 10% of infections"); newborns can acquire hsv-2 at birth, arboviruses (west nile and others) — mosquito or tick bites in summer; west nile also by transfusion or organ transplant, enteroviruses — "usually occurs in the summer and fall", autoimmune — anti-nmda receptor — young women, ovarian teratoma, after hsv encephalitis, weakened immunity — hiv, immunosuppressant drugs, chemotherapy; certain biologics raise hsv encephalitis risk, and others.
Why start acyclovir before the test results?
HSV is the most common sporadic cause and the one with a specific treatment; untreated, up to 70% die. StatPearls: "all patients with suspected encephalitis should be started empirically on acyclovir as soon as possible."
How is encephalitis different from meningitis?
Encephalitis inflames the brain tissue itself, causing confusion, behavior change, seizures and focal deficits; meningitis inflames the coverings. They often coexist — viral encephalitis "often coexists with viral meningitis" — and a stiff neck may be absent in HSV encephalitis.
Is there a treatment or vaccine for West Nile encephalitis?
No. Management "involves supportive care as there are no current antiviral treatment options," and "No licensed vaccines or medicines are available to prevent West Nile virus disease." Prevention means avoiding mosquito bites.
What is anti-NMDA receptor encephalitis?
An autoimmune encephalitis in which antibodies attack NMDA receptors on neurons. It mostly affects young women, can follow an ovarian teratoma or HSV encephalitis, often starts with psychiatric symptoms, and is treated with immunotherapy and tumor removal.
Do people with HSV encephalitis need isolation?
No. StatPearls: "Prophylactic treatment of close contacts and isolation precautions are not indicated." Some other forms of encephalitis spread through secretions, so infection control follows the organism.

Sources

Reviewed by Hae Suk Lee, RN

Educational summary for nursing students. Scenarios are fictional teaching cases. Always verify against current guidelines and your institution's protocols before acting in practice. Not medical advice.

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