DIAGNOSIS
■ EEG is confirmative (if diagnosis is in question).
■ Check glucose immediately.
■ Check electrolytes, magnesium, toxicology screen, liver and renal function,
pregnancy test (as indicated).
■ Obtain head CT.
■ Consider lumbar puncture.TREATMENT
■ Thiamine and glucose if hypoglycemic or if alcoholism suspected.
■ First-line therapy = benzodizepines—diazepam, lorazepam, or midazolam.
■ Lorazepam has a relatively longer duration of seizure suppression.
■ Load with phenytoin if benzodiazepines are effective.
■ Second-line therapy = phenytoin and/or phenobarbital
■ Phenytoin: Rapid administration may cause hypotension and cardiac
dysrhythmias due to its propylene glycol diluent; this may be avoided
with fosphenytoin (water soluble prodrug). Onset of action is 10–30
minutes.
■ Phenobarbital: Anticipate sedation, respiratory depression and hypotension.
Onset of action is 15–30 minutes.
■ Magnesium sulfate, if eclamptic
■ Pyridoxine, if isoniazid overdose suspected
■ Drug-induced coma (pentobarbital, midazolam, propofol) or general anes-
thesia, if resistant to aboveA 23-year-old military recruit is brought in by ambulance with mental
status changes. Narcan was given without effect. On arrival he is noted
to be minimally responsive to painful stimuli and hypotensive. D-stick is
normal. While the patient is being intubated, the skin is noted to be warm and
covered with a petechial rash. What is the most appropriate next step?
This patient likely has meningococcal meningitis and needs immediate
antibiotic therapy with cefotaxime or ceftriaxone IV. Until the diagnosis is con-
firmed, vancomycin should also be given to cover resistant strains of Streptococcus
pneumoniae.CNS INFECTIONSMeningitisMeningitis is bacterial, viral, fungal, or aseptic inflammation of the membranes
covering the brain or spinal cord.CAUSES
The causes of meningitis in adult patients include:
■ Bacterial
■ Strep. pneumoniae(most common overall, Gram-positive diplococci)
■ Neisseria meningitides (younger ages, Gram-negative rod)
■ Listeria monocytogenes (adults >60 years, Gram-positive rod)
■ Haemophilus influenzae type B; disappearing with the HIB-vaccineNEUROLOGY