Early recognition of meningitis

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Earlier in the month, the National Institute for Clinical Excellence issued a new guideline on bacterial meningitis and meningococcal disease in children. At the symposium we had two members of the Guideline Development Group. As well as our own Linda Glennie, we were joined by Dr Nelly Ninis, consultant paediatrician at St Mary's Hospital, who was able to explain the implications of this important guideline on the early recognition and treatment of septicaemia.

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  • NOTES FOR PRESENTERS: Key points to raise: Refer your audience to the table of symptoms and signs of bacterial meningitis and meningococcal septicaemia on pages 8 and 9 of the quick reference guide (QRG) and the NICE guideline. Common non-specific features of presentations in children and young people include fever, vomiting/nausea, lethargy, irritability/unsettled, ill appearance, refusing food or drink, headache, muscle ache/joint pain, respiratory symptoms/signs or breathing difficulty. Young babies may present with irritability and refusal to feed. Children and young people with septicaemia may present with the symptoms above, plus: chills/shivering, non-blanching rash, altered mental state, cold hands and feet, unusual skin colour, leg pain, back rigidity. The rash associated with meningococcal disease ranges from a non-specific macular rash to the characteristic purpuric (raised, non-blanching, bluish purple) rash which is mostly seen with septicaemia but is not always initially present. (This reference is taken from the full guideline). Be aware that a rash may be less visible in darker skin tones – check soles of feet, palms of hands and conjunctivae. Fever may not always present, especially in neonates. Additional information: The guideline assumes that fever in children younger than 5 years will be managed according to ‘Feverish illness in children‘ (NICE clinical guideline 47) until bacterial meningitis or meningococcal septicaemia is suspected. Recommendation 1.1.1 is provided in full in the notes of the following slide.
  • NOTES FOR PRESENTERS: Other recommendations to highlight during your presentation: Perform a very careful examination for signs of underlying meningitis or septicaemia in children and young people presenting with petechial rashes (see table 1 in the NICE guideline or the QRG). [1.3.1] Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis (this recommendation is from ‘Feverish illness in children‘ [NICE clinical guideline 47]). [1.1.3] Some children with bacterial meningitis present with seizures (see table 2 in ‘Feverish illness in children‘ [NICE clinical guideline 47]). Consider other non-specific features of the child‘s or young person‘s presentation, such as: - the level of parental or carer concern - how quickly the illness is progressing, and - clinical judgement of the overall severity of the illness. [1.1.5] Recommendation 1.1.1 i n full: Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs in table 1. Be aware that: some children and young people will present with mostly non-specific symptoms or signs and the conditions may be difficult to distinguish from other less important (viral) infections presenting in this way children and young people with the more specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia and the symptoms and signs may become more severe and more specific over time. Recognise shock (see table 1) and manage urgently in secondary care.
  • NOTES FOR PRESENTERS: Other recommendations to highlight during your presentation: Suspected bacterial meningitis without non-blanching rash Transfer cases of suspected bacterial meningitis without non-blanching rash directly to secondary care without giving parenteral antibiotics. [1.2.2] If urgent transfer to hospital is not possible, administer antibiotics [in line with recommendations in the NICE guideline]. [1.2.3] Suspected meningococcal disease (non-blanching rash or meningococcal septicaemia) Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, either in primary or secondary care. [1.2.4] Do not delay urgent transfer to hospital to give the parenteral antibiotics. [1.2.4] Withhold benzylpenicillin only in children and young people who have a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication. [1.2.5] If urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions) administer antibiotics to children and young people with suspected bacterial meningitis. [1.2.3] Recommendation 1.2.1 in full: Primary care healthcare professionals should transfer children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999. [1.2.1]
  • NOTES FOR PRESENTERS: Key points to raise: In children and young people with suspected bacterial meningitis or meningococcal septicaemia undertake and record physiological observations of heart rate, respiratory rate, oxygen saturation, blood pressure, temperature, perfusion (capillary refill) and neurological assessment (for example the Alert, Voice, Pain, Unresponsive [AVPU] scale) at least hourly. Recommendation 1.1.1 is provided in full in notes of the previous slide: Additionally, it can be found in table 1 on page 9 of the quick reference guide or in the NICE version of the guideline.
  • Early recognition of meningitis

    1. 1. BACTERIAL MENINGITIS AND MENINGOCOCCAL SEPTICAEMIA NICE 2010
    2. 2. <ul><li>Many thanks </li></ul><ul><li>Outstanding contribution to knowledge- across whole disease / care pathway </li></ul>
    3. 3. WHAT IS GUIDELINE ABOUT Meningitis – neonates and older children Meningococcal disease: MM, MS and mixed disease
    4. 4. WHY DO WE NEED IT?
    5. 5. BMJ 1906 “… .. The case was so manifestly a hopeless one that all that could be expected was the melancholy of establishing the diagnosis….”
