HEADACHE98 General Medical Emergencies
Escherichia coli), viruses, and Cryptococcus neoformans and tuberculosis
(immunosuppression including HIV).
(i) Haemophilus influenzae is now becoming rare following
vaccination programmes.
2 Prodromal malaise is followed by generalized headache, fever and vomiting,
with altered mental status and irritability and drowsiness progressing to
confusion or coma.
3 Pyrexia, photophobia and neck stiffness are found. Localized cranial nerve
palsies or seizures may occur.
4 Eliciting signs of meningeal irritation are rarely positive (<10%):
(i) Kernig’s sign: pain and spasm in the hamstrings on attempted
knee extension, with a flexed hip.
(ii) Brudzinski’s sign: involuntary flexion of both hips and knees on
passive neck flexion.
5 Always consider meningitis in the confused elderly, sick neonate, in genera l-
ized conv ulsive status epilepticus, and in coma of unk nown cause.
6 A petechial rash, impaired consciousness and meningism are features of
meningococcal septicaemia (meningococcaemia), but are relatively late
signs. Therefore look out for the earlier signs of possible meningococcaemia
such as:
(i) Muscle pain including leg pains, abnormal skin colour with
pallor or mottling, and cold hands and feet.
(ii) Rigors, vomiting, headache or abdominal pain and a rapid
evolution of illness within 24 h.
(iii) Progression to shock and obtundation indicate fulminant
meningococcal disease.
7 Gain i.v. access and send blood for FBC, coagulation profile, ELFTs, blood
sugar, viral studies and two sets of blood cultures (from different venepunc-
ture sites).
8 Attach a cardiac monitor and pulse oximeter to the patient, and perform a
CXR.MANAGEMENT1 Give the patient oxygen and commence a normal saline infusion.
2 Seek immediate senior ED doctor help, and give antibiotics as soon as the
diagnosis is suspected.
(i) Give ceftriaxone 4 g i.v. daily, or 2 g i.v. 12-hourly; or cefotaxime
2 g i.v. then 6-hourly.
(ii) Add benzylpenicillin 2.4 g i.v. 4-hourly if Listeria is possible,
such as in immunosuppression, adults >50 years, chronic alcohol
abuse, pregnancy or debilitation, or