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Thomas Lukens, MD Evaluation & Management of Delirious Patients with Suspected CNS Infection.

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Presentation on theme: "Thomas Lukens, MD Evaluation & Management of Delirious Patients with Suspected CNS Infection."— Presentation transcript:

1 Thomas Lukens, MD Evaluation & Management of Delirious Patients with Suspected CNS Infection

2 Thomas Lukens, MD FERNE Brain Illness and Injury Course

3 Thomas Lukens, MD 4 th Mediterranean Emergency Medicine Congress Sorrento, Italy September 17, th Mediterranean Emergency Medicine Congress Sorrento, Italy September 17, 2007

4 Thomas Lukens, MD Thomas W. Lukens MD PhD Associate Professor Department of Emergency Medicine MetroHealth Medical Center Case Western Reserve University School of Medicine Cleveland, OH

5 Thomas Lukens, MD Greetings from Cleveland, Ohio

6 Thomas Lukens, MD Disclosures ACEP Clinical Policies CommitteeACEP Clinical Policies Committee Advisory Board, FERNEAdvisory Board, FERNE

7 Thomas Lukens, MD Today’s Objectives Present a typical clinical situationPresent a typical clinical situation Discuss the diagnosis of deliriumDiscuss the diagnosis of delirium Review methods to diagnosis CNS infectionsReview methods to diagnosis CNS infections Consider treatment optionsConsider treatment options

8 Thomas Lukens, MD Clinical Case

9 Thomas Lukens, MD “Not feeling well” 68 year old male brought in by son68 year old male brought in by son 3 days of “not feeling well”3 days of “not feeling well” 2 days decreased alertness, intermittent confusion, anxious. Today thought he saw his deceased wife.2 days decreased alertness, intermittent confusion, anxious. Today thought he saw his deceased wife. Patient had fever at home, complains of headache, myalgiasPatient had fever at home, complains of headache, myalgias PMH- BPH, HTN, former alcoholic,PMH- BPH, HTN, former alcoholic, No psychiatric historyNo psychiatric history Medicines: Lisinopril, Doxazosin, ASA Medicines: Lisinopril, Doxazosin, ASA

10 Thomas Lukens, MD “Not feeling well” B/P 145/90, HR 118, RR 20, T 38.5B/P 145/90, HR 118, RR 20, T 38.5 Finger stick Glucose 100Finger stick Glucose 100 Exam- Confused, slurred speech, disinterested, somewhat uncooperativeExam- Confused, slurred speech, disinterested, somewhat uncooperative Skin- no rashSkin- no rash Fundi- unable to visualize, pupils equal & reactiveFundi- unable to visualize, pupils equal & reactive Neck supple, positive KernigsNeck supple, positive Kernigs Abdomen – soft, nontender, Lungs- clearAbdomen – soft, nontender, Lungs- clear CN – 2-12 intact, strength- symmetrical, gait- wide basedCN – 2-12 intact, strength- symmetrical, gait- wide based

11 Thomas Lukens, MD “Not feeling well” Consider his presentation- consistent with:Consider his presentation- consistent with: PsychosisPsychosis Alcohol withdrawAlcohol withdraw DementiaDementia DeliriumDelirium MetabolicMetabolic Acute MIAcute MI

12 Thomas Lukens, MD Delirium A: Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, awareness of the environment) with reduced ability to focus, sustain or shift attention sustain or shift attention B: Change in cognition (eg. memory deficit, disorientation, language disturbance) or development of a perceptual language disturbance) or development of a perceptual disturbance not due to pre-existing, established or disturbance not due to pre-existing, established or developing dementia developing dementia C: The disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of (hours to days) and tends to fluctuate during the course of the day. the day. D. Evidence of etiology

13 Thomas Lukens, MD Impression Patient with acute delirium and possible infection- related? Patient with acute delirium and possible infection- related? Infection – a common cause of delirium Infection – a common cause of delirium 35% in one series 35% in one series Drug interactions- also common Drug interactions- also common Anticholenergic effects Anticholenergic effects Delirium - common in elderly patients in the ED Delirium - common in elderly patients in the ED

14 Thomas Lukens, MD Etiology Delirium D:Drugsanticholinergics, ETOH E:EndocrineBS, Na, Ca, Mg, cortisol, etc. M:Metabolicorgan failure, hypoxia, etc. E:Epilepsy or seizurespostictal status N:Neoplasmespecially SIADH, CNS T:Traumaconcussion, surgery I:Infectionany I:Infectionany A: “Apoplexy” any vascular event MI, PE, CVA

