Jo BartlettSSN, Clinical Educator

Paediatric Critical Care, ORH

Meningococcal Disease

Objectives of lesson

• Understand causes, symptoms and clinical

management of meningitis, in particular

meningococcal meningitis / septicaemia

• Introduction to pathology and management of

shock

• Focus on caring for the highly dependant child,

caring for children and families under stress

Content of lesson• Definitions of Meningitis / Meningoccocal

disease and Septicaemia / Shock

• Causes

• Incidence

• Symptoms

• Treatment

• Nursing care of a child with meningitis, Septicaemia, and shock

• Case studies and discussion

Definition

Meningitis: Inflammation of the meninges (membranes which cover the brain and spinal cord)

Can lead to raised ICP causing herniation of the brain stem and death (approx 20%)

Meningitis causative agentsViral: Enterovirus, Herpes virus, Mumps virus

Fungal: Candida Albians (preterm neonates) Crptocoocus neoforms and Histoplasma (immunocompromised patients)

Bacterial: Haemophilus influenza B, Streptococcus pneumoniae, Strep B, Neisseria meningitidis, Meningococcus, TB, Salmonella and Listeria very rare

Staphylococcal infection following surgery or skull fractures where the dura is torn

YUK• Salmonella

• Candida

• Nisseria Meningitidis

• Haemophilus influenza

Raised ICP: Signs

• Reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a

• GCS drop of 3 or more)• Relative bradycardia and hypertension• Focal neurological signs• Abnormal posture or posturing• Unequal, dilated or poorly responsive pupils• Papilloedema• Abnormal ‘doll’s eye’ movements

Meningococcal Meningitis

• Vaccines for Meningococcal B, Meningococcal C Pnemoccocus and Haemophilus influenza B

• 40% of healthy individuals are asymptomatic carriers of Neisseria meningitidis in their upper resp tract,

• Infection occurs most often in children <5 years, peak 6 – 12 months, another peak occurs in adolescence

• Transmission via droplets / resp secretions

• Persons in direct contact with patient should receive antibiotic prophylaxis (same household)

Signs of Meningitis 1• Vary considerably depending on the child´s age

• Fever

• Headache , photophobia (rare in young children),

• Altered mental status older child (lethargy, sleepy, irritability, combative, confused ‘drunk’)

• Stiff neck, Kernig´s sign, Brudzinki´s sign (rare in babies)

• Unsteady gait, Jitteriness

• Seizures

• Photophobia

Signs of Meningitis 2• Hypothermia (more common in babies)

• Apnoea / cyanosis (common in babies)

• Vomiting, poor feeding

• Bulging fontanelle (in babies), high pitched cry, signs of a raised ICP

• Altered mental status (lethargy, irritability)

• Abnormal tone, floppy or stiff (in babies)

Kernigs sign

Brudzinki´s sign

Signs of Meningococcal Septicaemia• Hyper or hypothermia

• Limb or joint pain

• Characteristic haemorrhagic rash (petechiae and / or purpura)

• Abnormal skin colour (pale or mottled), cold hands. Capillary refill >2sec

• Tachycardia, Hypotension (late sign)

• Tachypnoea, cyanosis (late sign)

• Rigors, fits, Decreasing level consciousness

• Decreased urine output, metabolic acidosis

Meningococcal rash

Diagnosis• Clinical presentation

• LP with opening pressures recorded.

• CSF analysis definitive diagnostic test,

• Bacterial meningitis will reveal? cloudy sample, glucose low, protein high, lots of neutrophils, culture and gram stains will be +VE

• Viral or fungal meningitis will reveal a normal glucose, slightly raised protein, leucocytes and lymphocytes will be present,

• Laboratory: Elevated WCC or Neutropenia, high CRP

• Blood culture, Throat secretions

Treatment 1• Use personal protective equipment, initiate

respiratory isolation, standard precautions gloves aprons,

• Assess accurately, Reassess, Reassess

• Record properly,

• Get appropriate people, senior Drs, ask for help.

• Consider masks, goggles

Treatment 2• A= Maintain airway, oxygen,

• B= Intubation and ventilation,

• C= ECG monitor and pulse oximetry, Vascular access, if signs of dehydration or shock - fluid bolus, monitor fluid balance (urinary catheter)

• D= Pupils, AVPU, Temperature, Seizures?

