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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