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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Early recognition of meningitis
- 1. BACTERIAL MENINGITIS AND MENINGOCOCCAL SEPTICAEMIA NICE 2010
- 3. WHAT IS GUIDELINE ABOUT Meningitis – neonates and older children Meningococcal disease: MM, MS and mixed disease
- 4. WHY DO WE NEED IT?
- 5. BMJ 1906 “… .. The case was so manifestly a hopeless one that all that could be expected was the melancholy of establishing the diagnosis….”
- 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
- 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
- 11. IS IT MENINGITIS DOCTOR?
- 20. RASH- PITFALLS , PITFALLS, PITFALLS
- 22. SECONDARY CARE Recognition Resuscitation Referral to PICU Recovery
- 29. EMERGENCY CARE
- 32. MCD PATHWAY
- 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
Editor's Notes
- 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.