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Acute Care I > Neuro Emergencies: Meningitis > Flashcards

Neuro Emergencies: Meningitis Flashcards

(60 cards)

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1
Q

Meningitis is what?

A

an inflammation of the arachnoid membrane, pia mater, and the intervening cerebrospinal fluid (CSF)

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2
Q

Meningitis
The inflammatory process extends throughout what?

A

the subarachnoid space around the brain and spinal cord and involves the ventricles

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3
Q

Epidemiology
The incidence of bacterial meningitis has decreased significantly in developed countries since the introduction of vaccines against what bacterial pathogens?

A

Hemophilus influenaze type B
Streptococcus pneumoniae
Neisseria miningitidis

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4
Q

Epidemiology
What is the most common pathogen?

A

S. Pneumoniae

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5
Q

What pathogen is emerging as the most common cause of bacterial meningitis w/ increased incidence in elderly and immunocompromised individuals?

A

Listeria monocytogenes

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6
Q

Epidemiology
Predisposing factors include?

A

Acute otitis media
pneumonia
sinusitis
neurosurgical procedures
immunocompromised individuals and high risk groups

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7
Q

Pathophysiology of Meningitis
Infectious agents can gain access to the CNS by the following routes

A

Hematogenous spread
Direct transmission
Retrograde venous
Neuronal pathway
Iatrogenic

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8
Q

Pathophysiology of Meningitis
What is Hematogenous spread?

A

spread from a distant infectious site

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9
Q

Pathophysiology of Meningitis
What is Direct transmission?

A

otitis media, sinusitis, trauma, congenital malformations infected tooth

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10
Q

Pathophysiology of Meningitis
What is Retrograde Venous transmission?

A

usually from nasopharynx

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11
Q

Pathophysiology of Meningitis
What is neuronal pathway transmission?

A

Olfactory and peripheral nerves

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12
Q

Pathophysiology of Meningitis
What is iatrogenic transmission?

A

LP, VPS, and cranial procedure

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13
Q

Pathophysiology of Meningitis
Bacteria enter the CNS via?

A

choroidal vessels or
in cerebral endothelial cells of the blood-CSF barrier in the posterior capillary veins

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14
Q

Pathophysiology of Meningitis
Upon invasion of the CSF bacteria multiply to high concentrations secondary to?

A

inadequate immunoglobulins and complement in CSF

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15
Q

Pathophysiology of Meningitis
Release of proinflammatory cytokines such as? from what cell types?

A

IL-1 and TNF
meningeal and endothelial cells, macrophages and microglia

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16
Q

Pathophysiology of Meningitis
Cytokines enhance the passage of leukocytes by inducing what?

A

several families of adhesion molecules that interact with corresponding receptors on leukocytes

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17
Q

Pathophysiology of Meningitis
Cytokines can also increase the binding affinity of leukocyte selection for?
further contributing to?

A

its endothelial cell receptor

neutrophils in the subarachnoid space

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18
Q

Pathophysiology of Meningitis
Neutrophils release what?
That disrupt what?

A

prostaglandins, matrix metalloproteinases and free radicals

the endothelial intracellular tight junctions and subendothelial basal lamina

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19
Q

Pathophysiology of Meningitis
The ultimate result from all these processes is?

A

Vasogenic brain edema
Cerebrovascular dysregulation
elevated ICPs

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20
Q

Neurologic Complications of Meningitis include?

A

Hydrocephalus
Coma
Seizure
Deafness
Motor Deficits
Sensory Deficits
Cognitive Deficits
Cranial Nerve Palsy
Mycotic Aneurysm formation
Thrombosis
Death

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21
Q

Differential Diagnosis associated with Meningitis symptoms includes?

A

SAH
ICH
Epidural hematoma
GBS
Arnold Chiari malformation
Intracranial neoplasm
Electroly imbalance
Hypoglycemia
Seizure

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22
Q

Clinical Presentation
Classic Triad?

A

Fever
Nuchal rigidity
AMS

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23
Q

Clinical Presentation
Symptoms outside of the classic triad include?

A

HA
Photophobia
Vomiting
Lethargy
Myalgia
Seizures
Skin manifestations
Symptoms progress hours to days

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24
Q

Clinical Presentation
Clinical findings are often overlooked in?

A

infants
obtunded patients
elderly patients w/ heart failure
elderly patients w/ pneumonia
Immunocompromised individuals

