› ! Bacterial meningitis → › ! Subarachnoid hemorrhage → › Retropharyngeal abscess → › 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
› Reassessment loop
› Frequency
› Every 15 to 30 minutes if unstable
› Every 60 minutes if stable
› Repeat targets
› Mental status trend
› Vital signs trend
› Rash evolution
› New focal deficit
› Escalation triggers
› Worsening mental status
› Rising lactate
› Persistent hypotension
› New seizure
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