Clinical Emergencies in GP

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Clinical Emergencies in GP

• Meningitis

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What is it?

• Inflammation of the pia and arachnoid membranes.
• Causitive organism can be viral, bacterial,
  fungal, others or traumatic.
• Meningitis represents a variety of illness with
  varying severity.
• 90 of cases occur in the first five years of
  life.

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Bacterial Meningitis.

• Mortality can be between 10-20 even in those who
  receive optimal treatment.
• Swift action is needed.
• Causative organism is thought to be age
  dependant.
• Neonates- E-coli, gram ve, group B strep and
  listeria
• Children-haemophilis influenza (lt5yrs numbers
  have fallen since Hib vaccination), neisseria
  meningitidis, TB, Streptococcus pneumoniae

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Bacterial Meningitis 2

• Young adults-Meningococcus (gram ve, most common
  cause of pyrogenic meningitis), Leptospira
  ictohaemorrhagiae.
• Older adults-Pneumococcus.
• Elderly-Pneumococcus, Listeria and gram
  negatives.

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Epidemiology

• In 1992 there were 1,138 cases mostly caused by
  strep viridans (epidemic capability-African
  meningitis belt.)
• Back then only 30 of cases were given
  benzylpenicillin by their GP before admission.

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Rapid onset of symptoms

• Meningism
• -headache
• -photophobia
• -stiff neck
• Kernigs sign-with hips fully flexed, resists
  passive knee extension

• Raised ICP
• -Irritability
• -Drowsiness
• -fits
• -vomiting
• -decreased pulse rate
• -increased BP
• -bulging fontanelle
• -abnormal tone/posture

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Rapid onset of symptoms

• Septicaemia
• -rash
• -fever
• -arthritis
• -tachycardia
• -peripheral shut down
• -tachypnoea
• Small children/immunocompromised/elderly pts may
  not present typically.

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Action

• Call 999-get the patient to hospital as soon as
  possible.
• Give IV/IM benzylpenicillin immediately while
  awaiting transport.
• -Adult and child (gt10yrs) 1.2g
• -Child 1-9 yrs 600mg
• -Infant lt1yr 300mg
• Cefotaxime for penicillin allergic patients
• If possible IV access and blood cultures

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Secondary Care

• If bacterial meningitis is suspected an LP must
  be performed (unless contraindicated).
• Send CSF for gram satin, culture and sensitivity,
  cell count, glucose, protein and PCR. Take serum
  for comparison.
• Do not delay treatment for LP.
• CT scan if any doubt or raised ICP or focal signs
• LP findings can point towards the cause e.g.
  Fungal infection high protein,

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Contact Tracing

• Notifiable disease-contact tracing by local
  public health department.
• For single cases only treatment for very close
  contacts.
• Prophylaxis-rifampicin 600mg BD for 2 days or
  single dose of ciprofloxacin 500mg.
• Childs dose of rifampicin-10mg/kg for 2 days lt1yr
  5mg/kg for 2 days.