Meningitis: Steroids or not?

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The most important thing about treating meningitis is to give antibiotics as soon as possible.  The second most important thing is to institute appropriate supportive care.  Whether or not to give steroids as an adjunctive treatment is perhaps less clear to us…

A recent Cochrane review goes a long way to pointing us in the right direction, but still leaves a few questions open.  Join us for a quick tour of the literature and guidelines, in our quest for the truth about using steroids in meningitis.


Outline: Steroids for Meningitis PEMcast

[cp]: intro, disclaimer, rationale / theory: decrease inflammatory damage due to bacterial lysis

[cp]: Historical background: original studies were from an era when Haemophilus & Strep were common, decreased by vaccinations
?applicability to current (developed world) population of children and infectious agents

[CB]: Comments from Chris

Papers:

[RR]: Kennedy 1991 AmJDisChild – Pneumococcus

[cp]: Gupta 2004 ArchDisChild – Meningococcus

[cp]: Brouwer 2010 Cochrane review

[CB]: Peltola 2010 Pediatrics

Guidelines:

[cp] AAP (nothing recent – litigation fear??)
1990 guideline regarding steroids in meningitis
Nigrovic 2007 JAMA (Bacterial Meningitis Score)

[RR]: NICE Guideline (esp section 1.4.39 – steroids): Over 3 months age, start ASAP if within 12 hours: dexamethasone 0.15mg/kg IV, 6-hourly for 4 days
http://guidance.nice.org.uk/CG102

Review of NICE Guidance by Radcliffe, October 2011

[RR]: SIGN Guideline (esp section 6.4.2) Invasive MCD, start within 24 hours
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

[cp/CB]: local guidelines (dexamethasone 0.2mg/kg IV 6-hourly)

[all] Summary, goodbye

References

Kennedy WA, Hoyt MJ, McCracken GH Jr.
The role of corticosteroid therapy in children with pneumococcal meningitis.
Am J Dis Child. 1991 Dec;145(12):1374-8.
PubMed PMID: 1669663.

Gupta S, Tuladhar AB.
Does early administration of dexamethasone improve neurological outcome in children with meningococcal meningitis?
Arch Dis Child. 2004 Jan;89(1):82-3. Review. PubMed PMID: 14709520.

Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D.
Corticosteroids for acute bacterial meningitis.
Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004405. Review. PubMed PMID: 20824838.

Peltola H, Roine I, Fernández J, González Mata A, Zavala I, Gonzalez Ayala S,
Arbo A, Bologna R, Goyo J, López E, Miño G, Dourado de Andrade S, Sarna S,
Jauhiainen T.
Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol.
Pediatrics. 2010 Jan;125(1):e1-8. Epub 2009 Dec 14. PubMed PMID: 20008417.

American Academy of Pediatrics Committee on Infectious Diseases:
Dexamethasone therapy for bacterial meningitis in infants and children.
Pediatrics. 1990 Jul;86(1):130-3. PubMed PMID: 2193301.

Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM,
Schremmer RD, Schwab SH, Agrawal D, Mansour KM, Bennett JE, Katsogridakis YL,
Mohseni MM, Bulloch B, Steele DW, Kaplan RL, Herman MI, Bandyopadhyay S, Dayan P, Truong UT, Wang VJ, Bonsu BK, Chapman JL, Kanegaye JT, Malley R; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.
Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
JAMA. 2007 Jan 3;297(1):52-60. PubMed PMID: 17200475.

National Institute for Health and Clinical Excellence
The management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care
Last updated: 10 November 2011
http://guidance.nice.org.uk/CG102

Radcliffe RH.
Review of the NICE guidance on bacterial meningitis and meningococcal septicaemia.
Arch Dis Child Educ Pract Ed. 2011 Oct 27. [Epub ahead of print] PubMed PMID: 22034519.

