Papilloedema

The Meningitis Research Foundation in conjunction with the British Infection Society has developed an algorithm for the early management of suspected bacterial meningitis and this should be used as a guide to investigation and treatment.

EARLY RECOGNITION • Petechial/purpuric non-blanching rash or signs of meningitis

• A rash may be absent or atypical at presentation

• Neck stiffness may be absent in up to 30% of cases of meningitis

• Prior antibiotics may mask the severity of the illness i

Assess Severity & Immediate Intervention

• Airway Secure airway

• Breathing - respiratory rate and oxygen saturations High flow O2

• Circulation - pulse, capillary refill time, (hypotension late), urine output Large bore IV line

• Mental status - deterioration may be sign of shock or meningitis Fluid resuscitation

• Papilloedema i i

No raised ICP No shock No respiratory failure i i

Priorities

• Secure airway and high flow oxygen

• Volume resuscitation

• Senior review

• Manage in critical care

Lumbar puncture

• IV 2g cefotaxime / ceftriaxone immediately after LP

• Consider corticosteroids

• If LP will be delayed more than 30 minutes give IV antibiotics first

Priorities

• Secure airway and high flow oxygen

• IV 2g cefotaxime / ceftriaxone

• Consider corticosteroids

• Volume resuscitation

• Manage in critical care

• Low threshold for elective intubation and ventilation i

P oor resp onse

Further Intervention

• Pre-emptive intubation + ventilation

• Volume support

• Inotropic/vasopressor support

• Consider activated protein C

• Good glycaemic control

• In refractory circulatory failure, physiological replacement corticosteroid therapy may be beneficial

Good Response - Careful monitoring and repeated review

Additional Information - Warning signs requiring urgent senior review

• Rapidly progressive rash • CRT >4 secs • Oliguria • Systolic BP <90

• RR <8 or >30 • pulse <40 or >140 • Acidosis pH <7.3 or BE worse than -5 • WBC < 4 • GCS < 12 or fall in GCS >2 • Focal neurology

• Persistent seizures • Bradycardia and hypertension • Papilloedema CT scan and meningitis

• A normal CT scan does not exclude raised ICP • If there are no clinical contraindications to LP, a CT is not necessary beforehand • A CT scan may be useful in identifying dural defects predisposing to meningitis

Appropriate antibiotics for bacterial meningitis

• Ampicillin IV 2g qds should be added for individuals >5 years to cover listeria • Vancomycin ± rifampicin if pneumococcal resistance suspected

• Amend antibiotics on the basis of microbiology results Corticosteroids in adult meningitis

• Dexametasone 0.15 mg/kg qds for 4 days started with or just after first dose of antibiotics, particularly where pneumococcal meningitis is suspected • Do not give unless antibiotics are correct • Stop if non-bacteial cause is identified

Figure 4.1. Early management of suspected bacterial meningitis and menigococcal septicaemia in immunocompetent adults. Reproduced with kind permission of Heyderman et al. (2003) Early management of suspected bacterial meningitis and menigococcal septicaemia in immunocompetent adults. Journal of Infection 46(2): 75-7.

FURTHER INVESTIGATION AND MANAGEMENT

If you have managed the patient on your own up until this point, now is the time to call for expert medical help.

• A lumbar puncture (LP) should be considered.

• A CT scan is not always necessary prior to LP. A normal CT scan does not exclude raised intracranial pressure. If there are no clinical contraindications to lumbar puncture, a CT scan is not necessary beforehand.

• If the patient has predominantly meningococcal septicaemia, following assessment an LP is not indicated.

• If the patient has predominantly meningitis, consider an LP.

• In either case give 2g IV cefotaxime or ceftriaxone - if LP performed do not give until after LP.

• Antibiotics may need to be amended following microbiology results.

• If you are confident that you are using the correct antimicrobials, consider Dexam-etasone 0.15 mg/kg qds for four days (De Gan and Van de Beek 2002).

• If probable or confirmed meningococcal disease inform Public Health and assist with contact tracing as contacts will need prophylaxis treatment.

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