Rosen & Barkin's 5-Minute Emergency Medicine Consult (445 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ESSENTIAL WORKUP
  • Treat immediately based on clinical suspicion
  • Blood cultures. Give antibiotic therapy if at all possible after blood cultures but before other diagnostic procedures if patient is unstable.
  • Routine CT before lumbar puncture (LP) not always required. Generally indicated with:
    • Immune deficiency/HIV
    • History of CNS disease (abscess, bleed, mass lesion, stroke, shunt)
    • History of seizure <7 days
    • Focal neurologic deficit
    • Altered level of consciousness
    • Age >60 yr
    • Papilledema
  • LP: Every suspected meningitis patient unless contraindicated:
    • May delay LP when:
      • Risk for herniation (see above)
      • Unstable patient
      • Thrombocytopenia or bleeding diathesis
      • Spinal epidural abscess
      • Overlying soft tissue infection
  • CSF analysis:
    • Tube 1: Cell count and differential
    • Tube 2: Protein and glucose
    • Tube 3: Gram stain, culture, and sensitivity
  • May add acid-fast bacillus smear, TB culture, India ink and fungal cultures, VDRL, cryptococcal antigen as needed
    • Tube 4: Repeat cell count or save for additional tests.
    • Check for elevated opening pressure: Normal up to 200 mm H
      2
      O
    • Latex agglutination (optional):
      • Useful if other tests are not diagnostic
      • Best if urine and blood also tested
      • Detects:
        Meningococcus
        ,
        Pneumococcus
        , group B
        Streptococcus
        ,
        Haemophilus influenzae, E. coli, Cryptococcus
    • Polymerase chain reaction (optional):
      • Useful for virus (especially herpes simplex) and bacteria:
        N. meningitidis, S. pneumoniae, H. influenzae
        A and B
    • CSF interpretation:
      • Culture is diagnostic
      • >4 WBC/mL in CSF is highly sensitive for meningitis for age >3 mo and >9 WBC/mL for infants 29–90 days.
      • Cell count may be normal in HIV/AIDS.
      • Neonate: Up to 20–25 WBC/mL and protein up to 150 mg/dL in term and up to 100 mg/dL in preterm neonate may be normal.
    • Typical bacterial meningitis:
      • CSF glucose <40 mg/dL. Also ratio of CSF to blood glucose <0.6.
      • WBC >500/mL (usually 1,000–20,000). However, significantly fewer WBC count may be seen in the early course of the disease.
      • Differential >80% polymorphonuclear neutrophils (PMNs) is suggestive.
      • CSF protein >200 mg/dL. Normally <50 mg/dL.
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • Blood cultures (2 sets) before antibiotics
  • Urine culture and urinalysis
  • CBC with differential and platelets
  • Electrolytes/glucose:
    • Calculate CSF glucose to serum glucose ratio
    • Assess for metabolic acidosis, SIADH
    • BUN/creatinine for medication dosing
  • Prothrombin time, partial thromboplastin time, and platelet: Particularly in patients with petechiae or purpura:
    • Obtain before LP in severe sepsis or disseminated intravascular coagulation
  • Toxicology studies as needed
Imaging
  • CT: See essential workup section above.
  • CXR: Pneumonia, TB if suspected
DIFFERENTIAL DIAGNOSIS
  • Encephalitis
  • Brain, spinal, epidural abscess
  • Febrile seizure
  • CNS/systemic lupus erythematosus cerebritis
  • Intracranial bleed
  • Primary or metastatic CNS malignancy
  • Stroke
  • Venous sinus thrombophlebitis
  • Trauma
  • Toxic/metabolic
TREATMENT
PRE HOSPITAL
  • IV, O
    2
    , and transport. ABCs
  • Administer prophylactic antibiotics to any close personal contacts of patient diagnosed with meningococcal meningitis:
    • Adults:
      • Rifampin: 600 mg PO BID for 2 days;
        or
      • Ciprofloxacin: 500 mg PO single dose;
        or
      • Ceftriaxone: 250 mg IM (if pregnant)
    • Children:
      • Rifampin: 5 mg/kg if <1 mo old and 10 mg/kg if >1 mo old, BID for 4 doses
INITIAL STABILIZATION/THERAPY
  • Isolate patient as appropriate.
  • ABCs. Treat seizures.
ED TREATMENT/PROCEDURES
  • Ideally perform LP and give antibiotic ± steroids promptly.
  • If LP is delayed, give antibiotic ± steroids empirically before LP.
  • If CT is indicated prior to LP, empiric antibiotic ± steroids should be given prior to CT.
  • Steroids: If given, should be given prior to, or concurrently with, administration of antibiotics.
  • Antibiotics:
    • Obtain blood cultures before antibiotics.
    • Do not delay giving antibiotics to obtain LP or CT unless absolutely necessary.
  • IV (or IM) empiric antibiotics for presumed bacterial Infection:
    • Neonates:
      • 0–7 days old: Ampicillin 50–100 mg/kg q6h + gentamicin 2.5 mg/kg q8–12h
      • >7 days old: Ampicillin 50–100 mg/kg q6–8h; + cefotaxime 50 mg/kg q6h or gentamicin 2.5 mg/kg q8h
      • Add acyclovir 10–20 mg/kg q8h for suspected herpes simplex encephalitis.
    • Age 1–3 mo:
      • Ampicillin 50–100 mg/kg q6h; + ceftriaxone 75 mg/kg load, then 50 mg/kg q12h thereafter or cefotaxime 50 mg/kg q6h; + vancomycin 15 mg/kg q8h (if cephalosporin-resistant
        S. pneumoniae
        prevalent) ± dexamethasone (0.15 mg/kg q6h for 4 days)
    • Children >3 mo:
      • Ceftriaxone 100 mg/kg/d or 50 mg/kg q12h or cefotaxime 50 mg/kg q6h + vancomycin 15 mg/kg q8h ± dexamethasone 0.15 mg/kg q6h for 4 days
      • Immune deficient: Add gentamicin 2.5 mg/kg q8h or amikacin 7.5 mg/kg q12h or 5 mg/kg q8h.
