An otherwise healthy 29-year-old man is brought in to the emergency department (ED) because of 2 days of headache, flu-like symptoms, fever, and change in sensorium. On arrival at the ED his vital signs were: temperature 103.3°F, heart rate 138 bpm, respiratory rate 24 to 32 breaths/min, blood pressure 88/48 mm Hg, saturation 88% (room air), and Glasgow Coma Scale (GCS) 10. The patient's general examination revealed a patient in mild distress, injected conjunctivae, erythematous throat, pallor without cyanosis, petechial rash in lower extremities, nuchal rigidity, and normal cardiac and lung examination. Abdomen was mildly tender but no peritoneal signs were elicited. He was stuporous but arousable to loud voice and strong painful stimulation, he was able to follow some simple commands but inconsistently. Cranial nerves were normal and fundus did not show papilledema. He was localizing briskly with the upper extremities and withdrawing appropriately with both lower extremities. Reflexes were three-fourths throughout. A Foley catheter was inserted, obtaining only 10 mL of dark urine.
What are the initial steps for the management of this patient?
This patient's clinical presentation indicates an infection of the central nervous system (CNS) and systemic compromise, as signs of sepsis and septic shock are evident by the initial assessment performed in the ED. The initial evaluation of patients with a suspected CNS infection should include a detailed clinical history, assessment of epidemiologic factors, risk factors for infection, and medical comorbidities. Initial neurologic assessment provides important prognostic information and allows for comparison of serial neurologic examinations. This patient should be isolated in the ED, and droplet precautions should be maintained until a final etiologic diagnosis is made. Following initial assessment and determination of a potential CNS infection, initial steps in the management of this patient should include an evaluation of the ABCs (airway, breathing, and circulation), assessment of the hemodynamic status, collection of blood and cerebrospinal fluid (CSF) samples, and initiation of appropriate antimicrobial therapy. Patients with suspected meningitis who present with abnormal mental status or neurologic deficits, especially those with a GCS of 12 or less, require intensive care unit (ICU) admission for observation (Table 7-1).
Table 7-1.Indications for ICU Admission |Favorite Table|Download (.pdf) Table 7-1. Indications for ICU Admission
|Age older than 60 years|
|Change in mental status with depressed GCS ≤ 12|
|Clinical or radiographic evidence of brain edema and midline shift or hydrocephalus|
|New focal neurologic deficit or deterioration despite appropriate treatment|
|Seizures or metabolic complication|
|Septic shock and/or respiratory failure with need for mechanical ventilation|
Rapid neurologic deterioration and ensuing loss of consciousness with impairment of reflexes that maintain the airway mandate permanent airway control (Table 7-2).1 Failure to recognize imminent airway loss may result in complications such as aspiration, hypoxemia, and hypercapnia. Preferred induction ...