Scottish Intercollegiate Guidelines Network
Management of Invasive Meningococcal Disease in Children and Young People
Guideline No. 102, ISBN 978 1 905813 31 5, May 2008
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

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Meningitis Diagnosis and Management

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The word strikes fear into the heart of parents. You dare not mention the ‘M’ word unless you back it up with action, or a whole heap of calming reassurance…

The clinical features of meningitis are less straightforward in younger children, and CSF findings can be tricky to interpret. In this episode, our local Paediatric Infectious Diseases expert guides us through the topic with some clinical perspectives and insights.


Meningitis PEMcast: Outline

[cp]: intro / disclaimer

[cp]: clarification – meningitis (definition) vs meningococcal disease [MCD] (spectrum of meningitis, meningococcaemia, or both)

[all]: MCD prognosis depending on this spectrum, why?

[cp]: clarification meningitis vs encephalitis / meningo-encephalitis

Aetiology:

[cp]: – Non-infectious (‘aseptic’=non-bacterial): autoimmune, neoplastic, drug-induced

- Infectious

[RR]: viral – frequent offenders (Entero= Coxsackie/Echo, HSV less common)

[sf]: bacterial – frequent offenders

neonatal: maternal (Listeria,  Group B Strep) vs acquired source (E coli, Gram-negatives, eg Klebsiella, Staph aureus)

beyond neonatal period: Strep pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B

[CB]: less common pathogens – mycobacterium tuberculosis, measles, mumps, fungal, cryptococcal in immunocompromised kids

Clinical features:

[RR]: History (headache, neck stiffness, photophobia, fever – or hypothermia in neonates)

[sf]: Examination findings (fever, meningeal irritation, rarely Brudzinski or Kernig signs, altered mental state, focal neurology, seizures, drowsiness, irritability)

[cp]: differential diagnoses (including alternate causes of fever, altered mental state, headache, neck stiffness) esp Viral illness / influenza, tonsillitis, infant sepsis (eg UTI), non-specific infant unwellness (metabolic, cardiac, intussusception)

Absence of meningism is not reassuring in the younger child!

Investigations:

[RR]: bedside – blood sugar, urinalysis (differentials), ECG maybe

[sf]: lab – utility of FBC, U&E, CRP, ESR?
[cp]: lab – role for procalcitonin?

[CB]: lab – blood cultures – how often do we get the bacterium on blood culture?

[CB]: Timing of LP (do the LP as soon as it’s safe to do it)

[RR]: imaging – need for CT prior to LP? (compare adults vs children)

[sf]: Lumbar Puncture: cautions / contraindications (raised ICP, focal seizure, seizure without full recovery, cardiovascular or respiratory compromise)
Lower threshold for LP if recent oral antibiotics, esp if febrile convulsion

Needle depth (CHW): 1.5 mm/kg (for under 10kg), 1mm/kg (10-40kg)

CSF findings:

[cp]: – normal (age-related)

neutrophils ‘lymphocytes’

(non-neutrophils)

protein glucose

(CSF:blood ratio)

neonate 0 < 20 < 1.0 >= 0.6
over 1 month age 0 < 5 < 0.4 >= 0.6

[sf]: – typical viral picture (not useful in acute stage – treat as bacterial)

[RR]: – typical bacterial picture

[CB]: – oddballs: fungal, TB, Mumps

Management:

[cp]: Steroids? Best given “before” antibiotics – role to be discussed in next episode

[RR]: Presumed or confirmed bacterial: IV antibiotics
- antibiotic choice – local guidelines, neonates different (amoxycillin for Listeria, gentamicin, cefotaxime – avoid ceftriaxone – biliary sludging)
- antibiotic duration (?stop at 48 hrs when all cultures negative, vs several weeks for some organisms)
- waters muddied by prior oral antibiotic treatment

[sf]: Presumed or likely Viral:
- usually will get antibiotics initially
- supportive care (caution with IV fluids)
- when to give antiviral agent? (HSV, VZV?)
- acyclovir dosing – body surface area vs simple weight-based 10mg/kg

[CB]: Exotic bugs (immunocompromised / travel / cranial or spinal neurosurgery) – get Microbiology / Infectious Diseases specialist advice!