15 Thomas Lukens, MD Learning Objectives and Key Clinical Questions

16 Thomas Lukens, MD Session Objectives Discuss – how to evaluate this patient for cause of his delirium ? Discuss – how to evaluate this patient for cause of his delirium ? Review – Rapid diagnostic testing Review – Rapid diagnostic testing Determine- appropriate treatment Determine- appropriate treatment CNS Infection CNS Infection Agitation Agitation

17 Thomas Lukens, MD Key Clinical Questions What are the indications for LP? What are the indications for LP? When should a CT be performed before the LP. When should a CT be performed before the LP. When should an opening pressure be determined? When is it positive? When should an opening pressure be determined? When is it positive?

18 Thomas Lukens, MD Key Clinical Questions How can CNS viral infection be differentiated from bacterial infection using CSF analysis. How can CNS viral infection be differentiated from bacterial infection using CSF analysis.

19 Thomas Lukens, MD Key Learning Points Initial treatment: Initial treatment: Blood cultures, IV fluids, urine analysis Blood cultures, IV fluids, urine analysis » Large majority of patients with bacterial meningitis have positive blood cultures IV antibiotics- Ceftriaxone IV antibiotics- Ceftriaxone » Add Ampicillin (Listeria) age > 50 CT scan- signs of increased ICP CT scan- signs of increased ICP

20 Thomas Lukens, MD CT scan CT scan indicated before LP:CT scan indicated before LP: Clinical findings predictive of abnormal CTClinical findings predictive of abnormal CT Immunocompromised - HIV, transplantImmunocompromised - HIV, transplant Hx CNS lesion- tumor, abscess, strokeHx CNS lesion- tumor, abscess, stroke New onset seizure- within 1 weekNew onset seizure- within 1 week Papilledema- without venous pulsationsPapilledema- without venous pulsations Abnormal level consciousnessAbnormal level consciousness Focal neuro deficit- dilated nonrective pupil, gaze palsy, arm/leg drift, new visual field cutFocal neuro deficit- dilated nonrective pupil, gaze palsy, arm/leg drift, new visual field cut Hasbun R, NEJM (2001); 345:1727 Tunkel AR, Clinical Infectious Disease (2004); 39:1267

21 Thomas Lukens, MD Herniation Risk Overall – very low Overall – very low Normal CT doesn’t r/o ↑ ICPNormal CT doesn’t r/o ↑ ICP Brain shiftBrain shift Loss of grey- white differentiationLoss of grey- white differentiation Meningitis- can lead to ↑ ICPMeningitis- can lead to ↑ ICP Rennick- 4.3% herniation rateRennick- 4.3% herniation rate Pediatric populationPediatric population Flexor or extensor posturing, focal neurological signs or no response to pain- defer the LPFlexor or extensor posturing, focal neurological signs or no response to pain- defer the LP Rennick G. British Medical J (1993);306:953

22 Thomas Lukens, MD Lumbar Puncture Lumbar Puncture - Standard of care with suspected meningitis Lumbar Puncture - Standard of care with suspected meningitis Procedure options : Procedure options : Coagulopathy- reverse- replace factors, platelets Coagulopathy- reverse- replace factors, platelets Herniation risk- treat without LP Herniation risk- treat without LP Lateral decubitus position- opening pressure Lateral decubitus position- opening pressure Sitting position- more first time success Sitting position- more first time success Opening pressure- not needed for meningitis detection Opening pressure- not needed for meningitis detection If elevated > 250 mmHg, still take specimen If elevated > 250 mmHg, still take specimen

23 Thomas Lukens, MD CSF: Rapid Results Chemistries: protein, glucoseChemistries: protein, glucose Glucose ~ 60% of serum value, decreased with infectionGlucose ~ 60% of serum value, decreased with infection Protein – elevated in meningitis almost alwaysProtein – elevated in meningitis almost always Gram stainGram stain % positive, specificity > 97%60-90 % positive, specificity > 97% Likelihood + Gram stain related to concentration of bacteria in CSFLikelihood + Gram stain related to concentration of bacteria in CSF Latex agglutinationLatex agglutination Rapid, fairly sensitive: %Rapid, fairly sensitive: % False positives, results don’t change therapyFalse positives, results don’t change therapy Not recommendedNot recommended Tunkel AR, Clinical Infectious Disease (2004); 39:1267

