A 4-year-old girl is brought to the pediatric emergency department with a 2-day history of high fever, severe headache, and vomiting. Over the last 6 hours, she has become increasingly lethargic. Her temperature is 39.5°C (103.1°F), heart rate is 145/min, blood pressure is 112/68 mmHg, and respiratory rate is 26/min. On physical examination, she is difficult to arouse. She exhibits marked nuchal rigidity and a newly appreciated right-sided abducens nerve (cranial nerve VI) palsy. The remainder of the neurologic examination is limited by her somnolence but shows symmetric withdrawal to pain.
Arrange the following diagnostic and therapeutic steps in the most appropriate sequential order for managing this patient.
- 1Obtain blood cultures
- 2Administer empiric intravenous antibiotics and dexamethasone
- 3Obtain a non-contrast CT scan of the head
- 4Perform a lumbar puncture to obtain cerebrospinal fluid
Answer
The correct sequence is: 1) Obtain blood cultures; 2) Administer empiric intravenous antibiotics and dexamethasone; 3) Obtain a non-contrast CT scan of the head; 4) Perform a lumbar puncture to obtain cerebrospinal fluid.
In pediatric patients with suspected acute bacterial meningitis, the standard sequence is to obtain blood cultures, perform a lumbar puncture (LP), and then initiate empiric antibiotics. However, if the patient has signs of increased intracranial pressure (e.g., altered mental status, focal neurologic deficits like a CN VI palsy, or papilledema), an LP is contraindicated until a CT scan of the head rules out a mass effect to prevent brain herniation. Because a CT scan takes time, empiric antibiotics must be administered immediately after blood cultures are drawn, prior to the patient going to the CT scanner.
Step-by-Step Solution
Key Concept
Sequential management of suspected bacterial meningitis in patients with signs of increased intracranial pressure
Estimated Time:1m 30s