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25
Clinical Presentation In elderly patients neck stiffness may be difficult to evaluate d/t it possibly being caused by?
osteoarthritis stiffness of neck muscles
26
Clinical Signs Brudzinski's Sign
Spontaneous flexion of the hips during attempted passive flexion of the neck
27
Clinical Signs Kerning's Sign
Inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees
28
Diagnosis Hx will include
recent illness or sick exposure change in mental status focal deficit cranial nerve palsy
29
Diagnosis Physical should include?
inspection of skin otoscopic exam inspect oral cavity/throat CSF otorrhea or rhinorrhea
30
Diagnosis Lab Studies to check?
CBC (WBC elevated, Thrombocytopenia) BMP (Cr, Electrolytes) Coags PCR HIV
31
Diagnosis 50-90% of patients with bacterial meningitis have?
positive blood cultures
32
Diagnosis Imaging?
Head CT Exclude mass lesion or elevated ICP Prevent herniation d/t CSF removal
33
Algorithm With suspicion for bacterial meningitis, ask if the patient is/has
Immunocompromised hx of CNS disease new onset seizure papilledema altered consciousness focal neruo deficit delay in performatnce of diagnostic procedures
34
Algorithm If pt has any of the following what are the next steps? Immunocompromised hx of CNS disease new onset seizure papilledema altered consciousness focal neruo deficit delay in performatnce of diagnostic procedures
Blood cultures STAT Dexamethasone (b) + empirical antimicrobial therapy(c) Negative CT scan of the head Perform LP CSF findings c/w bacterial meningitis Perform Gram Stain
35
Algorithm Positive CSF Gram Stain Yes? No?
Yes - Dexamethasone (b) + targeted antimicrobial therapy No - Dexamethasone (b) + empirical antimicrobial therapy
36
Algorithm If pt does not have any of the following, what are the next steps? Immunocompromised hx of CNS disease new onset seizure papilledema altered consciousness focal neruo deficit delay in performatnce of diagnostic procedures
BC and LP STAT Dexamethasone (b) + empirical antimicrobial therapy CSF findings c/w bacterial meningitis Perform CSF gram stain
37
When to Order a Head CT
Immunocompromised CNS disease New onset seizure Papilledema Altered LOC Focal Neuro deficit
38
LP contraindications
Coagulopathy/thrombocytopenia Clinical signs of impending herniation Infection at LP site
39
LP landmarks
L3-L4 L4-L5 L5-S1
40
LP Make sure to check what?
Opening pressure
41
CSF analysis should include?
Color/clarity cell count protein glucose gram stain culture PCR and viral studies CSF to plasma glucose is about 2/3
42
CSF Characteristics in Bacterial vs. Viral Meningitis Bacterial: Color Cell count Glucose Protein Opening pressure
cloudy 200-20,000 PMN <40 >50-100 Markedly high
43
CSF Characteristics in Bacterial vs. Viral Meningitis Viral or aseptic Color Cell count Glucose Protein Opening pressure
clear or cloudy 100-1000PMN Normal >50 cells but usually less than bacterial normal or slightly elevated
44
Most common organisms and treatment Age < 1 mo Common bacterial pathogens? Antimicrobial therapy
Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species Ampicillin plus cefotaxime or ampicillin plus aminoglycoside
45
Most common organisms and treatment Age 1-23 mo Common bacterial pathogens? Antimicrobial therapy
Streptococcus pneumoniae, Neisseria meningitidis, S. Agalactiae, Haemophilus influenzae, E. coli Vancomycin plus a third gen cephalosporin
46
Most common organisms and treatment Age 2-50 Common bacterial pathogens? Antimicrobial therapy
N. meningitidis, S pneumoniae Vancomycin plus a third gen cephalosporin
47
Most common organisms and treatment Age > 50 years Common bacterial pathogens? Antimicrobial therapy
S. Pneumoniae, N. meningitidis, L. monocyotogenes, aerobic gram-negative bacilli Vancomycin plus ampicillin plus a third gen cephalosporin
48
Most common organisms and treatment Head trauma (Basilar Skull Fx) Common bacterial pathogens? Antimicrobial therapy
S. pneumoniae, H. influenzae, group A Beta-hemolytic streptococci Vancomycin plus a third gen cephalosporin
49
Most common organisms and treatment Head Trauma (Penetrating Trauma) Common bacterial pathogens? Antimicrobial therapy
Staphylococcus aureus, ccoagulase-negative staphylococci (especially Stahpylococcus epidermidis), aerobic gram-negative bacilli (including Pseudomonas aeruginosa) Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem
50
Most common organisms and treatment Postneurosurgery Common bacterial pathogens? Antimicrobial therapy
Aerobic gram-negative bacilli (including p. aeruginosa), S. aureus, coagulase-negative staphylococci (especially S. epidermidis) Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem
51
Most common organisms and treatment CSF shunt Common bacterial pathogens? Antimicrobial therapy
Coagulase-negative staphylococci (especially S. epidermidis), S. aureus, aerobic gram-negative bacilli (including P. aeruginosa), Propionbacterium acnes Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem
52
Antibiotics Third Gen Cephalosporine/dose/frequency?
Ceftriaxone 2g q12hr Cefotaxime 2g q4-6hr
53
Antibiotics Glycopeptide/dose/frequency?
Vancomycin 15-20mg/kg q8-12hrs
54
Antibiotics PCN/dose/frequency?
Ampicillin 2g q4hrs (in adults > 50y/o)
55
Antibiotics In immunocompromised patients add what? Instead of ceftriaxone or cefotaxime use what?
pseudomonal coverage cefepime 2g q8hr or meropenem 2g q8hr
56
Antibiotics Antiviral for HSV meningitis/dose/frequency?
Acyclovir 5-10 mg/kg TID
57
Antibiotics Narrow antibiotics based on?
culture results
58
When can droplet precautions be discontinued?
when on antibiotics for 24 hrs
59
Steroids steroid/dose/frequency/duration
dexamethasone 0.15mg/kg IV q6 hr for 2-4 days
60
Steroids Reduces risk of poor neurological outcome in pt with? Must be given when? Believed to minimize?
S. pneumoniae early inflammatory cascade

Acute Care I (30 decks)

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