Remote Primary Health Care Manuals

Meningitis

Consider meningitis in

 

Any child who

Any adult who

  • Is very unwell
  • Has had a fit — especially with fever
  • Has had antibiotics for 1–2 days and still unwell
  • Comes back unwell within 1 week of completing course of antibiotics
  • Fever with no obvious underlying cause
  • Is very unwell
  • Has headache, fever, stiff neck, altered mental status
  • Is old, frail or an alcohol misuser with confusion and fever
  • Has a first fit
  • Meningitis may present differently in babies, elderly and anyone recently on antibiotics
  • Potential cause for fever (eg infection, doesn't rule out meningitis)
  • Normal coma scale score doesn't rule out meningitis
  • If suspected meningitis urgent medical consult — treatment needs to be started quickly
Red Flags — Urgent Medical Consult
  • Sudden onset and very severe headache (‘worst headache ever’)
  • Headache AND fever AND neck stiffness
  • Photophobia (pain looking at light), blurred vision, confusion
  • More than one presentation with headache AND fever

Do not

  • Do not leave person alone
  • Do not allow person to go home until meningitis has been excluded and an alternative cause of symptoms has been found

Ask

Always suspect meningitis if 2 or more bolded signs present

  • Fever
  • Vomiting
  • Rash — purpuric or petechial (flat red-purple blotches/spots) that don’t blanch under pressure
  • Fitting
  • ALSO in child under 2 years
    • Not feeding well
    • Drowsiness
    • Irritable (eg high pitched ‘cat’ cry)
    • Bulging fontanelle
  • ALSO in older child or adult
    • Headache
    • Sensitive to light (photophobia)
    • Neck stiffness
    • Coma scale score — altered mental status

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Coma scale
  • Head-to-toe exam 

Do

  • Urgent medical consult
  • Put in IV cannula
  • Collect before giving antibiotics if possible, but do not delay treatment if you can’t get samples
    • Throat swab MC&S
    • Blood for blood cultures, POC Test — WBC 
  • Give ceftriaxone IV — adult 4g, child 100mg/kg/dose up to 4g — doses — single dose
    • AND benzylpenicillin IV — adult 2.4g, child 60mg/kg/dose up to 2.4g — doses — single dose
    • If unable to give IV — give both IM
    • If allergy to penicillin — medical consult
  • If child 1–2 months — also give gentamicin IV single dose — medical consult about dose
  • Give dexamethasone IV — adult 10 mg, child 0.15 mg/kg up to 10 mg — doses — single dose
    • If not available — give hydrocortisone IV — adult 200mg, child 4mg/kg/dose up to 200mg — doses — single dose
    • If unable to get IV access — give either IM
  • Look after person in a quiet, dark room
  • Be ready to support airway and give oxygen if needed
  • Be ready to treat fits
  • If pain and fever — give paracetamol — adult 1g, child 15mg/kg/dose up to 1g — doses — up to 4 times a days (qid)
  • Medical consult
    • About starting maintenance fluids — do not give more than 30mL/kg fluid without advice from emergency consultant
    • If they won’t reach hospital within 4 hours — may need repeat dose of benzylpenicillin or corticosteroid

Follow-up

  • Any person who has been in contact with sick person and has fever in next 2 weeks needs careful check

Public health issues

  • If meningitis confirmed
    • Notify local PHU
    • Make list of people in household the person has been in contact with in past week. Record weights of all children under 30kg
  • If meningococcal or HiB meningitis confirmed
    • Send list of contacts and weights to PHU
    • PHU will tell you if you need to treat contacts, give you advice about immunisation