Meningococcemia

Question 1

Giving advice over phone

Answer 1

• physician dependent
• don’t prescribe without having seen patient
• advise to make appointment

Question 2

Infants less than 6-8 weeks with fever?

Answer 2

EMERGENCY!!!!

- all other fevers are context specific and need more info

Question 3

Asking about severity of illness

Answer 3

be careful not to use medical terms that confuse parents

- don’t lead with questions, ask what they think is going on

Question 4

Determining severity of illness

Answer 4

Is there any end-organ hypoperfusion?

Any underlying conditions that could complicate things?

Question 5

Emergency conditions causing altered mental status

Answer 5

Hypoxia - organs and tissues need oxygen
Shock - end-organ perfusion
Hypoglycemia - glucose is critical substrate
Poisoning

Question 6

Causes of altered mental status

Answer 6

1-4 can cause shock and/or acidosis

1. Intussusception
2. Sepsis
3. DKA
4. Renal failure
5. CNS problems

Question 7

CNS causes of altered mental status

Answer 7

Seizure - decreased LOC
Tumor - increased ICP
Intracranial bleed - increased ICP (headache)
Infection - increased ICP
Trauma

Question 8

DDx of lethargy in teenager

Answer 8

Sepsis - fever, lethargy, decreased activity/appetite
Meningitis - fever, headache, stiff neck, AMS
Encephalitis - viral (fever and AMS)
Toxins - overdose
Pneumonia - fever, tachypnea and hypoxic

Question 9

Assessing Circulation

Answer 9

1. heart rate = very sensitive for volume status (DON’T OVERLOOK)
2. Capillary refill time = sensitive for hypovolemia
3. BP = not sensitive for circulation, body can compensate

Question 10

Airway positioning

Answer 10

Infant = towels/pillow under shoulders
1-3 ys = neutral position
3-10 yrs = extend neck
10+ = hyperextend neck

Question 11

Assess airway and breathing

Answer 11

• describe effort and rate
• listen and check oxygenation
• if not doing well, try jaw thrust

Question 12

Disability and environment

Answer 12

Disability/dextose
- quick neuro assessment for increased ICP
- assess mental status
- pupils
Exposure/Environment

Question 13

PE of bacterial meningitis

Answer 13

Neck stiffness - 57-92%
Fever - 66-100%
Brudzinski's or Kernig's - 61%
 Altered mental status - 46-95%
INFANTS? - bulging fontanel (harder to examine)

Question 14

Definition of Shock

Answer 14

inadequate delivery of substrates and oxygen to meet metabolic needs of tissue

• no longer aerobic metabolism
• disruption of cellular membranes and ion pumps
• cells swell and break down

Question 15

Compensation of Shock in Kids

Answer 15

kids can maintain their blood pressure much longer during shock than adults
- tachycardia and increased contractility
- increased venous tone and respiratory rate
HYPOTENSION = BAD SHIT

Question 16

Hypovolemic Shock

Answer 16

most common type

• inadequate fluid intake to compensate for loss
• AMS, tachypnea, tachycardia, hypotension, cool extremities

Question 17

Distributive Shock

Answer 17

Neurogenic and anaphylactic

• intravascular hypovolemia
• vasodilation, increased capillary permeability, 3rd space loss

Question 18

Cardiogenic Shock

Answer 18

Severe heart disease, dysrhythmia, cardiomyopathy, tamponade

- low cap refill, absent pulses, tachypnea, tachycardia, low UO

Question 19

Septic Shock

Answer 19

infectious organism releases toxins that affects fluid distribution and CO
- require repeated boluses of fluid and vasopressors

Question 20

Administration of Fluids in Shock

Answer 20

maintaining fluid status trumps everything in shock

- isotonic (normal saline) as fast as possible

Question 21

Intraosseus access

Answer 21

easy, fast and can replace IV if trouble starting IV

• can give any fluid thru it that you would IV
• distal femur, tibial plateau, proximal humerus
• don’t place into a fracture or infection

Question 22

DDx for fever and petechiae

Answer 22

Menningococcoal Sepsis
Kawasaki Disease
Toxic Shock Syndrome
RMSF
Scarlet Fever

Question 23

Meningococcal Sepsis

Answer 23

fever, petechiae –> MUST BE ON LIST
- patient otherwise looks well
- blood cultures taken and then ABx started
Neisseria meningitidis

Question 24

Toxic Shock Syndrome

Answer 24

fever and sun-burn appearing rash

- from staph toxin –> leads to shock

Question 25

Risks for meningococcal sepsis

Answer 25

``` Close quarters (military/college) Complement deficiency Asplenia ```

Question 26

Transmission of meningococcal

Answer 26

Air and respiratory droplets | incubation 1-10 days

Question 27

Disease course of meningococcal

Answer 27

1. Fever, chills, prostration, malaise, myalgias, rash | 2. Purpura, ischemia, coagulopathy, pulmonary edema, shock

Question 28

Mortality of meningococcal

Answer 28

10% --> higher if longer before treatment

Question 29

Sequelae of meningococcal

Answer 29

hearing loss, neuro disability, loss of digits, scarring

Question 30

Treating meningococcemia

Answer 30

IV Penicillin (penicillin G) - pediatrics = 250,000-300,000 units/kg/day (divided every 4-6 hrs) - adults = 12-24 million units a day (divided every 4-6 hrs)

Question 31

Initial treatment

Answer 31

as soon as cultures are drawn --> start vanco, ceftriaxone and if in endemic areas doxycycline - vanco = gram (+) and MRSA - ceftriaxone = gram (-) - doxy = tick

Question 32

Meningococcal Prophylaxis

Answer 32

Adults - ciprofloxacin Kids - rifampin or ceftriaxone *can't use rifampin or ciprofloxacin for pregnant

Question 33

Pre-renal failure

Answer 33

due to hypoperfusion = elevated BUN and Cr

Question 34

Meningococcal vaccine

Answer 34

Tetravalent Given to 11-18 year olds - given IM at 11 year old - booster at 16