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
› ! Bacterial meningitis → › ! Viral meningitis → › Encephalitis → › 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
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