Headaches quiz - Ch 148 (billie) Flashcards
What are the life threatening central nervous system infections that we are worried about in the ED
- bacterial meningitis
- viral encephalitis
- brain abscess
- spinal epidural abscess
what is aseptic meningitis
when inflammation of the meninges is due to causes other than bacterial infection such as drug rxn, rheumatologic conditions, or nonbacterial infections (viral/funal)
what are the MCC of aseptic meningitis
enteroviruses and echoviruses
what is the clinical triad of meningitis
- fever
- neck stiffness
- AMS
less than 1/2 of paients present with all three initially!
headache is also a common symptom
what physical exam findings should you look for in CNS infections
- nuchal rigidity
- kernigs sign (pain in back and legs w flexion of hip and ext knee)
- brudzinski’s sign (flexion of hips w passive flexion of neck)
- cranial nerve palsy
- skin for petechiae, splinter hemorrhages (systemic infection signs)
what is encephalitis
infection of the brain parenchyma that causes inflammation within the CNS. often caused by VIRAL infection
what is the most treatable cause of encephalitis
herpes simplex virus (HSV)
pts w encephalitis may mimic what other diagnosis? what additional symptoms should you look for to differentiate these?
may mimic meningitis (neck stiffness, fever, headache, AMS)
look for other symptoms such as:
- cognitive deficits
- psychiatric symptoms
- seizures
what is the diagnostic study of choice for suspected meningitis or encephalitis
lumbar puncture
when is CT brain indicated in suspected encephalitis or meningitis
when AMS, new onset seizures, immunocomp pts, focal neuro signs, or papilledema are present.
order BEFORE LP in these scenarios due to risk of CI to LP such as occult mass or signs of brain shift/herniation
when are blood cultures particularly helpful in the diagnosis of meningitis and encephalitis
to identify bacterial pathogens when empiric antibiotics are given prior to LP
in patients 50 years old or less with suspected bacterial meningitis, what is the empiric treatment?
3rd gen ceph (ceftriaxone(rocephin)) + vanc
add dexamethasone to decrease mortality and nero probs
what patients are at risk for listeria monocytogenes meningitis and what is the empiric treatment for these patients
50+years, pregnant, alcoholic, immunocomp
tx:3rd gen ceph (ceftriaxone(rocephin)) + vanc + ampicillin
add dexamethasone to decrease mortality and nero probs
what is the empiric treatment for patients with suspected encephalitis
IV acyclovir
if CSF analysis comes back + for encephalitis and the cause is CMV, what is the treatment
IV ganciclovir
if CSF analysis comes back + for encephalitis and the cause is not CMV or HSV what is the treatment
supportive. no evidence of any antivirals impacting tx outcome.
what is protocol for all patients with bacterial meningitis or encephalitis
admission to hospital for IV antimicrobial agents and further care
what is a brain abscess and what causes it
bacterial infection of the brain parenchyma composed of a central purulent cavity ringed by a layer of granulation tissue and outer fibrous capsule
what are presenting signs/symptoms of brain abscesses
nonspecific but may include:
- HA
- neck stiffness
- fever
- vomiting
- confusion
- AMS
- s/s may reflect origin of infection (eye/ear/sinus pain)
- symptoms may be present 1-8 weeks prior to dx
what is needed to make the diagnosis of a brain abscess?
imaging:
- CT noncontrast can be used
- CT w contrast more likely to identify it
- MRI also good
this was so nonspecific, plz read to interpret for yourself
what should be avoided in brain abscesses
LUMBAR PUNCTURE
what is needed to guide the management of brain abscesses after the diagnosis has been made
blood cultures or cultures of other sites of infection
what is the treatment for otogenic brain abscesses
Tax the metro
what is the treatment for odontogenic brain abscesses
what is the treatment for sinogenic brain abscesses
what is the treatment for penetrating trauma causing brain abscesses
Taze the van
what is the treatment for brain abscesses after neurological procedures
Taze the van
what is the treatment for brain abscesses from unknown sources
Tax the metro
what is a spinal epidural abscess
rare infection consisting of pyogenic material that accumulates in the epidural space.
where do up to half of epidural abscesses originate from? where do they most often occur?
hematogenous spread of bacteria from soft tissue, urine, or respiratory sources.
most occur in thoracic and lumbar spine
what is the classic triad of spinal epidural abscesses
- back pain
- fever
- neurological symptoms
present in only a minority of patients, but back pain is found in 70-90% of cases.
fever is also common
what are the typical stages of untreated epidural abscesses
- back pain, fever, localized spinal tenderness
- spinal irritation w radicular pain, hyperreflexia, nuchal rigidity.
- fecal or urinary incontinence plus focal neuro deficits
- motor paralysis of lower extremities
what are risk factors you should assess for when considering spinal epidural abscess
- immunocomp
- IVDU
- spinal surgery
- recent LP or epidural procedure
what are PE findings for epidural abscess
midline spinal tenderness to palpation or percussion
what neurologic findings should you look for that suggest cauda equina syndrome over epidural abscess
- decreased rectal tone
- decreased perineal sensation
this was an odd sentence. read for yourself plz.
what laboratory studies may be helpful in the diagnosis of epidural abscesses
- CBC
- ESR
- CRP
- blood cultures (+ in 40%, helpful for tx after dx)
what is the imaging modality of choice for epidural abscess? what is second line?
1st - gadolinium MRI
2nd - CT w myelography if MRi not possible
when should you give empiric abx therapy in epidural abscess suspicion? what abx are used?
- empiric tx indicated if neuro dysfunction, signs of sepsis/systemic illness, or immediate surgery is not available.
- use Vanc + ceftazidime/cefipime +/- gentamicin