24 Thomas Lukens, MD CSF PCR- detects amplified pathogen DNAPCR- detects amplified pathogen DNA High sensitivity, use when Gram stain negativeHigh sensitivity, use when Gram stain negative Broad based PCR- negative predictive value -100%Broad based PCR- negative predictive value -100% Not routinely recommendedNot routinely recommended CSF lactate- elevated in bacterial infectionCSF lactate- elevated in bacterial infection Non specific, not recommended as routine testNon specific, not recommended as routine test C-reactive protein- mirrors inflammationC-reactive protein- mirrors inflammation Not diagnostic for bacterial meningitisNot diagnostic for bacterial meningitis Distinguish viral from bacterial ?Distinguish viral from bacterial ? Not routinely recommendedNot routinely recommended Tunkel AR, Clinical Infectious Disease. (2004); 39:1267

25 Thomas Lukens, MD CSF CNS infection interpretation: – Viral - lymphs predominant – Bacterial - polys predominant Predictive model Pediatric population, retrospective 0- 6 scale 100% negative predictive value of score = 0 Nigrovic LE, Pediatrics (2002);110:712

26 Thomas Lukens, MD CSF Predictive Model 0 to 6 score PredictorPresentAbsent Positive Gram stain 20 CSF protein > 80mg/dl 10 Peripheral ANC > 10,000cells/mm 3 10 Seizure at or before presentation 10 CSF ANC > 1000 cells/mm 3 10 Nigrovic LE, Pediatrics (2002):110:712

27 Thomas Lukens, MD Empiric treatment Antibiotics Antibiotics Ceftriaxone or Cefotaxime Ceftriaxone or Cefotaxime Vancomycin + Ceftriaxone (Cefotaxime) Vancomycin + Ceftriaxone (Cefotaxime) » Combination recommended in infants/children » Some recommend in adults as well » Ampicillin > age (Listeria) Timing of antibiotics? Timing of antibiotics? » No prospective data » As soon as possible

28 Thomas Lukens, MD Empiric treatment Steroids: dexamethasone -Adults Steroids: dexamethasone -Adults Before or with 1 st dose of antibiotics (0.15mg/kg q 6h x 2-4 days) Before or with 1 st dose of antibiotics (0.15mg/kg q 6h x 2-4 days) – Mortality benefit in pneumococcal meningitis – Less neurological sequelae – Trend toward mortality benefit in meningococcal meningitis but not significant Cochrane Database Syst Rev (2007) Jan 24;(1)

29 Thomas Lukens, MD Delirium During the ED stay, the patient became increasing agitated and difficult to verbally de-escalate and reassure.During the ED stay, the patient became increasing agitated and difficult to verbally de-escalate and reassure. Treatment ?Treatment ? RestraintsRestraints BenzodiazepinesBenzodiazepines AntipsychoticsAntipsychotics PsychiatryPsychiatry

30 Thomas Lukens, MD Delirium treatment Benzodiazepines are as effective as haloperidol in controlling agitationBenzodiazepines are as effective as haloperidol in controlling agitation IM Midazolam, IM LorazepamIM Midazolam, IM Lorazepam Haloperidol less rapid effect than droperidolHaloperidol less rapid effect than droperidol Combination therapy also effective- lower dose of each neededCombination therapy also effective- lower dose of each needed Atypical antipsychotics- not proven more effective than benzodiazepines or haloperidol in deliriumAtypical antipsychotics- not proven more effective than benzodiazepines or haloperidol in delirium ACEP Clinical Policy. Ann Emerg Med (2006);47:79

31 Thomas Lukens, MDConclusions Delirium is a medical emergencyDelirium is a medical emergency Rapid determination of etiology is fundamentalRapid determination of etiology is fundamental Meningitis is a cause of acute delirium and needs early recognitionMeningitis is a cause of acute delirium and needs early recognition Emergent antibiotics and LP if meningitis suspectedEmergent antibiotics and LP if meningitis suspected

32 Thomas Lukens, MDRecommendations CT scan before LP if specific clinical findings present Ceftriaxone (Cefotaxime) – initial empiric therapy Add vancomycin, ampicillin as clinical picture dictates Steroids before antibiotics Agitation pharmacologic treatment Benzodiazepines +/- haloperidol

33 Thomas Lukens, MD Questions? ferne_memc_2007_braincourse_lukens_cnsinfection_091707_finalcd 9/17/2007 5:45 AM


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