    6. 6. 1966 STIEHM AND DAMROSCH. J PEDIATRICS <ul><li>Poor prognostic signs </li></ul><ul><li>Petechiae < 12 hours prior to admission </li></ul><ul><li>Shock (BP < 70 ) </li></ul><ul><li>Absence of meningitis in CSF </li></ul><ul><li>Low WBC <10 x 10 9 </li></ul><ul><li>ESR <10 mm/hr </li></ul><ul><li>Invariably fatal prognosis </li></ul><ul><li>Shock at presentation </li></ul><ul><li>Rapidly evolving rash </li></ul><ul><li>Depressed conscious level </li></ul>
    7. 7. 1978 RCP- DEATHS FROM MD <ul><li>1959-1978 deaths from MD unaltered </li></ul><ul><li>1978 - 96 Deaths from MD all analysed </li></ul><ul><li>Most frequent and lengthy delays occurred in recognition by parents </li></ul><ul><li>GPs- delays caused by failure to make or suspect the illness </li></ul><ul><li>Most promising measure to reduce mortality appears to be to familiarise doctors with the clinical features of the disease and the disastrous consequences of diagnostic failure </li></ul>
    8. 9. HORDER 1918 With a disease so protean in its manifestations, it is not surprising that frequent errors should arise in diagnosis. The chief difficulty lies in not suspecting the presence of the disease
    9. 10. RECOGNITION OF SIGNS AND SYMPTOMS OF MENINGITIS AND SEPTICAEMIA Key to changing prognosis is early recognition. This can only be achieved with education about symptoms and signs
    10. 11. IS IT MENINGITIS DOCTOR?
    11. 12. BMJ 1906 <ul><li>… . Many have doubted that 2 diseases , so different in their clinical course and in their distribution , could be due to one and the same organism. </li></ul>
    12. 14. SYMPTOMS AND SIGNS <ul><ul><li>Healthcare professionals should be trained in the recognition and management of meningococcal disease. </li></ul></ul><ul><ul><li>Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs outlined in table 1 in the NICE guideline. </li></ul></ul>
    13. 15. SYMPTOMS AND SIGNS <ul><li>Be aware that in children and young people: </li></ul><ul><ul><li>some will present with mostly non-specific symptoms or signs which may be difficult to distinguish from other less important (viral) infections presenting in this way </li></ul></ul><ul><ul><li>those with specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia. The symptoms and signs may become more severe and more specific over time. </li></ul></ul>
    14. 16. 2 1/2 YEAR OLD BOY, SUDDEN ONSET FEVER AND PAINFUL L HAND, PRESENTING TO A&E <ul><li>Triage: 1) ? Injury soft tissue 2)Unwell, pyrexia </li></ul><ul><li>Triage assessment: sudden onset pain L hand. No hx trauma, reluctant to have it touched. Is also generally unwell. Spots erupting on arm and back. Last had calpol 2 1/2 hrs ago. </li></ul><ul><li>Obs: Temperature 40 C </li></ul>
    15. 17. PRIMARY CARE <ul><li>Misdiagnosis….. </li></ul><ul><li>Half of children with meningococcal disease are seen but not admitted in 48hr prior to admission (Riordan BMJ1996, Harnden BMJ 2006) </li></ul><ul><li>Significant medico-legal implications for GPs </li></ul>
    16. 18. RECOGNITION IN PRIMARY CARE <ul><li>MCD and meningitis symptoms and signs </li></ul><ul><li>How worried are the parents? </li></ul><ul><li>How fast is this moving </li></ul><ul><li>How sick is the patient </li></ul>
    17. 19. MANAGEMENT IN PRE-HOSPITAL SETTING <ul><li>Transfer children and young people with suspected bacterial meningitis or meningococcal septicaemia to secondary care as an emergency by telephoning 999. </li></ul><ul><li>Antibiotics- only for suspected MCD not meningitis- Give only if it does not delay transfer </li></ul>
    18. 20. RASH- PITFALLS , PITFALLS, PITFALLS
    19. 21. PETECHIAL RASH <ul><li>Examine for septicaemia or meningitis </li></ul><ul><li>Start antibiotics if alarm criteria present </li></ul><ul><li>Investigate </li></ul><ul><li>Guidance on using investigations </li></ul>
    20. 22. SECONDARY CARE Recognition Resuscitation Referral to PICU Recovery
