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Contemporary paramedic practice involves working with up to date knowledge in order to be able to treat accordingly. Knowing the pathophysiology of meningitis ensures effective management and treating with therapeutic intervention to the required level. This case study outlines how meningitis affects the body and how it presents as clinical symptoms and signs. Additionally it describes why the symptoms occur and the pathology behind these. Epidemiological data is also outlined and referenced through to put a perspective on the relevance and those most at risk. Finally therapeutic interventions are outlined, what they are expected to do in order to improve the outcome for the patient.
A 4 year old presented at a doctor's surgery dehydrated and lethargic an ambulance was then called for an emergency transfer to hospital. The Mum of the child had expressed she usually gets up at 7am and had not woken until 10am. As the Mum went in to wake up the child she saw the patient had been sick in the night and was unrousable at the doctor's surgery. Upon arrival of the ambulance crew it was clear to see the patient of 4 years was acutely ill positioned in a "doll like fashion" and uninterested in her surroundings. The child displayed respiratory distress with shallow rapid breathing and showing the use of accessory muscle breathing. The patient was pale, capillary refill greater than 2 seconds with poor perfusion. Her G.C.S. was 13 upon arrival and B.M 5.7. Another sign that was seen on the child was a non-blanching rash around the lips, indicative of meningitis. The doctor had just secured an intravenous line and had administered benzyl penicillin intravenously. The clinical impression was meningitis, so an urgent transfer to hospital was made with a pre-alert being made through the doctors surgery to the receiving hospital. En route to the hospital the child was monitored on a 3-lead Electrocardiogram and baseline observations were taken. Additionally to the benzyl penicillin, oxygen, fluids and Paracetamol were also administered. Upon arrival as a pre-alert had been sent via the doctor's surgery the paediatric team were waiting in a resuscitation bay ready for a handover.
Meningitis is defined as the inflammation of the membranes if the brain or spinal cord-Meningitis Research Foundation. Meningitis can develop from different pathogens bacterial or viral. Viral meningitis is more common and less serious than bacterial meningitis. Meningitis can result in septicaemia if left untreated as it is caused by the same bacteria they can occur together or as separate cases. "In the U.K 3,500-4,000 cases are reported each year"-Department of Health. It is most prevalent in neonates and younger children with 17 cases being reported in the South-East of England alone in Children aged between 1-4 years old in the years of 2008-2009-Health Protection Agency. There are two types of meningitis viral and bacterial. Neisseria meningitis is the most common form of bacterial meningitis in children-Department of Health. To diagnose meningitis a lumbar Puncture to drain cerebrospinal fluid, to detect the white blood cell count, proteins and viruses present. The bacteria often start in the Naso-pharynx epithelium and are non-symptomatic. As the bacteria pass through the mucosa in the Nasopharyngeal epithelium lining to the bloodstream endotoxins are released. Endotoxins are toxins released from cells which create an inflammatory response. Within the blood vessels this causes damage to the endothelium lining as the endotoxins move against the endothelium lining causing a move of blood from the intra-vascular compartments to the extra -vascular compartments. As the bacteria travel in the circulatory system they cross the blood brain barrier into the cerebrospinal fluid. - Meningitis Research Foundation
The blood brain barrier is in the capillaries around the brain supplying it with essential substances such as oxygen and glucose It also acts as a protection mechanism to the brain to stop toxic substances from entering the brain and the surrounding cerebrospinal fluid within the central nervous system. In order to stop the transport of cells from passing into the cerebral bloodstream is in the structure of the blood vessels themselves. The cerebral blood vessels have the cell walls packed closely together to form a barrier against potentially harmful molecules such as toxins from passing across into the brain. -Biopsychology.
Within the subarachnoid space the bacteria multiply in the cerebrospinal fluid due to the supply of nutrients and low levels of anti-bodies. Cerebrospinal fluid increases whilst inflammation of the membranes surrounding the brain occurs. The patient subsequently becomes at risk of a reduction of cerebral perfusion, cerebral infarction and consequently brain death-Meningitis research foundation 2006. The patient is likely to be in the early stages of shock initially and compensating. Pathological consequences of the inflammatory mediators act locally at the site of infection, causing the cerebrospinal fluid to respond. Proteins and fluid leak out of the brain causing an increase in intracranial pressure resulting in a reduction of cerebral perfusion.
The clinical presentation results in the body compensating as the reduction of circulating volume of blood, causes the heart rate and contractility to increase to try and perfuse the main organs. The cardiac output is reduced resulting in hypotension, cool peripheries, tachypnoea and lethargy. As compensation for the reduction in circulation continues blood flow to the brain is being maintained at a premium. As time passes progression of the bacteria increases and compensatory mechanisms decrease, as physiological shock progresses. As cerebral blow flow is altered, cerebral spinal fluid increases, cerebral oedema also occurs as the blood capillaries leak causing hypoxia-Meningitis research foundation 2006.
