Approach to critical patient
›First 5 minutes
›Airway management if inability to protect airway
›Oxygen if oxygen saturation less than 92 percent
›Two large bore IV access or IO
›Cardiac monitor
›Point of care glucose
›Initial lactate
›Blood cultures before antibiotics if feasible without delay
›Early antibiotics within 60 minutes when bacterial meningitis suspected
›Adult empiric regimen selection
›Ceftriaxone IV 2 g every 12 hours
›Vancomycin IV 15 mg per kg to 20 mg per kg every 8 hours to 12 hours
›Vancomycin trough or AUC monitoring per local protocol
›Listeria coverage indications
›Age 50 years or older
›Pregnancy
›Immunocompromised
›Alcohol use disorder
›Chronic liver disease
›Diabetes mellitus (E11.9)
›Listeria coverage therapy
›Ampicillin IV 2 g every 4 hours
›Alternative if ampicillin unavailable local protocol dependent
›Encephalitis coverage
›Acyclovir IV 10 mg per kg every 8 hours
›Renal dosing adjustment when eGFR reduced
›Aggressive IV hydration to reduce nephrotoxicity risk
›Dexamethasone use
›Give before or with first antibiotic dose when bacterial meningitis suspected
›Dexamethasone IV 10 mg every 6 hours for adults local protocol dependent
›Stop if culture or PCR excludes pneumococcal disease per local protocol
Antimicrobial allergy pathways
›Severe immediate beta lactam allergy
›Infectious diseases consult urgent
›Alternative regimen local protocol dependent
›Desensitization consideration when high likelihood bacterial meningitis
Lumbar puncture timing and sequencing
›LP and imaging workflow
›If no CT before LP criteria and no shock then LP promptly then antibiotics if not already started
›If CT before LP criteria present then blood cultures then antibiotics then CT then LP when safe
›Do not delay antibiotics for imaging when high suspicion bacterial meningitis
Elevated intracranial pressure management
›ICP risk mitigation
›Head of bed 30 degrees
›Avoid hypotension
›Avoid hypoxemia
›Hyperosmolar therapy for herniation signs local protocol dependent
›Acute seizure treatment
›Benzodiazepine first line per local protocol
›Levetiracetam IV loading dose local protocol dependent
›Continuous EEG consideration when persistent altered mental status
›Serial reassessment targets
›Vitals every 15 minutes to 60 minutes depending on stability
›Mental status trend
›Urine output
›Lactate clearance in shock
›Rash progression
›New focal deficits