Case 23: 15yo - bacterial meningitis

Question 1

when is fever an emergency?

Answer 1

• Fever in infants <6-8w
• signs of hypoperfusion == brain, skin, kidneys, lung
• • other conditions == sickle cell dz, HIV, neutropenia, DM

Question 2

emergency conditions causing altered mental status that must be reversed quickly to prevent cellular damage

Answer 2

CABs == anything that reduces O2 and critical nutrients to cells

• hypoxia
• shock (septic/hypovolemic/cardiac) == inadequate O2, nutrients; pre-renal failure (increased BUN, Cr)
• hypoglycemia
• poisoning / toxic ingestion == reverse with antidostes

Question 3

causes of altered mental status, lethargy in teens

Answer 3

• sepsis == + fever, decreased urination
• DKA == + tachypnea
• toxic ingestion == + decreased UOP, rash, tachypnea
• pneumonia == (AMS w/ severe hypoxia) + fever, tachypnea
• hypoglycemia
• renal failure == decreased UOP + acidosis, tachypnea

CNS causes

• seizures == generalized
• tumor == increased ICP d/t mass effect + progressive behavioral changes, tachypnea
• subarachnoid hemorrhage == + severe HA
• meningitis == + increased ICP, fever, HA, stiff neck, photophobia
• encephalitis [virus] = + fever
• trauma == shaken baby syndrome –> intracranial bleed

Question 4

bacterial meningitis

• physical exam - early v. late (?in infants?)
• mortality
• complications
• urgent lab evaluation (and what labs would you get, but later?)

Answer 4

EARLY

• fever, chills, malaise, myalgia
• neck stiffness
• kernig / brudzinski’s
• AMS
• non-blanching rash

LATE

• purpura
• limb ischemia
• coagulopathy
• pulmonary edema
• shock

INFANTS

• bulging fontanelles
• focal seizures

mortality == 10-15% (adolescents = 21%)

complications (11-19%)

• hearing loss
• neurologic disability
• digit/limb amputations
• skin scarring
• increased ICP
• SIADH
• AKI (pre-renal) d/t shock

LABS

• CBC, differential and platelets, blood/urine culture and gram stain
• Chemistries (Na, K, Cl, CO2, BUN, creatinine, glucose) –> complication of SIADH, increased ICP

LATER LABS
- lumbar puncture

Question 5

SHOCK

• define
• physiology
• clinical findings (which are compensatory, and which are not?)

Answer 5

==> inadequate delivery of substrates & O2 for metabolic needs of tissues

• decreased aerobic O2 production
• disrupted cell membrane ionic pumps
• cellular edema –> membrane break down –> cell death

CLINICAL FINDINGS

• VS = increased HR, RR
• peripheral blood vessel constriction == cool, clammy extremities; delayed cap refill
• decreased peripheral pulses == vasoconstriction, decreased SV

Question 6

compensatory mechanisms that children have for shock

Answer 6

compensatory (nml BP)

• tachycardia == CO = HR*SV
• vasoconstriction == increased SVR
• increased heart contractility (SV, even with hypovolemia)
• increased venous tone == increased VR
• tachypnea == compensate for metabolic acidosis caused by lactic acidosis from increased glycolysis by O2-deprived tissues and cells

Question 7

is hypotension an early or late sign of shock in kids? why?

Answer 7

LATE

b/c kids can compensate well

Question 8

types of shock
- causes:
- signs and sxs:
==> key distinguishing features

Answer 8

HYPOVOLEMIC
- causes: fluid intake &laquo_space;fluid output(V/D, hemorrhage)
- signs and sxs: AMS, tachypnea, tachycardia, hypotension, cool extremities, oliguria
==>

CARDIOGENIC
- causes: severe congenital heart disease, dysrrhythmias, cardiomyopathy, tamponade
- signs and sxs: AMS, tachypnea, hypotension, cool extremities, oliguria
==> delayed capillary refill; +/- tachycardia

DISTRIBUTIVE == neurogenic, anaphylactic, +/-septic(toxins)
- causes: intravascular hypovolemia d/tvasodilation, increased capillary permeability, 3rd space fluid losses
- signs and sxs: INITIALLY as “warm shock) == tachypnea, tachycardia,
==> warm extremities, bounding pulses, adequate urination, mild metabolic acidosis
==> require repeated boluses of fluid; meds for cardiac contractility and vasoconstriction (epinephrine, norE, dopamine)

Question 9

most common type of shock worldwide

Answer 9

hypovolemic

Question 10

most common cause of shock in children

Answer 10

• hypovolemic = hemorrhage, diarrhea/dehydration

- septic shock

Question 11

management of menigococcemia

• Abx
• prophylaxis (post-exposure, general)