    21. 23. 8 MONTH OLD INFANT <ul><li>10.am - drowsy, warm- given paracetamol </li></ul><ul><li>12.45 - increasingly drowsy and unwell </li></ul><ul><li>1.45 arrive in A&E </li></ul><ul><li>Triage T38.4, RR46, HR 208. No CRT, AVPU </li></ul><ul><li>Vomting </li></ul><ul><li>3pm - still hot 38.5, give neurofen </li></ul><ul><li>3.20 - SHO- wrote down previous observations. Diagnosed purulent tonsilitis. Child still vomiting </li></ul><ul><li>Home 4.30 pm </li></ul><ul><li>By 5.30 increasingly unwell, odd colour. Back to hospital </li></ul>
    22. 24. HERRICK 1918 <ul><li>No medical emergency demands action more prompt, vigorous and unremitting </li></ul>
    23. 25. 6 / 12 INFANT <ul><li>PC- pyrexia / irritable </li></ul><ul><li>4 hours of fever. No other symptoms </li></ul><ul><li>SHO - T 38.9 , irritable, moving neck freely </li></ul><ul><li>P168, sats 93% in air, chest clear </li></ul><ul><li>ENT - ok </li></ul><ul><li>Few macular pink spots. 3mm trunk, face, back. Blanch </li></ul><ul><li>? For septic screen </li></ul>
    24. 26. <ul><li>Registrar review 15 mins later </li></ul><ul><li>Elicited baby had been grunting </li></ul><ul><li>Irritable, well hydrated, tachypnoeic RR 60, normal fontanelle. Blanching rash. </li></ul><ul><li>?UTI </li></ul><ul><li>? Chest infection </li></ul><ul><li>1.5 hrs later- temp 37.5, playing, happy </li></ul><ul><li>Still tachypnoeic. Increasing rash - all blanching </li></ul><ul><li>1 hr later- CXR -nil, urine -nil </li></ul>
    25. 27. <ul><li>3 hours later. Pulse 195, RR 70, cap refil good but looks pale and cold, slightly drowsy, rash - purpura </li></ul><ul><li>Gets antibiotics, 20mls / kg </li></ul><ul><li>1hr later - 8.5 degree toe- core gap, HR 190 </li></ul><ul><li>WCC 2.1, pl 165, urea 6.0 </li></ul><ul><li>Further bolus 20/kg </li></ul><ul><li>Gas- Ph 7.33, co2 3.13, hco3 15.1, BE -14.1 </li></ul><ul><li>Clotting deranged, fibrinogen 0.8- 10mls/kg FFP </li></ul><ul><li>10hrs post admission- Hr 170, RR55-70 </li></ul>
    26. 28. <ul><li>For the next 10 hours on the ward </li></ul><ul><li>HR 165-180 </li></ul><ul><li>RR 55-90 </li></ul><ul><li>T-C gap 4- 9 degrees </li></ul><ul><li>No further fluid bolus </li></ul><ul><li>Next gas 19 hours post admission BE -15.2 </li></ul><ul><li>Sudden deterioration, loss of BP, cardiac arrest </li></ul>
    27. 29. EMERGENCY CARE
    28. 30. SYMPTOMS AND SIGNS <ul><li>Recognise shock and manage urgently in secondary care. </li></ul><ul><li>Signs of shock </li></ul><ul><li>Capillary refill time more than 2 seconds </li></ul><ul><li>Unusual skin colour </li></ul><ul><li>Tachycardia and/or hypotension </li></ul><ul><li>Respiratory symptoms or breathing difficulty </li></ul><ul><li>Leg pain </li></ul><ul><li>Cold hands/feet </li></ul><ul><li>Toxic/moribund state </li></ul><ul><li>Altered mental state/decreased conscious level </li></ul><ul><li>Poor urine output </li></ul>
    29. 32. MCD PATHWAY
    30. 33. MENINGITIS PATHWAY Additional information: Alternative aetiologies- HSV/ TB Prescriptive on investigations Advice on CT scanning Fluids: do not restrict, monitor electrolytes, feed if possible
    31. 34. NEONATES- MENINGITIS <ul><li>< 3 months </li></ul><ul><li>Advice regarding CSF values </li></ul><ul><li>Advice regarding viral / TB aetiologies </li></ul><ul><li>Antibiotic advice for confirmed and unconfirmed disease </li></ul>
    32. 36. IMMUNE TESTING <ul><li>Group B disease or unconfirmed disease- do not test </li></ul><ul><li>> 1 episode of MCD or non B disease </li></ul><ul><li>MCD and other invasive bacterial infections </li></ul><ul><li>+ve FH for MCD or complement deficiency </li></ul>
    33. 37. <ul><li>Tests for complement deficiency </li></ul><ul><li>If confirmed – refer immunology and test family </li></ul>
    34. 38. AFTERCARE <ul><li>At last – its on the agenda! </li></ul><ul><li>Discuss requirement prior to discharge </li></ul><ul><li>Discuss pattern of recovery and long term effects </li></ul><ul><li>Offer information from support organisations </li></ul><ul><li>Healthcare professional need to recognise late onset effects </li></ul><ul><li>Formal audiology within 4 weeks of being fit to test </li></ul><ul><li>Severe or profoundly deaf need urgent assessment for cochlear implants </li></ul><ul><li>Paediatric review within 4-6 weeks of discharge to plan referral to other services </li></ul>

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