Four Grades of Encephalopathy

Managing the four grades of encephalopathy [1]:

Grades I and II

Grade	Symptoms
Grade I	Changes in behaviour with minimal change in level of consciousness
Grade II	Gross disorientation, drowsiness, possibly asterixis, inappropriate behaviour
Management Consider listing for transplant and transfer to tertiary referral centre Consider CT to rule out other causes Avoid stimulation (can raise intracranial pressure) and sedatives Monitor and treat any infection Consider lactulose (thought to play a role in reducing ammonia load thereby preventing worsening of encephalopathy)

Grade

Symptoms

Grade I

Changes in behaviour with minimal change in level of consciousness

Grade II

Gross disorientation, drowsiness, possibly asterixis, inappropriate behaviour

Management

Consider listing for transplant and transfer to tertiary referral centre
Consider CT to rule out other causes
Avoid stimulation (can raise intracranial pressure) and sedatives
Monitor and treat any infection
Consider lactulose (thought to play a role in reducing ammonia load thereby preventing worsening of encephalopathy)

Grades III and IV

Grade	Symptoms
Grade III	Marked confusion, incoherent speech, sleeping most of the time but rousable to vocal stimuli
Grade IV	Comatose, unresponsive to pain, decorticate or decerebrate posturing
Management Intubation and sedation Head elevation Consider ICP monitor if listed for transplant Treat seizures Mannitol and hyperventilation only if herniation imminent or severe raised ICP Barbiturates for refractory raised ICP

Grade

Symptoms

Grade III

Marked confusion, incoherent speech, sleeping most of the time but rousable to vocal stimuli

Grade IV

Comatose, unresponsive to pain, decorticate or decerebrate posturing

Management