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ACUTE BACTERIAL MENINGITIS in children : summarized


ACUTE BACTERIAL MENINGITIS
                                                               
                                                                Dr Sadia Hayat

EVALUATION
  • Fever, headache, vomiting
  • Irritability, excessive crying, feed refusal
  • Diplopia, photophobia ( it is positive in 16% cases)
  • Disorientation, fits, loss of consciousness
  • Skin rash, contact with a case of meningitis.
  • Vital signs (bradycardia, T0, BP, ↑breathing pattern, fundoscopy)
  • SOMI (neck stiffness is positive in 13 to 75 % cases , , Kernig’s Sign is positive in 10-53 % cases  & Brudzinski’s sign is positive in 11 to 66 % cases ) “So it means that negative SOMI do not necessarily rule out Meningitis.
  • Sensorium: irritability, drowsiness, coma,
  • Ant.fontenelle, OFC
  • Tone, reflexes, focal signs
  • Rash: petechial, purpuric
  • Fundoscopy

LAB WORK

·         TLC, DLC , Plt count
·         CSF: appearance, pressure, low glucose, high proteins, cytology- total & differential, smear, culture ( exclude ↑ICP, bleeding diathesis, local infection, focal signs)
·         Blood C/S
·         s/Na, K
·         Cranial USG
·         CT brain (plain & with contrast)

MANAGEMENT

·         Admit the patient
·         Maintain IV Line.
·         Pass NG Tube & aspirate gastric contents if unconscious.
·         TPR x 4 hourly.
·         Keep input output record.
·         Expose to Control Temperature.
·         Syp. Paracetamol 10-15 mg/kg/ 6 hourly via NG tube or orally.
·         For children < 01 year, daily OFC.
·         Keep in left lateral position with head slightly down during fits.
·         Give IV fluids (60-70% of maintenance N/5 saline if patient is unable to drink)
·         Start Antibiotics.
For Age 1 month up to  2 Years:-
o   Inj. Ampicillin    (75 mg/kg/dose) IV x 6 hourly for 10-14 days
o   Inj. Cefotaxime  (50 mg/kg/dose) IV x 6 hourly for 10-14 days
o   Inj. Dexamethasone,(0.2 mg/kg/dose x 6 hourly for 3 days)

For Age above 2 Years:-
·         Inj. Benzyl-Penicillin (100,000 units/kg/dose) x 6 hourly ATD for 10 days
·         Or inj Vancomycin 20mg /kg / dose X 8Hrly (slowly over 1 hour in 20 cc infusion( ( rapid infusion can cause Red Man Syndrome
o   Inj. Cefotaxime (50mg/kg/day) IVx 6 hourly for 10 days
o   Inj. Dexamethasone,(0.2 mg/kg/dose x 6 hourly for 3 days)
 (Tailor treatment with C/S report when available)
(Consult senior before switching to 2nd line drugs)

  • Control of Fits:-
o   Inj. Diazepam  (0.3 mg/kg/dose) IV SOS (may be repeated 3 times at 5 minutes interval)
o   Inj. Midazolam, 0.15 mg/kg IV stat.  Midazolin infusion may be needed
o   Inj. Phenytoin,  15 -20 mg/kg IV stat
Þ    For Further Control:-
Load with Inj./Tab. Phenobarbitone 10 mg /kg--- IV/ NG
then Tab. Phenobarbitone 5mg/kg/day via NG/Oral.

  • Observe for Early Complications

o   ICP: Raied ICP presents early as Tachycardia, Hypertension , Irregular pulses , there may or may not be a cranial nerve deficit such as unequal pupils. The classic Cushings Triad( Hypotension, bradycardia, and chain stokes breathing are terminal events). There may be  Papilledema after 24 hours of raised ICP . There may be 6th nerve palsy, tense fontanelle.
Raise head end by 20-30o to prevent cerebral edema.
Restrict IV fluids, 60-70% of daily maintenance
Inj. Mannitol, ½-1 Gm (5-10ml) IV x 8 hourly (before giving orders of mannitol in “ml” must see the Strength of mannitol that we are receiving in ward (as we sometimes get 5 % , 12.5% , 17% or 20% mannitol from hospital)
Inj. Dexamethosone 0.6mg/kg/day x IV x 8 hourly.
Keep bladder & bowel empty, and monitor Urine output. ( beware SHIFA Urine bags have wrong caliberation)
Hyperventilate to lower down ICP .
o   SIADH: Continued fits, coma, S.Na <130mEq/L; ↓S. osmolility,
                  ↓urine vol, ↑urine osmolality/ sp.gravity
Restrict IV fluids: 50% of maintenance
o   Adrenal Crises with Shock: Collapse, low BP, petechial rash
Normal Saline, 20 ml/kg IV over 10-20 min
Hydrocortisone, 20mg/kg x stat; then 6 hourly
o   Subdural Effusion: ↑Coma, ↑fits, ↑OFC, recurrence of fever,
            Cranial USG & CT Brain
Aspiration on both sides (involve neurosurgeon)

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