f*****w
发帖数: 1451 | 1 发热,头痛或者mental status change的病人来急诊,考虑脑膜炎或者大脑炎,需要查血
和抽blood culture,然后上empiric antiboitics,然后看head CT, LP, CSF analysis.
有一道题是HSV encephalitis的病人,来了也是发热(虽然不是高烧),mental change,鉴
别诊断是bacterial/ viras meningitis/encephalitis.常规抽血,血液培养,可是那道
题上直接继续脑穿刺了,没有上抗生素.
我的疑问是,在没有确定是病毒还是细菌的情况下,是否应该常规上抗生素,再去脑穿,脑
穿发现pinkish CSF,gram stain negative高度倾向病毒以后再停止抗生素,上抗病毒药
呢?
同学们给讲讲?谢谢! | l********z
发帖数: 810 | 2 I think we can first do CBC stat, and obtain the result of CBC, if leukocyte
very high with left shift, then consider bacterial infection and then add
antibiotics. But if CBC do not show any sign of bacterial infection, then
consider virus infection and go ahead with LP.
The case usually give out the very obvious result and clinical symptoms plus
signs for us to differentiate the bacteria or virus infection.
They do not want us to give antibiotics without any thought. | f*****w
发帖数: 1451 | 3 thanks, Ling mm.
Also, how do we tell if we need to do head ct before LP? For those two cases
, both of them didn't have the signs for elevated intracranial pressure. But
the bacterial case ordered head CT. The other one didn't.
leukocyte
plus
【在 l********z 的大作中提到】
: I think we can first do CBC stat, and obtain the result of CBC, if leukocyte
: very high with left shift, then consider bacterial infection and then add
: antibiotics. But if CBC do not show any sign of bacterial infection, then
: consider virus infection and go ahead with LP.
: The case usually give out the very obvious result and clinical symptoms plus
: signs for us to differentiate the bacteria or virus infection.
: They do not want us to give antibiotics without any thought.
| A*******s
发帖数: 9638 | 4 For MS change and fever, you always do a LP. CSF analysis will tell you
what the problem is.
leukocyte
plus
【在 l********z 的大作中提到】
: I think we can first do CBC stat, and obtain the result of CBC, if leukocyte
: very high with left shift, then consider bacterial infection and then add
: antibiotics. But if CBC do not show any sign of bacterial infection, then
: consider virus infection and go ahead with LP.
: The case usually give out the very obvious result and clinical symptoms plus
: signs for us to differentiate the bacteria or virus infection.
: They do not want us to give antibiotics without any thought.
| A*******s
发帖数: 9638 | 5 You have to do a CT first, then LP.
Why? Herniation if the 4th ventricle is not open.
cases
But
【在 f*****w 的大作中提到】
: thanks, Ling mm.
: Also, how do we tell if we need to do head ct before LP? For those two cases
: , both of them didn't have the signs for elevated intracranial pressure. But
: the bacterial case ordered head CT. The other one didn't.
:
: leukocyte
: plus
| f*****w
发帖数: 1451 | 6 Thanks. That's why I don't understand. According to UW CCS case, CT was
ordered for bacterial meningitis but not the HSV encephalitis even though
the initial presentations for both cases were similar.
【在 A*******s 的大作中提到】
: You have to do a CT first, then LP.
: Why? Herniation if the 4th ventricle is not open.
:
: cases
: But
| w******n
发帖数: 88 | 7 In the encephalitis case,head ct before LP is a neutral option.It is not
wrong.I prefer to ordering head ct before LP because meningitis is a
differential diagnosis.
though
【在 f*****w 的大作中提到】
: Thanks. That's why I don't understand. According to UW CCS case, CT was
: ordered for bacterial meningitis but not the HSV encephalitis even though
: the initial presentations for both cases were similar.
| w******n
发帖数: 88 | 8 "Almost all encephallitis in the united states is from herpes."---from
MTB.So if you suspect encephalitis,be very careful to give empiric
antibiotics.
analysis.
【在 f*****w 的大作中提到】
: 发热,头痛或者mental status change的病人来急诊,考虑脑膜炎或者大脑炎,需要查血
: 和抽blood culture,然后上empiric antiboitics,然后看head CT, LP, CSF analysis.
: 有一道题是HSV encephalitis的病人,来了也是发热(虽然不是高烧),mental change,鉴
: 别诊断是bacterial/ viras meningitis/encephalitis.常规抽血,血液培养,可是那道
: 题上直接继续脑穿刺了,没有上抗生素.
: 我的疑问是,在没有确定是病毒还是细菌的情况下,是否应该常规上抗生素,再去脑穿,脑
: 穿发现pinkish CSF,gram stain negative高度倾向病毒以后再停止抗生素,上抗病毒药
: 呢?
: 同学们给讲讲?谢谢!
| A*******s
发帖数: 9638 | 9 Can u provide the reference for that?
