Special Operations Forces Medical Handbook

4-36

for viral) Have you been exposed to others who have been ill or had meningitis? (Ear infections, sinus disease,
pneumonia, UTIs, bronchitis, sepsis, infected wounds may harbor meningitis organisms). Have you taken
any antibiotics recently? (presentation may be masked) Have you had meningitis in the past? (increased
susceptibility) Do you have any immune deciency? (increases susceptibility) Does it hurt to bend your neck
or touch your chin to your chest? (typically positive in infection) Have you noticed any new rash? (petechiae
in early meningococcal meningitis)

Objective: Signs
Using Basic Tools: Fever to 104°F; cervical meningismus (stiff neck, painful to move); prostration; toxic
appearance; positive Kernig’s sign (inability to completely extend the knees straight – stretches spinal cord);
positive Brudzinski sign (forward exion of the head produces exion at hip and knee – stretches spinal cord);
rash (may indicate activation of the clotting cascade—hemorrhagic fevers; or petechial with meningococcus).
Chronic infection: deafness.
NOTE: Do complete neurological examination, including Glasgow Coma Scale (see Appendix: Neuro Exam),
looking for alterations of mental status or ambulation, and focal neurological decits. Perform a thorough
examination for possible sources of infection, such as middle ear, sinus, lungs, urinary tract, and wounds.
Using Advance Tools: Lab: WBC count or blood smear (may show leukocytosis in bacterial meningitis),
urinalysis; RPR, blood cultures; chest X-ray

Assessment:
Differential Diagnosis: Other than by using the presence of systemic signs of infection and meningeal
signs, these diagnoses will be very difcult to distinguish in the eld. If in doubt, treat for bacterial meningitis.
Meningitis comes in many forms that are infectious, the most common including bacterial and viral. Fungal
forms also may occur in immuno-compromised patients. Other more rare forms include tuberculous, parasitic,
spirochetal.
Rickettsial infection - usually no leukocytosis; no meningeal signs; “tache noire” lesion (ulcer covered with
black, adherent crust).
Leptospirosis - look for conjunctival discharge; history of exposure to water which might be contaminated
with animal urine
Cerebral malaria - no meningeal signs; positive blood smear; thrombocytopenia
Malignancy - variable symptoms based on lesion location.
Severe viral or bacterial sepsis with headache, high fever, but without meningeal seeding.
Brain abscess - focal neurologic ndings; low-grade temperatures; no neck stiffness or tenderness
Subdural/Epidural hematoma - history of trauma with rapid or progressive development of symptoms.
Subarachnoid hemorrhage - often low-grade temperature; acute onset preceded by severe head aches; focal
neurologic ndings.
Stroke - variable symptoms based on lesion location.

Plan:
Treatment: Availability of certain procedures and medications may be limited in the eld.

1. Begin antibiotics as soon as possible if bacterial meningitis is suspected (time to antibiotic administration
   is correlated with outcome). Empiric Choices: Penicillin: 24 million units/day in 6 divided doses,
   ampicillin: 12 gm/day in 6 divided doses, vancomycin: 2 gm/day in 2 divided doses, ceftriaxone: 6
   gm/day in 3 divided doses.


2. Evacuate immediately.


3. Airway support and oxygen. Intubate as needed.


4. Fluid hydration with IV NS or LR.


5. Control fever with Tylenol.


6. If viral meningitis is suspected (slower onset, less severe symptoms), give acyclovir 12.5 mg/kg/day IV
   divided tid x 10 days.


7. Consider steroids (Decadron 0.4 mg/kg q 12 hour for 4 doses), with rst dose prior to starting antibiotics, if
   bacterial meningitis is likely present (based on an acute presentation).