• E= Serum glucose level, lab samples, lumbar puncture

• Medication as prescribed: antibiotics, antipyretics, inotropes, IVI.

DefinitionSepticaemia:

• Presence of pathogens in the blood

• Whole body inflammatory response or systematic inflammatory response syndrome

• Potentially deadly

Shock: DefinitionIs inadequate tissue perfusion. Resulting from the failure of the cardiovascular system to deliver sufficient oxygen and nutrients to sustain vital organ function.

Underlying cause must be recognised and treated promptly, or cell and organ dysfunction and death may result

Shock: Types Hypovolaemic: Most common in Children.

Inadequate circulating blood volume owing to blood or fluid loss (Septicaemia, Trauma, D+V, Burns)

Cardiogenic: Cardiac compensatory mechanism fail, heart attacks, following surgery

Distributive: In septic and anaphylactic shock, peripheral vasodilation, decreased venous return, hypotension • (also Neurogenic, disrupted autonomic pathways

from head injury, trauma to spinal cord)

Signs of (Septic) Shock in Children

• Tachycardia (may be absent in hypothermic patients, No fever in neutropenic patients)

• Signs of decreased perfusion:

• Decreased peripheral pulses compared to central pulses

• Flash cap refill or cap refill >2 sec• Mottled or cool extremities or vasodilation

• Tachypnoea

• Altered alertness, mental status

• Decreased urine output

• Metabolic acidosis, increased blood lactate

Management of Meningococcal Septacaemia• Monitor, ECG, Pulse oximetry, ABP, CVP, • A+B= Reduce muscle oxygen demand and help

restore ph balance by mechanical ventilation, • Sedate- Morphine and Midazolam• Paralyse-Vecuronium, Atracurium

• C= Support cardiovascular system: Inotropic drugs, Dopamine, Milrone, Noradrenaline, Adrenaline, Steroids (vasopressin)

• C=Restore intravascular volume with fluid resuscitation

Management of Meningococcal Septacaemia• C=Treat DIC,cristalloid/colloid/blood products:

PRC, FFP,Platlets, Cryo,Vit K• D= Antibiotics• D= Neuro obs, ICP, Anticonvulsants for fits, Head

circumference, Scan, PUPILS. • D= Maintain normothermia: warm or cool• E= Support other organs which fail (kidneys –

haemofiltration)• E= Fasciotomies for compartment syndrome

release, measure tension of tissue• F= Blood sugars, dextrose or insulin• Support family

Aquarius CRRT

DIC• Is a secondary process, which is poorly

understood• Excess activation and subsequent depletion of

clotting factors produces unrestrained clotting, then excessive bleeding (now disputed)

• Micro-thrombi are present causing ischemia then necrosis of extremities.

• Bigger clots cause pulmonary emboli, strokes and renal failure.

• Thrombocytopenia (low platelets), prolonged PT and APTT, decreased fibrinogen

Complicationsof Meningitis/ Meningococcal Septicaemia

• Brain swelling, raised ICP, Death

• Seizures

• Subdural effusions, Brain abscess, Infarcts

• Hydrocephalus, Cranial nerve palsy’s

• Hearing and sight impairments

• Learning disability

• DIC causing tissue necrosis - Amputation of toes/fingers/limbs

Suggestions for further study• Treatment of shock

• Antibiotics used

• Age specific vital signs and laboratory variables

• Familiarize with crash trolley in placement area

• Consider long-term implications of complications of Meningitis for patient and family

References, Bibliography Aehlert B (2007) Mosby´s Comprehensive Pediatric

Emergency Care, revised edition, Elsevier

Helfaer M and Nichols D (eds) (2009) Roger´s Handbook of Pediatric Intensive Care ( 4th edition) Lippincott Williams & Wilkins

Hazinski M (1992) Nursing Care of the Critically Ill Child (2nd Edition) Mosby

Barry P, Morris K and Ali T (eds) (2010) Paediatric Intensive Care, Oxford University Press

NICE clinical guideline 102, Bacterial meningitis and meningococcal septicaemia, 2010

Meningococcal disease ppt, available from author (Dr. Shelley Segal, ORH)

Useful Websites www.meningitis-trust.org public support

www.meningitis.org produced leaflet

www.inmed.co.uk (educational materials for health professionals)

www.nice.org.uk Nice guidelines