Viral, or aseptic, meningitis is the most common form of meningitis in the
United States. This typically mild and non-lethal disease is usually caused
by enteroviruses. Enteroviruses are present in mucus, saliva, and feces and
can be transmitted through direct contact with an infected person or an
infected object or surface. Other viruses that cause meningitis include
varicella zoster (the virus that causes chicken pox and can appear decades
later as shingles), influenza, mumps, HIV, and herpes simplex type 2 (
genital herpes).
Only herpetic encephalitis can be effectively treated. That is why you
should never miss a diagnosis of HSV encephalitis.
【在 w******n 的大作中提到】
: "Almost all encephallitis in the united states is from herpes."---from
: MTB.So if you suspect encephalitis,be very careful to give empiric
: antibiotics.
:
: analysis.
| a*****o
发帖数: 174 | 10 but waiting for CBC w/ diff takes 30 mins in in-patient setting, one hour in
out-pt setting:
Would it be appropriate to delay abx treatment in bac. meningitis for 30
mins to see the white count? Or, should give empiric abx immediately after
blood C/S is drawn while waiting for CBC, then CT -->LP?
plz advice me if i'm wrong about below:
the point in bac. meningitis is
a) abx proceeding all treatment methods (but after blood c/s)
b) CT proceeding LP to look for possible herniation
leukocyte
plus
【在 l********z 的大作中提到】
: I think we can first do CBC stat, and obtain the result of CBC, if leukocyte
: very high with left shift, then consider bacterial infection and then add
: antibiotics. But if CBC do not show any sign of bacterial infection, then
: consider virus infection and go ahead with LP.
: The case usually give out the very obvious result and clinical symptoms plus
: signs for us to differentiate the bacteria or virus infection.
: They do not want us to give antibiotics without any thought.
| | | a*****o
发帖数: 174 | 11 请前辈说说如果CT结果真的有high ICP的可能，在meningitis/encephalitis的病人接
下去咋处理呢？delay LP？
【在 A*******s 的大作中提到】
: You have to do a CT first, then LP.
: Why? Herniation if the 4th ventricle is not open.
:
: cases
: But
| l********z
发帖数: 810 | 12 If physical exam show ICP signs or neurological signs, you should do CT
before LP. If not, then go straight for LP. | l********z
发帖数: 810 | 13 You are right, we should give antibiotics immediately after draw blood
culture. Do not need wait for CBC result.
in
after
【在 a*****o 的大作中提到】
: but waiting for CBC w/ diff takes 30 mins in in-patient setting, one hour in
: out-pt setting:
: Would it be appropriate to delay abx treatment in bac. meningitis for 30
: mins to see the white count? Or, should give empiric abx immediately after
: blood C/S is drawn while waiting for CBC, then CT -->LP?
: plz advice me if i'm wrong about below:
: the point in bac. meningitis is
: a) abx proceeding all treatment methods (but after blood c/s)
: b) CT proceeding LP to look for possible herniation
:
| l********z
发帖数: 810 | 14 I think the CCS will give us very obvious sign of herniation. If so, then go
straight for neurosurgery.
【在 a*****o 的大作中提到】
: 请前辈说说如果CT结果真的有high ICP的可能，在meningitis/encephalitis的病人接
: 下去咋处理呢？delay LP？
| A*******s
发帖数: 9638 | 15 I will never do a LP without a scan(CT or MRI) in practice.
It does not matter if ICP high or not. As long as the 4th ventricule is open
, you can go ahead for LP. In fact, we always see high opening pressures in
meningitis patients. For pseudotumor cerebri, the opening pressure is also
high. We tap them all the time.
However, if there is a space occupying lesion like tumor on the scan, do not
tap them without checking with NSG.
【在 a*****o 的大作中提到】
: 请前辈说说如果CT结果真的有high ICP的可能，在meningitis/encephalitis的病人接
: 下去咋处理呢？delay LP？
| a*****o
发帖数: 174 | 16 谢谢A++ 和lingz MM。
喃喃地说：不知道CCS里的开颅手术咋开order。。。 | f*****w
发帖数: 1451 | 17 I think in case of increased intracranial hypertention.we need to hyperventilate
pt, mannitol.
【在 a*****o 的大作中提到】
: 请前辈说说如果CT结果真的有high ICP的可能，在meningitis/encephalitis的病人接
: 下去咋处理呢？delay LP？
| f*****w
发帖数: 1451 | 18 Neurosurgen consult.craniotomy.preop prep?
【在 a*****o 的大作中提到】
: 谢谢A++ 和lingz MM。
: 喃喃地说：不知道CCS里的开颅手术咋开order。。。
| A*******s
发帖数: 9638 | 19 Fionaww is right.
You can not measure ICP without a LP.
think in case of increased intracranial hypertention.we need to
hyperventilate
pt, mannitol.
【在 f*****w 的大作中提到】
: Neurosurgen consult.craniotomy.preop prep?
|
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