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Jo Bartlett SSN, Clinical Educator Paediatric Critical Care, ORH Meningococcal Disease.

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Presentation on theme: "Jo Bartlett SSN, Clinical Educator Paediatric Critical Care, ORH Meningococcal Disease."— Presentation transcript:

1 Jo Bartlett SSN, Clinical Educator Paediatric Critical Care, ORH Meningococcal Disease

2 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

3 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

4 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%)

5 Meningitis causative agents Viral: 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

6 YUK Salmonella Candida Nisseria Meningitidis Haemophilus influenza

7 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 dolls eye movements


9 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)

10 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

11 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)

12 Kernigs sign

13 Brudzinki´s sign

14 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

15 Meningococcal rash


17 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

18 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

19 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.

20 Definition Septicaemia: Presence of pathogens in the blood Whole body inflammatory response or systematic inflammatory response syndrome Potentially deadly

21 Shock: Definition Is 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

22 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)

23 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

24 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

25 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

26 Aquarius CRRT

27 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

28 Complications of Meningitis/ Meningococcal Septicaemia Brain swelling, raised ICP, Death Seizures Subdural effusions, Brain abscess, Infarcts Hydrocephalus, Cranial nerve palsys Hearing and sight impairments Learning disability DIC causing tissue necrosis - Amputation of toes/fingers/limbs

29 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

30 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 ( 4 th edition) Lippincott Williams & Wilkins Hazinski M (1992) Nursing Care of the Critically Ill Child (2 nd 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)

31 Useful Websites public support produced leaflet (educational materials for health professionals) Nice guidelines

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