Meningococcemia
OVERVIEW
- Neisseria meningitidis bacteraemia -> endotoxin mediated fulminant multi-organ failure
- mortality 10-12%
HISTORY
- sudden onset -> sore throat, fever, vomiting, headache, myalgia
- SIRS -> shock
- purpuric rash
- obtunded
- meningitis in 85% develops
RISK FACTORS
- asplenia
- complement deficiency
- contact history
- Pacific island or Maori or Indigenous descent
- crowded living environment
- malnourished
- unimmunized
- immunosuppressed
EXAMINATION
- haemodynamically unstable
- multi-organ failure
- diffuse macular rash -> discrete non-blanching petechiae -> purpura (initially in mucous membranes)
- extensive skin and limb necrosis
INVESTIGATIONS
- blood cultures: gram –ve diplococcus
- lance purpuric lesion -> gram stain
- meningococcal PCR
- LP if not contraindicated
- FBC: infection and anaemia and platelet count (?DIC)
- U+E: renal function and SIADH
- LFT’s: liver dysfunction
- Coag’s: DIC
- Lactate: degree of shock
- ABG: metabolic state
MANAGEMENT
Goals
(1) early antibiotics
(2) management of refractory shock
(3) management of DIC
(4) management of cerebral oedema
Resuscitate
A – intubation often indicated because altered LOC
B – protective lung ventilation because of ARDS development
C – large bore access -> may require an intraosseous line, fluid resuscitation + titrated inotropic support, blood product replacement for DIC
D – prevention of cerebral oedema in meningitis (steroids – controversial) -> give in meningitis and shock
Electrolytes and Acid-Base abnormalities
- Hyponatraemia – SIADH
- Renal failure
- Metabolic acidosis – > hyperlactaemia
Specific treatment
- antibiotics: empiric =
-> cefotaxime 100mg/kg LD -> 50mg/kg Q6hrly
-> ceftriaxone 100mg/kg IV OD
-> high dose penicillin 2million units Q2 hourly (adults)
-> chloramphenicol
-> amoxicillin 75mg/Kg Q6hrly + cefotaxime for kids < 3 months – limb fasciotomies Underlying cause -> the place of all of these are uncertain
- anti-endotoxin antibodies
- cytokine therapies
- corticosteroids
- plasmapheresis
- activated protein C
PUBLIC HEATH MEASURES
- Neisseria meningitidis
- requires droplet precautions
- post-exposure prophylaxis needed for close contacts if <24h treatment with appropriate antibiotics
- ciprofloxacin 500 mg (child younger than 5 years: 30 mg/kg up to 125 mg; child 5 to 12 years: 250 mg) orally, as a single dose, OR
- ceftriaxone 250 mg (child 1 month or older: 125 mg) IM, as a single dose (preferred option for pregnant women), OR
- rifampicin 600 mg (neonate: 5 mg/kg; child: 10 mg/kg up to 600 mg) orally, 12-hourly for 2 days
(NB. interacts significantly with many drugs (eg with the oral contraceptive pill) and is contraindicated in pregnancy and severe liver disease.)
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC