Peds question: what to do when signs of ICP?

[tiburones]

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Hey everyone, just a quick question:

When a kid presents with signs of ICP in the context of suspected meningitis, what do you do in terms of diagnostics? CT or LP? I've seen both, and recently got a Uworld question that said in little kids you go for the LP first because there's little risk of herniation. The same question also said that in adults you should give empiric abx first and then get an LP whereas in kids you do the LP and THEN do the empiric abx. On the other hand, I've read in other review books that you should always do the LP before abx.

Can anybody clarify this LP, CT and Abx question for me?

Muchas gracias!

 

[PokerDoc]

Well first off, very rarely (i dont think ive ever seen it) would a CORRECT answer ever say to give antibiotics before drawing cultures or doing LP, whatever. It can muddle your findings.

I am going off the top of my head so others PLEASE correct me if I'm wrong here.

Let's stick with the peds topic since you asked that in your subject. Most of the time, you do not need a CT before proceeding to the LP. The only times you would want the CT is if there are discrete signs of increased ICP, most specifically, papilledema, focal neurologic deficits, new onset seizure, or possibly altered mental state.

For children in the first two months of life, you are most worried about GBS, E. Coli, and then way down the list Listeria. So after LP, you empirically treat with Amp + Gent (can also use cefotaxime i believe instead of gent).

For older children, same deal, except now you're worried about S. pneumo and Neisseria, so your treatment will involve IV Vanco (to cover to possible MRSA and other gram+ and ceftriaxone (cefotaxime).

The last consideration in children > 6mo is you have to give them dexamethasone to protect them against longterm neurologic sequelae (particularly hearing loss). Some sources may say > 3mo, but I doubt the test would put you somewhere between that age range and ask you to decide.


If anyone needs to correct anything or elaborate please do! This is the knowledge I'm heading into the test with haha.

 

[ThePursuit]

Well first off, very rarely (i dont think ive ever seen it) would a CORRECT answer ever say to give antibiotics before drawing cultures or doing LP, whatever. It can muddle your findings.

I am going off the top of my head so others PLEASE correct me if I'm wrong here.

Let's stick with the peds topic since you asked that in your subject. Most of the time, you do not need a CT before proceeding to the LP. The only times you would want the CT is if there are discrete signs of increased ICP, most specifically, papilledema, focal neurologic deficits, new onset seizure, or possibly altered mental state.

For children in the first two months of life, you are most worried about GBS, E. Coli, and then way down the list Listeria. So after LP, you empirically treat with Amp + Gent (can also use cefotaxime i believe instead of gent).

For older children, same deal, except now you're worried about S. pneumo and Neisseria, so your treatment will involve IV Vanco (to cover to possible MRSA and other gram+ and ceftriaxone (cefotaxime).

The last consideration in children > 6mo is you have to give them dexamethasone to protect them against longterm neurologic sequelae (particularly hearing loss). Some sources may say > 3mo, but I doubt the test would put you somewhere between that age range and ask you to decide.


If anyone needs to correct anything or elaborate please do! This is the knowledge I'm heading into the test with haha.

I agree for most of that except that in true life threatening cases (like N. mening) nobody gives a flying F@#$@% about your cultures, give the kid some ABX. If you don't, they'll die while waiting for your precious LP for serology. But as a rule you try to get diagnostic data before you muddle it up with meds.

I like cefotax just because of the sensorineural hearing loss that you can give the kiddos with Gent. amp covers the Listeria, Gent/cefotax covers E.coli, the vancomycin is used because some S. pneumo strains are beta-lactam resistant I guess. (NOT to treat MRSA or staph mening like I've heard soooo many residents and students tell me in the clinics).

 

[PokerDoc]

I thought S. Pneumo was the one bug that wasn't resistant yet (hence why it is still preached that we stop giving big guns for every little case of strep throat).

 

[turkeyjerky]

No, Group A Step (strep pyrogenes) is the organism you're thinking of.

There are two major algorithms you can follow here:
1) Signs of increased ICP (focal neurologic findings, seizures, papilledema, decreased LOC) (or real world, esp w/ really sick patient):
Abx-->CT-->LP
2) No signs of increased ICP: LP-->Abx (before results come back)

As far as kids w/ signs of increased ICP, not exactly sure. I would presume that a CT should be gotten first to r/o impending herniation. The major issue here is sick vs not sick. If sick, they get immediate fluids (if shocky) and abx. If not sick, then it's more of a r/o sepsis scenario and you can dither around w/ the LP before giving them the abx.

 

[ThePursuit]

No, Group A Step (strep pyrogenes) is the organism you're thinking of.

There are two major algorithms you can follow here:
1) Signs of increased ICP (focal neurologic findings, seizures, papilledema, decreased LOC) (or real world, esp w/ really sick patient):
Abx-->CT-->LP
2) No signs of increased ICP: LP-->Abx (before results come back)

As far as kids w/ signs of increased ICP, not exactly sure. I would presume that a CT should be gotten first to r/o impending herniation. The major issue here is sick vs not sick. If sick, they get immediate fluids (if shocky) and abx. If not sick, then it's more of a r/o sepsis scenario and you can dither around w/ the LP before giving them the abx.

I'm too lazy to look up the age cut-off right now, but I distinctly remember imaging prior to LP definitly NOT being done as often for young children. I think it is in part due to increased hesitancy for exposure of rads, partly due to their fontanelles being able to buffer ICP unlike adults? Obviously if they have an obvious focal neuro deficit or something, you probably should. It's been a long time since peds rotation though.

 

[turkeyjerky]

I'm too lazy to look up the age cut-off right now, but I distinctly remember imaging prior to LP definitly NOT being done as often for young children. I think it is in part due to increased hesitancy for exposure of rads, partly due to their fontanelles being able to buffer ICP unlike adults? Obviously if they have an obvious focal neuro deficit or something, you probably should. It's been a long time since peds rotation though.

Yeah, I agree--the OP was asking about what to do when there are specifically signs of increased ICP.

 

[wanderlustin]

I'm confused.....I thought always giving abx first is appropriate because you have at least an hour(ish, can't remember exactly) until that would screw up your LP results. I mean, obviously a lot of docs don't practice this, but that's what the EBM shows. Comments?

 

[kingkenny]

Antibitiocs can be given for upto 2 hrs before LP is done and it will not screw up LP results. That being said, I would not pick that answer because the rule of thumb is diagnostics before antibiotics.

Agree with Turkeyjerkey on the answer though. Based on how sick the kid is, you proceed from there.

 

[trobin28]

I checked in Sabatines pocket medicine, which has a great chart on meningitis mangt: If concerned about increased ICP --> Obtain BCx -->Start empiric Abx --> Obtain Head CT -->LP(if not contraind). FYI, Other reasons to consider obtaining head CT before LP were age>60, immunosuppressed, h/o CNS d/o, new onset of seizures and altered mental status. Hope this helps.

 

[OveractiveBrain]

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