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Alright, let's talk about the diagnosis and treatment of
meningitis in children. The
lumbar puncture is the gold standard diagnostic test for
identifying meningitis.
00:12
It can be done sidelying or sitting. The typical place of
puncture is the L4-L5
landmark. The needle for the puncture is usually put into
the subarachnoid space
in between those 2 vertebrae. You may note that the iliac
crests are almost directly
assigned from it so basically they form kind of a straight
line across the back.
00:39
Nurses often use that landmark to know where to put numbing
cream before
an infant or a child's lumbar puncture so that to help
relieve some of the pain
associated with it. Think about these positions and think
about the young infant's
airway. One thing that often goes unnoticed by some people
not as familiar with
children and with infants especially is that the infant
airway especially when
they're a neonate is very floppy and very sensitive to
occlusion. If you curl them
up, either way they have to be curled up for this particular
test. It actually can
cause airway compromise. It can even cause them to stop
breathing. So for this
reason, it's super super important that when you have an
infant having a lumbar
puncture, there is somebody monitoring their airway at all
times. Usually, a nurse
is required to be in the room. A respiratory therapist is
required to be in the room
and the physician or provider performing the procedure. This
is just a closer look at
a lumbar puncture procedure with the needle going into that
subarachnoid space
between L4 and L5. So, lumbar puncture findings are usually
diagnostic, meaning
between L4 and L5. So, lumbar puncture findings are usually
diagnostic, meaning
you can diagnose the disease of meningitis based on them.
The culture and
sensitivity is needed to diagnose the organism causing them.
If increased
intracranial pressure is suspected, sometimes a CT scan of
the head may occur
before the LP. The blood culture, while it is probably going
to be done, is not
always reliable. It may be inconsistent in identifying
meningitis and the source of
it. Alright, let's review treatment and prevention of
meningitis. So, basically the
prognosis for meningitis depends on the time it was
identified, how quickly it was
identified, and also the antibiotic initiation if it was
bacterial or able to be treated
by antibiotics or antifungals. Sometimes fungal meningitis
can also be treated by
medication. The main treatment is antibiotics and if a child
has bacterial meningitis
especially or fungal meningitis, they're going to receive IV
antibiotics in the
hospital. Antibiotics are going to be adjusted based on what
pathogen is
specifically identified in the cerebrospinal fluid from the
lumbar puncture. And this
is based on the culture and sensitivity results. The goal of
course of treatment is to
get rid of any bacteria or whatever organism it is from the
CSF because CSF is
supposed to be a sterile fluid. Other treatments you may see
are intravenous fluids
to help keep the infant or child hydrated, antiepileptic
medications if they have had
signs and symptoms of seizure activity or have had seizures,
intracranial pressure
monitoring if there has been any concern for increased
intracranial pressure
basically, and then of course isolation precautions which
would have been initiated
hopefully the moment they slept in the hospital. Vaccines,
nurses, and antibiotics
all play important roles into prevention of meningitis.
Fortunately, we have
vaccines now from many of the serious forms of meningitis to
help prevent them.
04:10
The meningococcal vaccine is given the first time in early
adolescence and then the
second dose should be given around age 16. The pneumococcal
vaccine, that series
begins around 4 months of age. And the Haemophilus influenza
or HIB vaccine
series begins around 2 months of age. Nurses play a major
role in helping educate
the public and their patients and families about the
importance of vaccines. And
antibiotics are sometimes used prophylactically so
preventatively in patients with a
high risk of meningococcal disease or group B strep. This is
the NCSBN Clinical
Judgment Measurement Model. It's a framework being used now
for many
NCLEX exam questions and case studies. You may also see it
on nursing school or
see questions framed using it on your nursing school exams.
So now, we're going to
connect some of the content you just heard to the first 2
important steps of this
model, recognize cues and analyze cues. To be able to
recognize and analyze cues
in an infant or child who may have meningitis, you have to
be really aware of how
they may present and how they may present differently if
they're a neonate versus
an older infant or a child or adolescent. Remember, the
neonates may be very very
subtle in how they present the meningitis. They may have
only feeding differences.
05:40
They may be refusing feeds. They may or may not have a
fever. They may even be
hypothermic so never rely on a temperature as a sign of
illness because it may
not be present. They may be very irritable or lethargic.
And, you may see some
fontanelle abnormalities. You may also see some seizure
activity or they may have
seizure activity that has not been identified such as lip
smacking or eye deviation
or nystagmus, some of the more subtle signs of infant
seizures that can be very
focal and very limited in how they present. In older
children, the signs and
symptoms of meningitis will be more pronounced usually, but
may not be classic
like the ones you may see in older child or adult. So they
may complain of neck
stiffness or pain. They may complain of pain in general not
being able to localize
it. They're more likely to have vomiting and pretty forceful
vomiting. They're more
likely to have nuchal rigidity or stiffness of their neck.
The Brudzinski and the
Kernig signs are not extremely useful in the pediatric
population and not super
consistent but you may still see them use as a way to add
assessment findings or
to elevate suspicion of meningitis. And lastly, being aware
of the various ways
meningitis can be given to a child to different organisms
that do result in
meningitis and the risk factors for how to transmit these
organisms and how
children may get these organisms is very important as well.
Being able to be aware
of not just the first 2 types of bacterial and viral but all
the types of meningitis
helps you know what questions to ask as part of the history
taking so you can
identify the infants and children that are at the high risk
for meningitis or more
likely to have symptoms related to meningitis.