[all]: last words, goodbye

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UltraSound uses in Pediatric Emergency Medicine

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Everyone’s doing it… Is it time for your Pediatric ED to join the UltraSound craze?  For adult Emergency Medicine, there seems to be a strong following and a reasonable evidence-base.  That may be coming to the kiddy world, but maybe it’s not all that it’s cracked up to be?

In this episode, we discuss the evolution of bedside clinical ultrasound use in the pediatric emergency medicine setting.  As always, we’d love to hear your comments…


Outline: Ultrasound PEMcast

CP: Intro, disclaimer, EBM-light discussion…
Levy & Noble 2008 (Pediatrics) gives a reasonable overview (full reference below).

CP: overview:
Established uses in Adult EM
Translation to PEM setting
Procedural uses in PEM
Diagnostic uses in PEM
New & crazy directions

JCR: What got you interested in UltraSound?

CP: Established uses in Adult EM
Diagnostic: FAST
Aorta
Procedural: CVC
Femoral Nerve Block
JCR: extending diagnostic uses: DVT, resuscitation/shock, Echo, [for experts: gallstones, pneumothorax, retinal detachment, more]
and Procedural uses: vascular access, nerve blocks, fracture reduction [more]

RR: Advantages of translating U/S skills to PEM setting?
no radiation
aid to clinical skills
improved success with procedures
potential to save time
potential to increase parent/patient satisfaction
look cool…

CP: Barriers to implementing U/S in the Paediatric ED:
lack of skilled users
trauma infrequent (& often conservatively managed)
operator-dependent (therefore medicolegal risk with diagnostic studies)
resistance to change (within ED and even Radiology Dept)
less cooperative patients

RR: Procedural uses in PEM
Vascular access esp CVC
Nerve blocks esp Femoral Nerve Block
For the brave:
foreign body localisation & removal
fracture reduction
joint aspiration
abscess incision & drainage
lumbar puncture

JCR [comment]

CP: Diagnostic uses in PEM
Bladder volume (pre-SPA)
Volume status – IVC: Aorta ratio
Hip effusion
For the brave:
appendicitis
pyloric stenosis
pregnancy
intussusception
echo (innocent murmur)

JCR [comment]

JCR: Evidence base supporting the use of UltraSound by Emergency Physicians?

RR: New & crazy directions
ETT placement (confirmation)(either directly scanning trachea, or visualising sliding pleura)
ETT sizing pre-intubation (using a formula)
Raised intracranial pressure (optic nerve diameter)
Fractures of skull, tibia (toddlers fractures missed on X-Ray)
Peritonsillar abscess
Scrotal pain (suspected torsion)
?minor head injury in infants with open fontanelle (risky)

CP: personal track-record theory

JCR: Credentialling in Australia (& worldwide)
Further qualifications in U/S

All: Summary, goodbye

By the way… check out www.UltraSoundVillage.com

Reference

Levy JA, Noble VE.
Bedside ultrasound in pediatric emergency medicine.
Pediatrics. 2008 May;121(5):e1404-12. Review. PubMed PMID: 18450883.

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Intussusception-Rotavirus Vaccine Risk

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Last time we spoke about intussusception and its treatment.  This week, we try to discover whether there is a real link between rotavirus vaccines and this rare cause of abdominal pain in infants.

Discussing vaccine efficacy and risks often engenders strong feelings from both sides of the river… the traditional believers AND the ‘anti-vaxxers’.  As with many controversies, it depends how you interpret the numbers – where your innate beliefs lie will influence how you see the data.  Join us as we try to walk the middle ground of objectivity…


Intussusception: Is Rotavirus Vaccination a real risk?

