Emergency Neurologic Life Support: Meningitis and Encephalitis
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REVIEW ARTICLE
Emergency Neurologic Life Support: Meningitis and Encephalitis David F. Gaieski • Barnett R. Nathan Scott D. Weingart • Wade S. Smith
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Published online: 9 September 2012 Ó Neurocritical Care Society 2012
Abstract Bacterial meningitis and viral encephalitis, particularly herpes simplex encephalitis (HSE), are severe neurological infections that, if not treated promptly and effectively, lead to poor neurological outcome or death. Because treatment is more effective if given early, the topic of meningitis and encephalitis was chosen as an Emergency Neurological Life Support protocol. This protocol provides a practical approach to recognition of and urgent treatment for bacterial meningitis and HSE, including imaging and spinal fluid analysis, and discusses the choice of empirical treatments until the cause of infection is determined. Though uncommon in its full form, the typical clinical triad of headache, fever, and neck stiffness should alert the clinical practitioner to the syndromes. Early attention to the airway and maintaining normotension is crucial in treatment of these patients, as is rapid treatment with anti-infectives and, in some cases, corticosteroids.
D. F. Gaieski (&) Department of Emergency Medicine and Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA e-mail: [email protected] B. R. Nathan Division of Neurocritical Care, Department of Neurology, University of Virginia, Charlottesville, VA, USA S. D. Weingart ENLS Course Co-Chair, Division of ED Critical Care, Mount Sinai School of Medicine, New York, NY, USA W. S. Smith ENLS Course Co-Chair, Department of Neurology, University of California, San Francisco, CA, USA e-mail: [email protected]
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Keywords Infection Bacterial meningitis Viral meningitis Herpes encephalitis Protocol
Introduction Meningitis and encephalitis are potentially life-threatening central nervous system (CNS) diseases, the first presentation of which is frequently to the emergency department (ED). The annual incidence of bacterial meningitis in adults in the U.S. is approximately 4–6 cases per 100,000 [1–3]. Encephalitis is a less common disease than meningitis: while accurate estimates of incidence are difficult to obtain, its overall incidence is lower, and the non-herpes varieties display seasonal variation. Bacterial meningitis and bacterial or viral encephalitis are medical, neurologic, and, occasionally, neurosurgical emergencies, which carry substantial morbidity, and mortality despite modern approaches. In one study, 48 % of patients with bacterial meningitis presented within 24 h of the onset of symptoms [2]. Therefore, patients who have a hyper-acute (hours) to acute (hours to days) onset of headache and altered mental status should be considered as potentially having meningitis or encephalitis. Although fever is a major feature in this infectious illness, additional symptoms including stiff neck (typically elicited by neck flexion), fever, new rash, focal neu
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