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Acute Care I > Neuro Emergencies: Meningitis > Flashcards

Neuro Emergencies: Meningitis Flashcards

1
Q

Meningitis is what?

A

an inflammation of the arachnoid membrane, pia mater, and the intervening cerebrospinal fluid (CSF)

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2
Q

Meningitis
The inflammatory process extends throughout what?

A

the subarachnoid space around the brain and spinal cord and involves the ventricles

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3
Q

Epidemiology
The incidence of bacterial meningitis has decreased significantly in developed countries since the introduction of vaccines against what bacterial pathogens?

A

Hemophilus influenaze type B
Streptococcus pneumoniae
Neisseria miningitidis

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4
Q

Epidemiology
What is the most common pathogen?

A

S. Pneumoniae

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5
Q

What pathogen is emerging as the most common cause of bacterial meningitis w/ increased incidence in elderly and immunocompromised individuals?

A

Listeria monocytogenes

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6
Q

Epidemiology
Predisposing factors include?

A

Acute otitis media
pneumonia
sinusitis
neurosurgical procedures
immunocompromised individuals and high risk groups

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7
Q

Pathophysiology of Meningitis
Infectious agents can gain access to the CNS by the following routes

A

Hematogenous spread
Direct transmission
Retrograde venous
Neuronal pathway
Iatrogenic

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8
Q

Pathophysiology of Meningitis
What is Hematogenous spread?

A

spread from a distant infectious site

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9
Q

Pathophysiology of Meningitis
What is Direct transmission?

A

otitis media, sinusitis, trauma, congenital malformations infected tooth

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10
Q

Pathophysiology of Meningitis
What is Retrograde Venous transmission?

A

usually from nasopharynx

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11
Q

Pathophysiology of Meningitis
What is neuronal pathway transmission?

A

Olfactory and peripheral nerves

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12
Q

Pathophysiology of Meningitis
What is iatrogenic transmission?

A

LP, VPS, and cranial procedure

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13
Q

Pathophysiology of Meningitis
Bacteria enter the CNS via?

A

choroidal vessels or
in cerebral endothelial cells of the blood-CSF barrier in the posterior capillary veins

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14
Q

Pathophysiology of Meningitis
Upon invasion of the CSF bacteria multiply to high concentrations secondary to?

A

inadequate immunoglobulins and complement in CSF

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15
Q

Pathophysiology of Meningitis
Release of proinflammatory cytokines such as? from what cell types?

A

IL-1 and TNF
meningeal and endothelial cells, macrophages and microglia

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16
Q

Pathophysiology of Meningitis
Cytokines enhance the passage of leukocytes by inducing what?

A

several families of adhesion molecules that interact with corresponding receptors on leukocytes

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17
Q

Pathophysiology of Meningitis
Cytokines can also increase the binding affinity of leukocyte selection for?
further contributing to?

A

its endothelial cell receptor

neutrophils in the subarachnoid space

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18
Q

Pathophysiology of Meningitis
Neutrophils release what?
That disrupt what?

A

prostaglandins, matrix metalloproteinases and free radicals

the endothelial intracellular tight junctions and subendothelial basal lamina

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19
Q

Pathophysiology of Meningitis
The ultimate result from all these processes is?

A

Vasogenic brain edema
Cerebrovascular dysregulation
elevated ICPs

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20
Q

Neurologic Complications of Meningitis include?

A

Hydrocephalus
Coma
Seizure
Deafness
Motor Deficits
Sensory Deficits
Cognitive Deficits
Cranial Nerve Palsy
Mycotic Aneurysm formation
Thrombosis
Death

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21
Q

Differential Diagnosis associated with Meningitis symptoms includes?

A

SAH
ICH
Epidural hematoma
GBS
Arnold Chiari malformation
Intracranial neoplasm
Electroly imbalance
Hypoglycemia
Seizure

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22
Q

Clinical Presentation
Classic Triad?

A

Fever
Nuchal rigidity
AMS

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23
Q

Clinical Presentation
Symptoms outside of the classic triad include?

A

HA
Photophobia
Vomiting
Lethargy
Myalgia
Seizures
Skin manifestations
Symptoms progress hours to days

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24
Q

Clinical Presentation
Clinical findings are often overlooked in?

A

infants
obtunded patients
elderly patients w/ heart failure
elderly patients w/ pneumonia
Immunocompromised individuals

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25
Q

Clinical Presentation
In elderly patients neck stiffness may be difficult to evaluate d/t it possibly being caused by?

A

osteoarthritis
stiffness of neck muscles

26
Q

Clinical Signs
Brudzinski’s Sign

A

Spontaneous flexion of the hips during attempted passive flexion of the neck

27
Q

Clinical Signs
Kerning’s Sign

A

Inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees

28
Q

Diagnosis
Hx will include

A

recent illness or sick exposure
change in mental status
focal deficit
cranial nerve palsy

29
Q

Diagnosis
Physical should include?

A

inspection of skin
otoscopic exam
inspect oral cavity/throat
CSF otorrhea or rhinorrhea

30
Q

Diagnosis
Lab Studies to check?

A

CBC (WBC elevated, Thrombocytopenia)
BMP (Cr, Electrolytes)
Coags
PCR
HIV

31
Q

Diagnosis
50-90% of patients with bacterial meningitis have?

A

positive blood cultures

32
Q

Diagnosis
Imaging?