      • CNS surgery: Vancomycin 15 mg/kg q8h; + meropenem 40 mg/kg q8h or ceftazidime 50 mg/kg q8h or cefepime 50 mg/kg q8h
      • Penetrating head trauma: Vancomycin 15 mg/kg q8h; + cefepime 50 mg/kg q8h or ceftazidime 50 mg/kg q8h or meropenem 40 mg/kg; + gentamicin 2.5 mg/kg q8h or amikacin 5–10 mg/kg q8h
    • Adults:
      • Ceftriaxone 2 g q12h or cefotaxime 2 g q4–6h; + vancomycin 15–20 mg/kg q8–12h (not to exceed 2 g/dose or 60 g/kg/d); + dexamethasone (15 mg/kg) up to 10 g q6h IV, continue for 4 days if causative agent is
        S. pneumoniae
      • >50 yr: Add ampicillin 2 g q4h to above regimen for Listeria coverage
      • Immune impaired: Vancomycin 15–20 mg/kg q8–12h + ampicillin 2 g q4h; + meropenem 2 g q8h or cefepime 2 g q8h
      • CNS surgery, shunt, head trauma: Vancomycin 15–20 mg/kg q8–12h; + meropenem 2 g
      • Vancomycin dosing for patients with normal renal function: 50–89 kg (1 g q12h), 90–130 kg (1.5 g q12h), >130 kg (2 g q12h)
  • Other medication considerations:
    • Dexamethasone:
      • Benefits are not conclusive.
      • May be beneficial for children with
        H. influenzae
        meningitis and may be beneficial in children >6 wk and adults with
        S. pneumoniae meningitis
        . May reduce neurologic sequelae
      • Give before or with antibiotics in patient with altered mental status, focal neurologic deficit, papilledema, or CNS trauma, surgery, or space-occupying lesion. Give if CSF is cloudy, has positive Gram stain, or >1,000 WBC/mm
        3
        .
    • Penicillin allergy (severe):
      • Aztreonam or chloramphenicol may be used in place of cephalosporins.
      • Do not delay therapy for lesser allergy history.
    • Vancomycin:
      • Add when concerned about penicillin-resistant pneumococcal infection.
    • Acyclovir if suspect herpes simplex virus encephalitis
MEDICATION
  • Acyclovir: 30 mg/kg/d q8h IV (Neonate: 20 mg/kg/d q8h IV)
  • Amikacin: Peds: 7.5 mg/kg q12h or 5 mg/kg q8h IV. Newborn: Load 10 mg/kg followed by 7.5 mg/kg q12h IV
  • Ampicillin: 2 g q4h (peds: 50–100 mg/kg q6h–q8h) IV, max. 12 g/d
  • Aztreonam: 2 g (peds: 30 mg/kg) q6–8h, max. 6–8 g/d IV
  • Bactrim: 5–10 mg/kg trimethoprim q12h IV
  • Cefepime: 2 g q8h, max. 6 g/d IV
  • Cefotaxime: 2 g (peds: 50 mg/kg) q6h, max. 8–12 g/d IV
  • Ceftazidime: 2 g q8h, max. 6 g/d IV
  • Ceftriaxone: 2 g (peds: 50–75 mg/kg) q12h, max. 4 g/d IV
  • Chloramphenicol: 1–1.5 g (peds: 12.5 mg/kg) q6h, max. 4–6 g/d IV
  • Dexamethasone: 10 mg (peds: 0.15 mg/kg) q6h IV for 4 days
  • Gentamicin: Peds: 2.5 mg/kg q8h IV
  • Meropenem: 2 g (peds 40 mg/kg) q8h IV, max. 6 g/d
  • Tobramycin: Peds: 2.5 mg/kg q8h IV
  • Vancomycin: 1–2 g q8–12h IV (peds: 15 mg/kg q8h)
  • Vancomycin and aminoglycosides: Adjust for renal function and serum concentration levels.
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Known or suspected bacterial infection
  • Immune-compromised host
  • Any toxic-appearing patient
Discharge Criteria
  • Clear viral infection. Controlled symptoms.
  • Thorough and specific discharge instructions
  • Careful follow-up plan discussed with primary care physician prior to discharge
PEARLS AND PITFALLS
  • Meningitis generally does not present as uncomplicated febrile seizure in children.
  • Failure to diagnose or delay in treatment of meningitis results in catastrophic outcome for patients, and not infrequently, negative medicolegal consequences for the physicians involved.
ADDITIONAL READING
  • American Academy of Pediatrics.
    Red Book: 2012 Report of the Committee on Infectious Diseases.
    29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
  • Chávez-Bueno S, McCracken GH Jr. Bacterial meningitis in children.
    Pediatr Clin North Am
    . 2005;52(3):795–810.
  • Fitch MT, van de Beek D. Emergency diagnosis and treatment of adult meningitis.
    Lancet Infect Dis
    . 2007;7(3):191–200.
  • Nelson JD, McCracken GH. Treatment of neonatal meningitis.
    Pediatr Infect Dis J
    . 2005;24(7).
  • Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for management of bacterial meningitis.
    Clin Infect Dis
    . 2004;39:1267–1284.
  • Upadhye S. Corticosteroids for acute bacterial meningitis.
    Ann Emerg Med
    . 2008;52:291–293.
  • van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults.
    N Engl J Med
    . 2006;354(1):44–53.

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