Guidelines for the Early Clinical and Public Health Management of ...

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Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) Section A Clinical evaluation for suspected bacterial meningitis or meningococcal septicaemia History Examination Suspect severe sepsis if: Bad prognostic signs include: ‣ Headache/photophobia ‣ Neck and back stiffness ‣ Vomiting/off feeds (infant) ‣ Lethargy/altered consciousness/altered or inappropriate behaviour ‣ Irritability (infant) ‣ Fever ‣ Rash (meningococcal) ‣ Reduced urine output (or dry nappy reported by parent) Classic clinical features of meningococcal disease can appear relatively late in the illness. Early clinical features include: ‣ Leg pains ‣ Cold hands & feet ‣ Abnormal skin colour (25) Be aware: The rash in early meningococcal infection is typically a non-blanching erythematous macular rash. However, in the early stages it may blanch with pressure. ‣ Ensure Airway is clear ‣ Breathing pattern is satisfactory ‣ Circulation pulse rate and volume, BP, capillary refill ‣ Pyrexia ‣ Floppy/abnormal tone (infant) ‣ Skin changes ‣ Characteristic rash (meningococcal) ‣ Meningism/bulging fontanelle (infant) ‣ Decreased level of consciousness ‣ Signs of raised ICP: • fluctuating consciousness, • ↑BP & relative bradycardia • unequal, dilated or poorly responsive pupils • focal neurological signs • seizures, abnormal posture • papilloedema (late sign) ‣ Other babies may have floppy abnormal tone ‣ Older children/adultsmay appear aggressive or have inappropriate behaviour. ‣ Tachycardia ‣ Tachypnoea ‣ Rapid, low volume pulse ‣ Slow capillary refill time (>2 sec) ‣ Skin to core temperature difference ‣ Evolving characteristic rash ‣ Oliguria ( 5.0 mmols/l or rising ‣ Coagulopathy ‣ Rapidly evolving characteristic rash ‣ Altered conscious state ‣ Beware meningococcal sepsis without signs of meningitis (meningism) These patients constitute a very high risk group and warrant vigilant monitoring and early aggressive therapy and importantly constant clinical re-evaluation to see if treatment goals are achieved. Monitoring in Emergency Department: Cardiac, Non-invasive BP, Pulse Oximetry, Core Temperature -22-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) Section B Guidelines for the MANAGEMENT OF THE HAEMODYNAMICALLY STABLE PATIENT WITH meningitis Summary of management approach 1. ABC management ‣ Assess and maintain airway and breathing as required ‣ Administer 100% O 2 at 15 L/min ‣ Assess circulation and secure vascular access (intravenous or intraosseous) 2. Summon help, alert ICU team 3. Order first dose antibiotics to be drawn up 4. Draw bloods stat 5. Give dexamethasone before or at the time of antibiotics 6. Give IV/IO antibiotics without undue delay 7. Commence IV fluids 8. Evaluate for presence of cerebral oedema 9. If cerebral oedema / ↑ICP → intensive care with guided neurological care 10. Consider intubation 11. Lumbar puncture should be carried out if the patient is haemodynamically stable and there are no contraindications 12. Reassess clinically 13. If meningococcal infection suspected obtain throat swab and/or pernasal swab 14. Consider further consultation: (microbiology/neurology/nephrology/infectious diseases) 15. Notify public health and infection Control. Ensure contact chemoprophylaxis and information as per agreed protocol. -23-
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