A

Head CT
Exclude mass lesion or elevated ICP
Prevent herniation d/t CSF removal

33
Q

Algorithm
With suspicion for bacterial meningitis, ask if the patient is/has

A

Immunocompromised
hx of CNS disease
new onset seizure
papilledema
altered consciousness
focal neruo deficit
delay in performatnce of diagnostic procedures

34
Q

Algorithm
If pt has any of the following what are the next steps?
Immunocompromised
hx of CNS disease
new onset seizure
papilledema
altered consciousness
focal neruo deficit
delay in performatnce of diagnostic procedures

A

Blood cultures STAT
Dexamethasone (b) + empirical antimicrobial therapy(c)
Negative CT scan of the head
Perform LP
CSF findings c/w bacterial meningitis
Perform Gram Stain

35
Q

Algorithm
Positive CSF Gram Stain
Yes?
No?

A

Yes - Dexamethasone (b) + targeted antimicrobial therapy
No - Dexamethasone (b) + empirical antimicrobial therapy

36
Q

Algorithm
If pt does not have any of the following, what are the next steps?
Immunocompromised
hx of CNS disease
new onset seizure
papilledema
altered consciousness
focal neruo deficit
delay in performatnce of diagnostic procedures

A

BC and LP STAT
Dexamethasone (b) + empirical antimicrobial therapy
CSF findings c/w bacterial meningitis
Perform CSF gram stain

37
Q

When to Order a Head CT

A

Immunocompromised
CNS disease
New onset seizure
Papilledema
Altered LOC
Focal Neuro deficit

38
Q

LP contraindications

A

Coagulopathy/thrombocytopenia
Clinical signs of impending herniation
Infection at LP site

39
Q

LP landmarks

A

L3-L4
L4-L5
L5-S1

40
Q

LP
Make sure to check what?

A

Opening pressure

41
Q

CSF analysis should include?

A

Color/clarity
cell count
protein
glucose
gram stain
culture
PCR and viral studies
CSF to plasma glucose is about 2/3

42
Q

CSF Characteristics in Bacterial vs. Viral Meningitis
Bacterial:
Color
Cell count
Glucose
Protein
Opening pressure

A

cloudy
200-20,000 PMN
<40
>50-100
Markedly high

43
Q

CSF Characteristics in Bacterial vs. Viral Meningitis
Viral or aseptic
Color
Cell count
Glucose
Protein
Opening pressure

A

clear or cloudy
100-1000PMN
Normal
>50 cells but usually less than bacterial
normal or slightly elevated

44
Q

Most common organisms and treatment
Age < 1 mo
Common bacterial pathogens?

Antimicrobial therapy

A

Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species

Ampicillin plus cefotaxime or
ampicillin plus aminoglycoside

45
Q

Most common organisms and treatment
Age 1-23 mo
Common bacterial pathogens?

Antimicrobial therapy

A

Streptococcus pneumoniae, Neisseria meningitidis, S. Agalactiae, Haemophilus influenzae, E. coli

Vancomycin plus a third gen cephalosporin

46
Q

Most common organisms and treatment
Age 2-50
Common bacterial pathogens?

Antimicrobial therapy

A

N. meningitidis, S pneumoniae

Vancomycin plus a third gen cephalosporin

47
Q

Most common organisms and treatment
Age > 50 years
Common bacterial pathogens?

Antimicrobial therapy

A

S. Pneumoniae, N. meningitidis, L. monocyotogenes, aerobic gram-negative bacilli

Vancomycin plus ampicillin plus a third gen cephalosporin

48
Q

Most common organisms and treatment
Head trauma (Basilar Skull Fx)
Common bacterial pathogens?

Antimicrobial therapy

A

S. pneumoniae, H. influenzae, group A Beta-hemolytic streptococci

Vancomycin plus a third gen cephalosporin

49
Q

Most common organisms and treatment
Head Trauma (Penetrating Trauma)
Common bacterial pathogens?

Antimicrobial therapy

A

Staphylococcus aureus, ccoagulase-negative staphylococci (especially Stahpylococcus epidermidis), aerobic gram-negative bacilli (including Pseudomonas aeruginosa)

Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem

50
Q

Most common organisms and treatment
Postneurosurgery
Common bacterial pathogens?

Antimicrobial therapy

A

Aerobic gram-negative bacilli (including p. aeruginosa), S. aureus, coagulase-negative staphylococci (especially S. epidermidis)

Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem

51
Q

Most common organisms and treatment
CSF shunt
Common bacterial pathogens?

Antimicrobial therapy

A

Coagulase-negative staphylococci (especially S. epidermidis), S. aureus, aerobic gram-negative bacilli (including P. aeruginosa), Propionbacterium acnes

Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem

52
Q

Antibiotics
Third Gen Cephalosporine/dose/frequency?

A

Ceftriaxone 2g q12hr

Cefotaxime 2g q4-6hr

53
Q

Antibiotics
Glycopeptide/dose/frequency?

A

Vancomycin 15-20mg/kg q8-12hrs

54
Q

Antibiotics
PCN/dose/frequency?

A

Ampicillin 2g q4hrs (in adults > 50y/o)

55
Q

Antibiotics
In immunocompromised patients add what?
Instead of ceftriaxone or cefotaxime use what?

A

pseudomonal coverage
cefepime 2g q8hr or meropenem 2g q8hr

56
Q

Antibiotics
Antiviral for HSV meningitis/dose/frequency?

A

Acyclovir 5-10 mg/kg TID

57
Q

Antibiotics
Narrow antibiotics based on?

A

culture results

58
Q

When can droplet precautions be discontinued?

A

when on antibiotics for 24 hrs

59
Q

Steroids
steroid/dose/frequency/duration

A

dexamethasone 0.15mg/kg IV q6 hr for 2-4 days

60
Q

Steroids
Reduces risk of poor neurological outcome in pt with?
Must be given when?
Believed to minimize?

A

S. pneumoniae
early
inflammatory cascade

Acute Care I (24 decks)

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