A 54-year-old woman is evaluated in the emergency department for a 24-hour history of severe headache, fever, and progressive confusion. Her temperature is 39.4°C (102.9°F), blood pressure is 110/68 mm Hg, and pulse is 114/min. On physical examination, the patient is lethargic and oriented to person only. Neck stiffness is elicited upon flexion. There are no focal neurologic deficits. Arrange the following management steps in the most appropriate chronological sequence for this patient.
- 1Obtain blood cultures
- 2Administer empiric intravenous antibiotics and dexamethasone
- 3Perform computed tomography of the head
- 4Perform lumbar puncture
Cevap
The correct sequence is to obtain blood cultures, followed immediately by administering empiric antibiotics and dexamethasone, then performing a computed tomography of the head, and finally performing a lumbar puncture.
In patients with suspected bacterial meningitis who have altered mental status, new-onset seizures, focal neurologic deficits, or papilledema, a computed tomography scan of the head is required before a lumbar puncture to rule out increased intracranial pressure. However, obtaining the imaging can delay definitive diagnosis. Therefore, blood cultures should be drawn immediately, followed by the administration of empiric antibiotics and dexamethasone. Once therapy is initiated, the computed tomography scan can be performed safely, followed by the lumbar puncture. This sequence prevents dangerous delays in treatment while mitigating the risk of brain herniation.
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Anahtar Kavram
Algorithmic management of suspected bacterial meningitis in patients with indications for imaging prior to lumbar puncture.
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