›First 5 minutes
›Immediate
›Cardiac monitor
›Continuous pulse oximetry
›Two large bore IV lines if unstable
›Point of care glucose
›Airway and breathing
›If SpO2 less than 92 percent then oxygen
›If inability to protect airway then intubation pathway
›Circulation and sepsis
›If MAP less than 65 mmHg then fluid bolus and vasopressor pathway
›If septic shock concern then lactate and blood cultures early
Empiric antimicrobials and antivirals
›Empiric therapy timing
›If suspected bacterial meningitis then antibiotics within 60 minutes
›If imaging needed before LP then do not delay antibiotics
›Adult empiric bacterial meningitis
›Ceftriaxone IV 2 g every 12 hours
›Alternative
›Cefotaxime IV 2 g every 4 to 6 hours
›Vancomycin IV weight based per local protocol
›Target trough local protocol dependent
›If age 50 years or older or immunocompromised then add ampicillin IV 2 g every 4 hours
›If severe beta lactam allergy then alternatives local protocol dependent
›Adjunctive dexamethasone
›Dexamethasone IV 10 mg every 6 hours
›Timing
›Before or with first antibiotic dose
›Stop criteria
›If bacterial meningitis excluded
›Encephalitis coverage when indicated
›Acyclovir IV 10 mg per kg every 8 hours
›Renal adjustment required
›Diagnostic sequence
›Blood cultures times two before antibiotics if no delay
›CT head without contrast before LP if high risk features
›LP with opening pressure and full CSF panel when safe
›MRI brain if encephalitis concern or persistent deficit
›MRI spine if epidural abscess concern
Symptom control and supportive care
›Supportive care
›Acetaminophen for fever and pain
›IV fluids if hypovolemia
›Antiemetic as needed
›Electrolyte correction