Answer 11

ANTIBIOTICS

• empiric coverage (any fever, rash) == ceftriaxone + vancomycin
• penicillin = peds dose (250-300K Units/kg/day - divided q4-6h –> max 12Mill per day); adult dose (12-24Mill Units/day - divided q4-6h)

POST-EXPOSURE PROPHYLAXIS == for close contacts; health care workers

• ADULTS: ciprofloxacin, rifampin, (PREGNANT: ceftriaxone, azithromycin)
• CHILDREN: rifampin PO, ceftriaxone IM

GENERAL PROPHYLAXIS (high school, college, military)

• first dose @ 11-12yo
• booster @ 16yo
• • if receive first dose >16yo = no booster needed

Question 12

• how to assess for “sick” v. “not sick”

Answer 12

CABs == anything that reduces O2 and critical nutrients to cells

CIRCULATION
- HR, capillary refill time, cold core

AIRWAY
- signs of airway obstruction == neck position / jaw thrust

BREATHING

• look at the chest
• listento the chest in the axillae
• look at alighment of trachea
• WOB, RR, lung sounds, O2 sat

DFG = don’t forget glucose

DEF

DISABILITY
- mental status, ICP (unequal pupil size, reaction to light)

EXPOSURE AND ENVIRONMENT
- expose and examine all parts of patient (keep warm)

Question 13

what is this: lethargy + pinpoint pupils

Answer 13

opioid ingestion

Question 14

diffdx of fever and petechiae
- what’s #1?
==> how should you manage a patient who presents with this?

Answer 14

#1 meningococcal sepsis (even if pt otherwise looks well)
==> blood culture, empiric Abx

• Kawasaki == fever, polymorphic truncal rash, “strawberry” tongue, diffuse oral erythema, erythema/edema of hands and feet
• Toxic shock syndrome (TSST) == fever, sunburn-looking rash (sandpaper)
• Rocky Mountain Spotted fever == fever, petechiae (palms and soles)
• scarlet fever == fever, sandpaper rash, strawberry tongue (12-48h later: trunk –> extremities); rash resolved +desquamation of skin and bright red tongue (4-5d later)
  + “Pastia’s signs (linear petechiae), beefy red pahrynx,

Question 15

most important thing in management of shock

Answer 15

1) PERFUSION - FLUID BOLUSES (NS) asap

intraosseous access if IV line cannot be placed within 90sec –> b/c can be injected into bone marrow via needle = absorbed almost immediately into circulation

Question 16

in a patient with meningitis, increased ICP and SIADH is a component of the disease. Should you give fluid resuscitation?

Answer 16

YES - this is the most important part of shock management

once patient is no longer in shock – can fluid restrict to decrease ICP and risk of cerebral edema

Question 17

fluid management in septic shock (specifically - why?)

Answer 17

b/c can initially be compensated shock “warm shock”

1) repeated NS boluses of fluid - as much as needed to attain perfusion (PEDS = 50-100ml/kg; ADULTS = max 2L) until improve sxs = HR, cap refill, BP

if perfusion still inadequate after 60cc/kg
2) ionotropes = increase cardiac contractility
3) vasopressors [epinephrine, NorE] = increase BP by vasoconstriction

Question 18

Sarah is a previously healthy, 15-year-old girl

She has acute onset of progressive mental status changes, fever, lethargy, and tachypnea

She has not had anything to eat or drink all day

She has not urinated in over 12 hours.
Question
Based on what you know so far, what do you think are possible causes of Sarah’s illness?

 Multiple Choice Answer:
A		Central nervous system tumor	
B		Cystitis	
C		Diabetic ketoacidosis	
D		Encephalitis	
E		Hypoglycemia	
F		Ingestion	
G		Meningitis	
H		Pneumonia	
I		Renal failure	
J		Sepsis

Answer 18

• *MOST LIKELY **
• sepsis
• meningitis

?MAYBE?

• encephalitis
• ingestion
• pneumonia

NOT

• cystitis == b/c would have increased urination
• DKA == would have had prior hx of polyria, polydipsia c/w T1DM
• hypoglycemia == would not have fever, decreased output

Question 19

Which one of the following maneuvers is the LEAST reliable for determining adequacy of circulation?

 Multiple Choice Answer:
A		Palpate a peripheral pulse.	
B		Check to see if the patient's extremities are warm.	
C		Check for capillary refill.	
D		Check blood pressure.	
E		Check the patient's heart rate.

Answer 19

• warm peripheries

- BP

Question 20

how to asses/open airway in patients depending on the age

• infant
• 1-3 yo
• 1-8yo
• adolescent

Answer 20

• Infant: Place a blanket under the shoulders to tip the head into a “sniffing” position (nose tipped slightly upward).
• 1-3 years old: A neutral position keeps the head slightly tipped back.
• 1-8 years old: Extend the neck. Extend more as patient gets older.
• Adolescent: Hyperextend the neck.

