Atul Jaidka PRO
Echo Fellow | TGH
Case
Differential
Fever + Neurologic Symptoms
Fever + Neuro Symptoms
- Drugs: NMS, Seratonin Syndrome, Sympathomimetics, ETOH Withdrawal
- Infection: Meningitis, encephalitis, abscess
- Metabolic: Thyroid Storm
- Structural: Intracranial Bleed, Stroke, Tumour, Vascular (Ie. Vasculitis, TTP, Lupus)
Sensitive/Specific Physical Exam for Meningitis?
Meningitis
- Jolt Accentuation: Sensitivity 97%, Specificity 60%
- Kernig or Brudzinksi: Sensitivity 9%, Specificity 100%
- Poor sensitivity - focal neuro signs 23%, rash 22%
- Neck Stiffness: 70% Sensitive
Most Common Bugs?
Age 1 month to 50 years
- Strep Pneumoniae
- Meningcocci
- H. Influenzae
Listeria Risk Factors?
Listeria
- Age > 50
- Alcoholism
- Malignancy
- Immunosuppresion, HIV
- Diabetes
- Renal Failure
- Pregnancy
Neurosurgical Patients?
Neurosurgical Patients
- Staph Aureus
- Staph Epidermidis
- Gram Negative Bacilli
CT before LP?
If you have CNS mass or high ICP, removal of CSF can cause herniation
CT Before LP
- Papilledema
- Seizures within 1 week
- Focal Neuro Defecits
- Age >60
- Obtunded or Unconscious
- Immunocompromised
- History of CNS Disease
How do you interpret the LP?
Glucose
Protein
WBC
CSF
- Gram Stain
- Culture
- Additional Tests
- Acid fast stain
- HSV PCR
- Specific Bugs: West Nile, VZV, etc
Empiric Antibiotics
A(intubate)
B
C
Dexamethasone 0.15mg/kg q6h x 4 days
Should be before or with Abx (ideally 20-30 min before). Evidence Limited but some support decreased rates of hearing loss, neuro complications, mortality benefit.
Antimicrobials?
Ceftriaxone + Vancomycin + Ampicillin + Acyclovir
Why Vanco?
Penicillin Resistant Pneumococcus
Morning Report
By Atul Jaidka
Morning Report
Oh no my brain hurts...
