Approach Considerations
Prehospital care of children with bacterial meningitis usually is confined to transporting children who are critically ill or have... [Show More] experienced a seizure. General supportive care is required, depending on the child’s condition. Subsequent diagnosis of a potentially transmissible disease must be communicated to prehospital care providers, especially with N meningitidis infections.
Patients must be treated in a facility where emergencies can be managed and nursing and medical staff are experienced in caring for critically ill patients. Accordingly, they may require a transfer to a pediatric hospital or large general hospital. Depending on the child’s condition, admission to a pediatric intensive care unit (ICU) may be warranted.
If the child is critically ill or experiencing a seizure, immediate stabilization and support are necessary. If the child is hemodynamically stable, intravenous (IV) fluids should be administered at maintenance. Careful record of the patient’s weight, urine specific gravity, and serum osmolarity will help guide further fluid therapy. Patients who present with dehydration should be rehydrated and should not undergo fluid restriction. Seizures should be treated promptly and should be expected at any time during the initial management.
Whenever bacterial meningitis is suspected, a lumbar puncture is indicated (see Workup). Adequate analgesia is essential; in one study, only one-third of pediatric emergency physicians adhered to analgesia recommendations, and less often in infants than older children. [26] If the child’s condition is unstable or there is suspicion of increased intracranial pressure (ICP), the lumbar puncture should be delayed. In ill children, this delay should not delay the commencement of antibiotic therapy.
If lumbar puncture cannot be performed promptly, administration of antibiotics should be initiated. However, sterilization of cerebrospinal fluid (CSF) will occur. Date suggest that complete CSF sterilization occurs within 2 hours for meningococcal meningitis and within 4 hours for pneumococcal infections.
Consultation with a pediatrician, an infectious disease specialist, or a critical care specialist may be needed. The primary care physician must coordinate the follow-up care and keep all involved specialists informed so that prompt action can be taken if any concerns exist.
In general, pediatric patients with bacterial meningitis require hospitalization to complete their entire parenteral antibiotic course. However, in view of the constant pressure to decrease hospital stays, there are very select occasions when older pediatric patients may reasonably be discharged from the hospital to continue parenteral antibiotics at home.
In a retrospective study of children with bacterial meningitis complicated by stroke, treatment with heparin or aspirin appeared to be safe and to discourage stroke recurrence, with heparin possibly being the more effective of the two medications. Sixteen patients were treated with heparin (6 patients) or aspirin (10 patients), either after an initial infarction or following a recurrence. None of the heparin patients had a stroke following treatment, while four of the aspirin patients (40%) did. However, the 14 patients who received no antithrombotic therapy after an initial stroke had the greatest incidence of infarction, with eight of them (57%) suffering an additional stroke. None of the treated patients experienced an intracranial hemorrhage [Show Less]