Question 21

signs of compensated shock

is this still considered shock?

Answer 21

YES

• Tachycardia (the earliest sign of potential shock)
• poor pulses,
• prolonged capillary refill

Question 22

You watch as the team misses attempt after attempt to place an IV. Dr. Freed also tries and is unsuccessful.

Question
What type of access should be placed now? (Select the ONE best answer.)

Multiple Choice Answer:
A Central venous line (femoral, subclavian, internal jugular)
B Intraosseous line
C Place an NG tube and give 20cc/kg of fluid over 30 minutes.
D Peripheral arterial line (radial)
E Give fluids by mouth and continue to try a peripheral line.

Answer 22

B

for infants, kids <6yo, adults where can’t get an IV in immediately and NEED IT

can give fluids, any drugs

efficacy: intraosseous line = central venous line&raquo_space; peripheral lnies

Question 23

where to use IO?

• contraindications of IO insertion
• contraindications of IO insertion

Answer 23

• distal femur
• proximal/distal tibia
• iliac crests

KIDS = prox tibia, distal femur

DO NOT USE STERNUM

contraindications of IO insertion

• osteogenesis imperfecta
• at the site of fractured bone
• bone recently used for intraosseous access
• bone with overlyign area of cellulitis, infection, burn

complications of IO insertion

• fractures
• infusion of fluid into subcu tissue == compartment syndrome
• osteomyelitis
• microscopic fat & BM emboli == not really clinically significant

Question 24

a 15yo comes in with meningitis and shown to have septic shock. After several fluid boluses to boost her volume, she is found on repeat CMP to have elevated BUN: Cr. Should you renally dose her antibiotics?

Answer 24

The cause is probably pre-renal (due to underperfusion of her kidneys secondary to shock), so re-establishing perfusion by giving more fluid should be our current focus of treatment. Drug dosing does not have to be adjusted unless these elevations persist.

Question 25

at-risk populations for meningococcal disease that need vaccination

Answer 25

- Those with complement component deficiency or functional or anatomic asplenia - Individuals who are part of a community outbreak - Those who are traveling internationally to a region with hyperendemic or endemic meningococcal disease

Question 26

A 6-year-old boy presents to the ED with three days of diffuse muscle aches and occasional chills. Today, he had a headache and abdominal pain. He reports that he does not feel hungry because he feels sick to his stomach. He denies recent cough, congestion, sore throat, joint pains, or sick contacts. His vitals are: T 101.3 F, BP 108/71 mmHg, P 110 bpm, R 28 bpm, O2 sat 100% on RA. On physical exam, you notice blanching, erythematous macules on his ankles and several petechiae on his wrists. Upon questioning, his mother says that the spots on his wrists previously looked like the spots on his ankles. His neck is supple and there is no hepatosplenomegaly or lymphadenopathy. He reports no sick contacts, but recently visited his cousins in North Carolina. What is the best next step in management? Single Choice Answer: Please select one answer. A Give acetaminophen, obtain a Monospot, write a note for activity restriction, and advise his mother to bring him back if he is unable to tolerate fluids B Perform skin scraping of macules and examine under microscope with KOH prep C Admit the patient, obtain CBC, blood and CSF cultures, and await culture results to guide antibiotic therapy D Admit the patient, obtain CBC, blood and CSF cultures, then give loading doses of doxycycline 2.2 mg/kg and ceftriaxone 100 mg/kg/day E Give acetaminophen and obtain CBC, UA, and BUN/Cr

Answer 26

D ``` myalgia chills HA abd pain, anorexia fever tachycardia blanching, erythematous macules and petechiae (migrating) ``` recent travel to N Carolina - monospot would not be positive until after 1 mo - definitely admit b/c he seems pretty sick doxy is bad for his teeth and bones, but it would be weird to sit and weight for cultures to give antibiotics if you really think it's an infection Given the patient’s abdominal pain, headaches, myalgias, fever, and nausea, followed by blanching erythematous macules, which may be transitioning to petechiae and purpura, this presentation is classic for RMSF. His recent travel to North Carolina also fits with the geographical distribution of RMSF. The treatment of choice is doxycycline. N. meningiditis coverage with ceftriaxone is also necessary given his rash, headaches, and fevers.

