Meningococcemia Flashcards
Giving advice over phone
- physician dependent
- don’t prescribe without having seen patient
- advise to make appointment
Infants less than 6-8 weeks with fever?
EMERGENCY!!!!
- all other fevers are context specific and need more info
Asking about severity of illness
be careful not to use medical terms that confuse parents
- don’t lead with questions, ask what they think is going on
Determining severity of illness
Is there any end-organ hypoperfusion?
Any underlying conditions that could complicate things?
Emergency conditions causing altered mental status
Hypoxia - organs and tissues need oxygen
Shock - end-organ perfusion
Hypoglycemia - glucose is critical substrate
Poisoning
Causes of altered mental status
1-4 can cause shock and/or acidosis
- Intussusception
- Sepsis
- DKA
- Renal failure
- CNS problems
CNS causes of altered mental status
Seizure - decreased LOC Tumor - increased ICP Intracranial bleed - increased ICP (headache) Infection - increased ICP Trauma
DDx of lethargy in teenager
Sepsis - fever, lethargy, decreased activity/appetite
Meningitis - fever, headache, stiff neck, AMS
Encephalitis - viral (fever and AMS)
Toxins - overdose
Pneumonia - fever, tachypnea and hypoxic
Assessing Circulation
- heart rate = very sensitive for volume status (DON’T OVERLOOK)
- Capillary refill time = sensitive for hypovolemia
- BP = not sensitive for circulation, body can compensate
Airway positioning
Infant = towels/pillow under shoulders
1-3 ys = neutral position
3-10 yrs = extend neck
10+ = hyperextend neck
Assess airway and breathing
- describe effort and rate
- listen and check oxygenation
- if not doing well, try jaw thrust
Disability and environment
Disability/dextose - quick neuro assessment for increased ICP - assess mental status - pupils Exposure/Environment
PE of bacterial meningitis
Neck stiffness - 57-92% Fever - 66-100% Brudzinski's or Kernig's - 61% Altered mental status - 46-95% INFANTS? - bulging fontanel (harder to examine)
Definition of Shock
inadequate delivery of substrates and oxygen to meet metabolic needs of tissue
- no longer aerobic metabolism
- disruption of cellular membranes and ion pumps
- cells swell and break down
Compensation of Shock in Kids
kids can maintain their blood pressure much longer during shock than adults
- tachycardia and increased contractility
- increased venous tone and respiratory rate
HYPOTENSION = BAD SHIT
Hypovolemic Shock
most common type
- inadequate fluid intake to compensate for loss
- AMS, tachypnea, tachycardia, hypotension, cool extremities
Distributive Shock
Neurogenic and anaphylactic
- intravascular hypovolemia
- vasodilation, increased capillary permeability, 3rd space loss
Cardiogenic Shock
Severe heart disease, dysrhythmia, cardiomyopathy, tamponade
- low cap refill, absent pulses, tachypnea, tachycardia, low UO
Septic Shock
infectious organism releases toxins that affects fluid distribution and CO
- require repeated boluses of fluid and vasopressors
Administration of Fluids in Shock
maintaining fluid status trumps everything in shock
- isotonic (normal saline) as fast as possible
Intraosseus access
easy, fast and can replace IV if trouble starting IV
- can give any fluid thru it that you would IV
- distal femur, tibial plateau, proximal humerus
- don’t place into a fracture or infection
DDx for fever and petechiae
Menningococcoal Sepsis Kawasaki Disease Toxic Shock Syndrome RMSF Scarlet Fever
Meningococcal Sepsis
fever, petechiae –> MUST BE ON LIST
- patient otherwise looks well
- blood cultures taken and then ABx started
Neisseria meningitidis
Toxic Shock Syndrome
fever and sun-burn appearing rash
- from staph toxin –> leads to shock
Risks for meningococcal sepsis
Close quarters (military/college) Complement deficiency Asplenia
Transmission of meningococcal
Air and respiratory droplets
incubation 1-10 days
Disease course of meningococcal
- Fever, chills, prostration, malaise, myalgias, rash
2. Purpura, ischemia, coagulopathy, pulmonary edema, shock
Mortality of meningococcal
10% –> higher if longer before treatment
Sequelae of meningococcal
hearing loss, neuro disability, loss of digits, scarring
Treating meningococcemia
IV Penicillin (penicillin G)
- pediatrics = 250,000-300,000 units/kg/day (divided every 4-6 hrs)
- adults = 12-24 million units a day (divided every 4-6 hrs)
Initial treatment
as soon as cultures are drawn –> start vanco, ceftriaxone and if in endemic areas doxycycline
- vanco = gram (+) and MRSA
- ceftriaxone = gram (-)
- doxy = tick
Meningococcal Prophylaxis
Adults - ciprofloxacin
Kids - rifampin or ceftriaxone
*can’t use rifampin or ciprofloxacin for pregnant
Pre-renal failure
due to hypoperfusion = elevated BUN and Cr
Meningococcal vaccine
Tetravalent
Given to 11-18 year olds
- given IM at 11 year old
- booster at 16
