Emergencies: Meningitis, Sepsis

Question 1

Pathophysiology of meningitis

Answer 1

Pathogen in SA space => meningeal inflammation
Cytokine production => increased vascular permeability
-leak of plasma proteins

Increased cerebral edema, ICP
Reduced cerebral perfusion

Question 2

Source of infection => CNS

Answer 2

Hematogenous spread
-bacterial thromboemboli

Via skull

• ears
• sinuses
• osteomyelitis source

External

• penetrating cranial injuries
• cerebral, spinal surgery
• lumbar puncture

Question 3

Infective agent

• most common cause
• most common bacteria
• neonates U1wk
• neonates 1-6wks
• children, adults
• elderly
• post surgery
• IC

Answer 3

MOST COMMON CAUSE - VIRUSES
-often less severe, self limiting
Most common bacteria
-H inf
-N men
-S pneu

U3months - GBS
-Ecoli, listeria

3months - 6y/o -N meningidites
-S pneumoniae, H influenzae

6-60 years - N meningidites
-S pneumoniae

60+ - S pneumoniae
-N meningidites, listeria

IC - listeria

Post surgery - S aureus, S epidermidis, G-ves

Question 4

Presentation - main features

Signs that you shouldn’t solely rely on

Answer 4

Headache
Fever
Neck stiffness
Confusion

Typical symptoms/signs can be absent in IC, young

Kernig - pain/resistance on passive knee extension
Brudzinski - neck flexion => hip, knee flexion

Question 5

Specific presentation of

• meningococcal meningitis
• pneumococcal meningitis
• H influenzae meningitis

Answer 5

MM - local outbreaks

• Rapid progression => toxic shock
• Endotoxin release => multiorgan thrombosis, bleeds, necrosis, limb loss
• Petechial/purpuric rash on lower body

PM - recent lung, ear, sinus, valve infection
-patients with increased infection risk

HI - recent URTI in child

Question 6

Investigations

-what is the criteria for head CT

Answer 6

Blood cultures - assess for cause
Gold standard for viral and increasingly for bacterial - CSF PCR

Criteria for head CT - exclude significant brain swelling, shift => contraindication to LP due to herniation risk

• focal neuro signs
• papillodema
• cont/uncontrollable seizures
• GCS U12

Question 7

Management

• preadmission
• admission
• close contacts

Answer 7

Preadmission - IV/IM benzylpenicillin

ABx ASAP IN SUSPECTED BACTERIAL
GIVE ABX ASAP IF BLOOD, CSF CULTURE DELAYED
Dexmeth => reduce inflammatory response => fewer complications

Prophylactic ciprofloxacin

Question 8

Vaccines currently used

Answer 8

MenB, C - routine baby imms

Men ACWY - teenagers, uni students

Question 9

Red flags to intiate sepsis 6

Answer 9

AVPU - acute confusion, P, U
Systolic BP U90
HR 130+
RR 25+
O2 needed to maintain SaO2 92%+
Non blanching rash, mottled, cyanotic
Anuric
High lactate
Recent chemo

Question 10

Sepsis 6 mamagement

Answer 10

Give
-O2, ABx, fluid challenge
Take
-urine output, blood cultures, lactate

Manage underlying cause