[cp] intro, disclaimer, overview

[cp] History: the RotaShield experience

Evidence – selected papers:
[rr] Belongia 2010 (USA surveillance)
[sf] TGA-Study 2011 (Australia)
[cp] Buttery 2011 (post-marketing surveillance Australia)
[sf] Patel 2011 NEJM (Mexico & Brazil)
[rr] Greenberg 2011 NEJM (editorial of Patel paper)
[cp] (similar studies/reports from numerous countries)

WHO position:
[cp] 2007 position paper
[rr] 2009 update of position paper (& NUVI implementation statement)
[sf] 2011 safety statement

Australian Health authorities’ position:
[cp] CMO letter 2011
[sf] Health Department Provider Info

Current practicalities:
[cp] Immunisation Handbook (Ch 3.18 Rotavirus)
[rr] Choice of vaccine
[sf] Timing of vaccination (catch-ups ?not allowed)
[cp] Both rotavirus infection and intussusception are Notifiable Diseases in (Western) Australia

[all] Summary, goodbye

ZDogg MD says: Immunize!

ZDoggMD \”Immunize!\” on YouTube

References

Belongia EA, Irving SA, Shui IM, Kulldorff M, Lewis E, Yin R, Lieu TA, Weintraub E, Yih WK, Li R, Baggs J; Vaccine Safety Datalink Investigation Group.
Real-time surveillance to assess risk of intussusception and other adverse events after pentavalent, bovine-derived rotavirus vaccine.
Pediatr Infect Dis J. 2010 Jan;29(1):1-5. PubMed PMID: 19907356.

Rotavirus vaccination and risk of intussusception
Therapeutic Goods Administration
25 February 2011
http://www.tga.gov.au/safety/alerts-medicine-rotavirus-110225.htm

Buttery JP, Danchin MH, Lee KJ, Carlin JB, McIntyre PB, Elliott EJ, Booy R, Bines JE; PAEDS/APSU Study Group.
Intussusception following rotavirus vaccine administration: post-marketing surveillance in the National Immunization Program in Australia.
Vaccine. 2011 Apr 5;29(16):3061-6. PubMed PMID: 21316503.

Patel MM, López-Collada VR, Bulhões MM, De Oliveira LH, Bautista Márquez A, Flannery B, Esparza-Aguilar M, Montenegro Renoiner EI, Luna-Cruz ME, Sato HK, Hernández-Hernández Ldel C, Toledo-Cortina G, Cerón-Rodríguez M, Osnaya-Romero N, Martínez-Alcazar M, Aguinaga-Villasenor RG, Plascencia-Hernández A, Fojaco-González F, Hernández-Peredo Rezk G, Gutierrez-Ramírez SF, Dorame-Castillo R, Tinajero-Pizano R, Mercado-Villegas B, Barbosa MR, Maluf EM, Ferreira LB, de Carvalho FM, dos Santos AR, Cesar ED, de Oliveira ME, Silva CL, de Los Angeles Cortes M, Ruiz Matus C, Tate J, Gargiullo P, Parashar UD.
Intussusception risk and health benefits of rotavirus vaccination in Mexico and Brazil.
N Engl J Med. 2011 Jun 16;364(24):2283-92. PubMed PMID: 21675888.

Greenberg HB.
Rotavirus vaccination and intussusception–act two.
N Engl J Med. 2011 Jun 16;364(24):2354-5. PubMed PMID: 21675894.

Rotavirus Vaccines
World Health Organization
Weekly Epidemiological Record (WER) 10 August 2007, vol. 82, 32 (pp 285–296)
http://www.who.int/wer/2007/wer8232/en/index.html

Rotavirus Vaccines: an update
World Health Organization
Weekly Epidemiological Record (WER) 18 December 2009, vol. 84, 50 (pp 533–540)
http://www.who.int/wer/2009/wer8451_52/en/index.html

New and Under-utilized Vaccines Implementation (NUVI): Rotavirus
World Health Organization
Updated November 2009
http://www.who.int/nuvi/rotavirus/en/

