Welcome Applicants! Friday, January 16, 2015

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1 Welcome Applicants! Friday, January 16, 2015

2 Prep Question A 5-year-old boy is brought to the office 4 hours after falling off his bicycle. His mother reports that he was not wearing a helmet, and bystanders said that he did not lose consciousness. When his friends brought him home, he was tearful and sleepy but was answering questions appropriately. His mother noted an abrasion on the left side of his head and applied ice to a small area of swelling on the left temple. Over the last several hours, however, he has become increasingly confused and has had multiple episodes of vomiting. On physical examination, he is difficult to arouse, and his right pupil is larger than his left. Of the following, a TRUE statement regarding the patient s likely diagnosis is that A. Improved survival is associated with prompt neurosurgical intervention in symptomatic patients B. Intracranial injury is unlikely because there was no loss of consciousness C. Mannitol is the initial treatment of choice D. The gradual onset of symptoms is most consistent with a concussion E. The injury is caused by laceration of the veins that bridge the dural sinuses and the brain

3 Let s meet our patient. What are your first thoughts** in terms of treatment/stabilization

4 Qualifying our patient s level of consciousness Level of Consciousness Normal Lethargic Obtunded Stuporous Comatose Description Awake, easy to arouse and maintain alertness Difficult to maintain alertness Decreased alertness, responsive to pain, other stimuli Decreased alertness, responsive only to pain Unresponsive, even to pain

5 Let s go to the thinking chair. Why is our patient stuporous?** Metabolic derangement Toxin or overdose Seizure Increased ICP Vascular Trauma

6 Let s talk with mom

7 Finishing the exam.

8

9 Meningitis

10 Epidemiology & Pathophysiology Bacteria/viruses gain entry into bloodstream through mucosal surfaces, invade the meninges and replicate, which induces an inflammatory response Bacterial vs Aseptic* 1 in 4 aseptic cases will have definitive cause found Who gets what bug? Well it depends

11 What are the 3 most common causes of bacterial meningitis in neonates?** GBS, E coli, Listeria Bacteria What are the two most common bacterial pathogens that cause meningitis in children >1 month?** Strep pneumoniae Neisseria meningitidis Etiology You are taking care of a very ill-appearing baby who you suspect is septic. An LP is suspicious for meningitis. Mom reports AGE sxs prior to delivery and also received imported cheese from France as a gift. What organism are you worried about? Listeria Fungi Viruses Which bacteria should you also consider in a patient adopted from a foreign country or a patient whose mom has withheld vaccinations due to fears of complications? Hib

12

13 Predisposing problems. 1) Your patient has a history of multiple infections and now has Neisseria meningitis. What disorder should you test this patient for? Terminal complement deficiency (C5-9) 2) You are taking care of a HgbSS patient with suspected bacterial meningitis based on CSF studies. What 3 organisms are you worried about? Neisseria, Strep pneumo, Hib 3) Other: Neurosurgery or head trauma within past month, CSF leak, presence of neurosurgical devices, cochlear implants, recent illness

14 It s in the history** Infants Fever Lethargy Irritability Especially with exam Prefer to be motionless AMS Vomiting Seizures Older Children Malaise Myalgia HA Photophobia Neck stiffness Anorexia Nausea

15 Kernig sign- thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful Brudzinski sign- involuntary lifting of the legs when lifting a patient s head Absence DOES NOT exclude meningitis!!

16 Clinical Manifestations** What is this physical exam finding? What organism do you suspect? Other than an LP, what diagnostic test can you do in an unstable patient to detect the organism? Purpura fulminans N. meningitidis** Skin biopsy Remember the fontanelle Neurologic findings AMS Papilledema Cranial nerve palsies (Lyme disease)** Focal deficits

17 Diagnostically speaking Labs: BCx, CBC/diff, chemistry panel, LFTs (especially if suspecting HSV) CSF Studies Radiology

18 What kind of imaging?** A CT of the head is necessary before LP in patients with signs or symptoms of increased ICP and should be considered for Altered mental status (GCS <12 or drop in GCS of 2) Immune deficiency Papilledema Focal neurologic deficit [excluding isolated CN VI or VII palsy] CSF shunt Hydrocephalus CNS trauma History of neurosurgery or a space-occupying lesions Signs or symptoms of parameningeal infection or tumor

19 Order of tubes 1. Gram stain, culture, sensitivity 2. Glucose, protein 3. Cell count and differential 4. Miscellaneous studies (fungal/viral/chemistry)

20 Glucose (mg/dl) CSF analysis** Protein (mg/dl) WBC (cells/µl) Diff Gram stain Healthy newborn < 30 No PMNs Negative Healthy child < 10 No PMNs Negative Bacterial meningitis Enteroviral meningitis Fungal Meningitis < 1/2 serum, often < 10 > 100 > 1000 >50% PMNs, often >90% Normal , often < 100 < 1/2 serum >50%PMNs early <50%PMNs late > Lymphocyte predominant Positive in 60-80% Negative +/-hyphae TB meningitis < 1/2 serum, often < 10 > Lymphocyte predominant Negative

21 Management Bacterial meningitis** Neonate: Ampicillin, Gentamicin/Claforen, consider Acyclovir!!Supportive Care!! > 2 months: Vancomycin and Ceftriaxone/Claforen *Tailor antibiotic therapy once culture results obtained! Aseptic meningitis Supportive care Acyclovir for HSV meningitis Empiric therapy if suspect/cannot rule out bacterial meningitis until cultures are negative

22 Complications** Shock Seizures Increased ICP Subdural effusions** Focal neurologic deficits Cerebral edema SIADH** close monitoring of I/Os and electrolytes is very important, especially for bacterial meningitis cases!

23 In the long run ** Mortality % for bacterial meningitis Intellectual deficits** Hydrocephalus Spasticity Blindness Hearing loss** Caused by infection +/- antibiotics

24 Our patient s course Have a great day! Noon Conference: Feedback Sessions (Students Off!!)

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