So what should we do for our patients when they’re in the Emergency Department?
First and foremost, focus on those ABC’s.
So if your patient needs airway management,
breathing management, or circulatory management,
focus on those processes first.
Talking about the empiric antibiotic therapy that you wanna give.
The first antibiotic is ceftriaxone 2 grams.
You know, I don’t wanna stress dosing too much for the purposes of these lectures,
but here I wanna make sure that we focus on the fact that it’s 2 grams of ceftriaxone.
And the reason that I wanna focus on that
is because it’s a different dosing than what we mostly do when we give ceftriaxone
Ceftriaxone is often dosed as 1 gram IV.
We give 2 grams IV here because that allows it to cross the blood brain barrier
and get to high enough concentrations with in the CSF.
The other empiric antibiotic that’s given is Vancomycin.
If you’re worried about listeria
and primarily we’re worried about listeria in the extremes of age.
So in the very young and the very old,
you wanna go ahead and treat with ampicillin.
Dexamethasone should be added on for patients
in whom there’s concern about bacterial meningitis.
Dexamethasone has been studied and found to decrease morbidity.
Primarily to diminish or decrease hearing loss for patients
who have strep pneumos associated meningitis.
So definitely in that category you wanna go ahead and give Dexamethasone.
It’s important to note actually that Dexamethasone should be given before the antibiotics
in order for it to have its maximum effect and can generally be given pretty rapidly.
And then lastly, Acyclovir is the medication that can be used to treat HSV associated encephalitis.
You know, a big question that always comes up.
You’ve seen a patient in the Emergency Department.
You did all the appropriate testing.
You did the LP and it comes back positive.
Do you need prophylaxis to prevent yourself from getting meningitis?
So who needs prophylaxis and family members may ask you this as well.
So the people who need prophylaxis is actually a relatively small limited group of people.
So generally households or intimate contacts.
So do you live with the person?
You know or have intimate relations with them?
And then the last part are health care workers with exposure to mucosal secretions.
So it’s not just did you shake the person’s hand
when they arrive in the Emergency Department?
It’s did you do there intubation?
You know where you’re exposed to their mucosal secretions?
Did they cough on you?
Did you have a closer relationship
than just you know having a brief conversation with their patient?
You don’t need to prophylaxis everything.
So you don’t need to prophylaxis all the other kinds of meningitis
except for Neisseria meningitides.
That’s the only one that requires prophylaxis.
The key thing is, is you might not necessarily know early on exactly what it is.
So sometimes we do broaden it to other people
in whom we’re concerned about bacterial meningitis.
The prophylaxis choices are Rifampin for four doses,
or alternatively, you can do Ciprofloxacin or Ceftriaxone for a single dose.
So for the most part, it’s a pretty benign treatment.
It’s something where generally no harm is done
but we wanna make sure we’re limiting it
and giving it to the appropriate people.
Not just kind of broadly giving out these medications.
So the conclusions here, meningitis and encephalitis,
the classic presentation is fever, headache,
and altered mental status, but be wary, some patients may trick you
especially the immunocompromised patients and elderly patients
may present with more subtle symptoms.
Neuroimaging is not required for patients prior to lumbar puncture
but should be reserved for those in whom there’s a seizure,
concern for mass lesion,
or in whom you are concerned for elevated intracranial pressure.
Also, added in there are people in whom there’s concern for papilledema found in exam.
So elevated intracranial pressure.
Empiric treatment should be started once there is concern for meningitis or encephalitis.
Go ahead and start those antibiotics.
That’s gonna be the thing that’s gonna benefit your patient the most.
Lumbar puncture can be performed after the antibiotics have been administered
within a few two to four hours
after those antibiotics with having minimal effects on the cerebral spinal fluid.
Prophylaxis should be considered for close contacts
in the case of Neisseria meningitides meningitis.