Rotavirus vaccine and intussusception
Global Advisory Committee on Vaccine Safety
World Health Organization 2011
http://www.who.int/vaccine_safety/topics/rotavirus/rotarix_and_rotateq/Dec_2010/en/index.html
Extract from report of GACVS meeting of 8-9 December 2010, published in the WHO Weekly Epidemiological Report on 28 January 2011:http://www.who.int/wer/2011/wer8605/en/index.html

CMO Letter on Intussusception and rotavirus vaccine
Immunise Australia Program
Department of Health and Ageing (Australian Government)
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-cmo-intussusception

Rotavirus vaccine and intussusception: Information for Immunisation Providers
Immunise Australia Program
Department of Health and Ageing (Australian Government)
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/ITO135-cnt

The Australian Immunisation Handbook 9th Edition 2008
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home
Rotavirus Chapter:
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-rotavirus

Australian national notifiable diseases and case definitions
Department of Health and Ageing (Australian Government)
http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-casedefinitions.htm

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Intussusception

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Intussusception is a ‘telescoping’ of the bowel on itself, commonest in infants between 5 and 10 months of age.  Usually, the classic triad of abdominal pain, vomiting and red-currant-jelly stools is not present, so how do we diagnose this sneaky little condition?

In this episode, we explore the clinical presentation, investigation and management of this bowel-threatening condition.


Outline: Intussusception PEMcast

[cp] intro, disclaimer, background

[cp] History (of the condition)
[rr] Aetiology & Pathophysiology
[sf] Incidence (worldwide)
[cp] incidence in Australia, and at our hospital

[sf] Clinical: History
[rr] Examination findings (caution about triad – usually not the case; highlight pallor – including parental report of)
[cp] Differential diagnoses (including causes of altered conscious state)
[rr] Investigations: AXR
[sf] Investigations: U/S

[cp] Treatment: air enema
[rr] Treatment: surgical reduction

[sf] Complications (including perforation, recurrence)

[all] Summary, goodbye

References & Further Reading

Blanco FC
Intussusception
Medscape Reference
http://emedicine.medscape.com/article/930708-overview

Irish MS
Pediatric Intussusception Surgery
Medscape Reference
http://emedicine.medscape.com/article/937730-overview

Winslow BT, Westfall JM, Nicholas RA.
Intussusception.
Am Fam Physician. 1996 Jul;54(1):213-7, 220. Review. PubMed PMID: 8677837.

Applegate KE.
Clinically suspected intussusception in children: evidence-based review and self-assessment module.
AJR Am J Roentgenol. 2005 Sep;185(3 Suppl):S175-83. Review.
Erratum in: AJR Am J Roentgenol. 2005 Dec;185(6 Suppl):S213. PubMed PMID: 16120899.

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Assessing Self-Harm Risk

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Assessing the risk of self harm or suicide in adolescents is a daunting concept for the occassional player.  Many Emergency Departments have a qualified Mental Health professional embedded in their clinical workforce… which means that we can become de-skilled in the art of risk assessment.

Last time, we discussed the HEADSS assessment tool for communicating with adolescent patients, and this is a great place to start.  In this episode we explore some of the elements of a structured mental health assessment.


Outline:  Self-Harm Risk Assessment

Usual to have low mood at times (due to challenges, etc)
Assessment = History, Examination, “Special investigations”
ie History, Mental State Examination, +/- structured assessment tool, +/- referral to Mental Health professional

Why do people harm themselves?
The effect of cultural / social trends

Structured suicide risk-assessment scores eg Pierce, SADPERSONS, etc
-evidence of validity?
-widely used? or not?
-applicable to adolescents?

PATHOS assessment tool (chronicity, planning, hopelessness)

HEADSS assessment as a structured conversation

Management options:
Medical management in parallel with psychiatric and other issues (eg self-poisoning, self-harm injuries)
Reassurance alone may occassionally be sufficient
Referral to Mental Health professional – acutely or follow-up
Short-term agreement / contract to not self-harm
Social work – support services, organisations, financial, legal, etc
Drug & alcohol / addiction medicine service
Sexual health services
Medications ? (caution with benzos; SSRIs – may suggest to GP but dont start in ED)

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