Question 27

The mother of a 5-year-old boy calls your office asking if she should take her son to the emergency room or wait another day. She states that her son suddenly developed a “high fever” and is extremely tired. When you ask about her son’s behavior, she states that he also seems very confused. She also noticed he had developed reddish-purplish spots on his extremities. What is the next best step in management of this patient? Single Choice Answer: Please select one answer. A Have the patient make an appointment to come to your office today B Tell the mother to take her son to an ED immediately C Have the patient hydrate well over the weekend and follow up with you in a few days D This patient most likely ingested something. Recommend ipecac to induce emesis and call 911

Answer 27

B. This patient is exhibiting signs of sepsis, more specifically, of meningococcemia. Although it is important to replenish this patient’s fluids and control his fever, it should not be done in an outpatient setting. This is a medical emergency! Sepsis can lead to altered mental status. Signs and symptoms of sepsis include: fever, nausea, vomiting, diarrhea, apnea/dyspnea, oliguria, pallor, tachypnea, tachycardia, lethargy, irritability, petechiae, purpura, tremors, and seizures. ``` SUDDEN high fever lethargy confusion rash on extremities ``` likely not toxic ingestion . There is no indication for inducing emesis, and this can present a risk of aspiration in a child with altered mental status.

Question 28

A previously healthy 14-year-old female presents to the ED with a one-day history of fever and altered mental status. Vital signs on presentation include: BP 120/70 mmHg, HR 145 bpm, RR 42 bpm, temp 39.7 C, oxygen sat 93%. Physical exam reveals nuchal rigidity, cool extremities, 1+ distal pulses, diffuse petechial rash, and capillary refill > 2 seconds. What is the important first step in management? ``` Single Choice Answer: Please select one answer. A Place IV and start NS bolus B Order CBC, CMP, PT, and INR C Start empiric antibiotic therapy with IV ceftriaxone D Obtain a head CT E Order blood cultures ```

Answer 28

A ``` fever AMS tachycardia tachypnea fever ``` == meningitis This patient is in septic shock due to meningococcal infection and should immediately be started on IV fluids in order to maintain perfusion to vital organ systems. Although this patient has a normal blood pressure, other vital signs and physical examination point to shock (HR and RR are both significantly elevated), which first and foremost requires fluid resuscitation.

Question 29

A 12-day-old baby girl is brought to the ED by her foster mother due to fussiness and tactile fevers. The baby's teenage biological mother did not receive prenatal care and delivered her baby at home. On further questioning, you find out that the patient has had only two wet diapers per day and two loose green stools per day. On exam, the patient is irritable and her anterior fontanelle is tense. Which of the following diagnoses are of emergent concern at this time? ``` Single Choice Answer: Please select one answer. A Down syndrome B Fetal alcohol syndrome C Group B strep sepsis/meningitis D Meconium ileus E Poor weight gain ```

Answer 29

C bulging fontanelle == meningitis The patient's mother did not have prenatal care and likely did not have screening for group B strep during pregnancy. She also delivered at home and would not have had access to antibiotics during delivery. Group B strep is a common and serious cause of sepsis and meningitis in newborns.

Question 30

infectious diffdx for bulging fontanelle

Answer 30

Meningitis Encephalitis Otitis Media

Question 31

An 11-month-old boy is brought to the ED by ambulance. His father called 911 after the patient’s eyes deviated to the left as his arms and legs were twitching. During this time he was unresponsive. He has had a tactile fever for three days, and parents mention that he has not been as playful as usual during this time as well. His parents have not had him vaccinated due to personal beliefs. In the ED his vital signs are T 39.1°C, HR 155 bpm, RR 28 bpm, BP 100/65 mmHg, O2 100% (on RA). He does not cry but whimpers during most of your physical exam (including when you look in his ears). You order a CBC and metabolic panel, which are significant for a leukocytosis with a left shift and mild acidosis. Urinalysis and blood/urine cultures are pending. Which of the following additional studies would you obtain? ``` Single Choice Answer: Please select one answer. A Chest x-ray B Toxicology screen C Lumbar puncture D Electroencephalogram (EEG) ```

Answer 31

C focal seizure fever tired UNVACCINATED tachycardia tachypnea this patient’s fever and leukocytosis make infection a much more likely diagnosis than toxic ingestion In a young child with fever and altered level of consciousness we should always have a high suspicion for meningitis. This patient’s parents expressed concerns about his behavior at home before his seizure, and his mental status during your examination is not normal. While very few patients presenting with febrile seizure actually have meningitis, this patient’s lack of immunizations put him at increased risk. Furthermore, clinical signs of meningitis in patients under 12 months of age can be very subtle, and so a high level of suspicion is important. A lumbar puncture will help rule in or out meningitis and guide treatment. Note that in some cases the clinician will request a head CT prior to performing a lumbar puncture if there are concerns about increased intracranial pressure. A head CT in itself may not be helpful in the evaluation of a patient with a seizure, although it may be useful in cases where trauma is suspected, or to look for calcifications (such as with cytomegalovirus infection or tuberous sclerosis).