As the bacteria begin to invade the body, each body system in turn displays distinctive clinical presentations. Often meningitis symptoms start with "menigial symptoms" such as a headache and photophobia caused by an increase of cerebral spinal fluid in the subarachnoid membranes," the brain tissue becomes squeezed against the inflamed menigies"-Meningitis Lorrie Klosterman. As the blood flow reduces the cardiac output is decreased causing an increase in heart rate and pulmonary oedema due to capillary leaks from vascular damage caused by the endotoxins and progression of shock. Falling levels of consciousness measured using the Glasgow Coma Scale occur due to altered cerebral blood flow, brain metabolism and acidosis from septicaemia from altered levels of shock. Confusion and levels of consciousness can also present in the patient as the bacteria destroy the neurons responsible for body function as they communicate through chemical messages-Meningitis Lorrie Klosterman. Blood sugars must be obtained and documented as hypoglycaemia is common due to acidosis from septicaemia in the later stages of shock. Metabolism disarrangements can also trigger hypokalemia and hypocalcaemia -Meningitis research foundation 2006. A non-blanching purpuric rash in some not all cases of meningitis can also develop. Clinically tachycardia, cool peripheries and hypotension result as hypoxia, metabolic disarrangements and endotoxins produce a reduction in myocardial function. Renal failure can also be indicative of meningitis as hypovolemia causes urine retention or little output. As the bacteria damage the endothelial cells, it activates a clotting system to restore the damage in the lining of the skin. This causes intravascular coagulation of the endothelium cells which pathologically presents as a purpuric non-blanching rash. In the case study this is seen in the patient around her mouth, presented as purple spots around her lips which is an indicative sign of meningitis-NICE Clinical Guidelines 2010.
Management of the case.
As Paramedics follow guidelines set by the Joint Royal Colleges ambulance Liaison Committee-JRCALC, the treatment given is stated in the JRCALC Guidelines 2006 and indications outlined for treatment.
Benzyl penicillin was administered due to the indicators and clinical presentation of meningococcal disease. Benzyl penicillin is a Î²-lactam antibiotic that breaks down various bacteria which include Neisseria bacteria. Benzyl penicillin is administered slowly intravenously preferably, rather than intramuscularly due to poor absorption but can be administered intramuscularly if rapid access can't be gained in the emergency setting-JRCALC Guidelines 2006. Benzyl penicillin inactivates an enzyme that is crucial for bacteria cell growth and reaches its peak within 15-30 minutes of administration-Electronic Medicines Compendium 2008. This enzyme is known as peptidoglycan transpeptidase; the Benzyl penicillin causes the pressure in the bacterial cell to rise until the cell lyses and is destroyed. Peptoglycan chains are created for strength during cell wall synthesis of the bacteria. Benzyl penicillin bonds to the Peptoglycan chain, forming a peptide cross-link. This causes a weak cell bridge and preventing new bacteria cells from entering the chain or forming. Osmosis causes lyses which destroys the remaining bacteria- Bicillin LA, Wyeth, 1994.The earlier the recognition of symptoms that faster treatment can begin to try and destroy the bacteria. Time of treatment can vary between individual cases, some can be treated over 10 days others depend upon factors such as possible raised intracranial pressure and possible sepsis. Pre-hospitably the guidelines for JRCALC Guidelines 2006 are adhered to and clinical indications of meningitis are treated through an ABCDE approach and an initial dose of Benzylpenicllin is administered as early as possible.
Various side effects from Benzyl penicillin are sudden hypotension-JRCALC guidelines 2006 due to sudden release of toxins into the bloodstream from the displacement and destroying of them. This is another reason for fluid administration continuation as the Benzyl penicillin is released slowly, so hypotension is likely to continue, resulting in poor capillary perfusion. Other side effects include gastro-intestinal upset and hypersensitivity-JRCALC guidelines 2006.
Paracetamol has anti-pyretic features as it works on the hypothalamus of the brain. It works by blocking the production of prostaglandins which transmit messages to the brain-electronic medicine compendium 2008. Oxygen was administered to counteract hypoxia, to increase the levels of inspired oxygen. Side effects can include irritation and drying to mucous membranes over a period of time-JRCALC Guidelines 2006. As the transfer time was over a period of 15 minutes, the decision to continue high flow oxygen administration to the child was made, as this is a protocol guideline for paediatrics to have oxygen administered at high flow. Oxygen was administered to maintain the oxygen saturation levels and reverse hypoxia due following guidelines by JRCALC Guidelines 2006.
Intravenous fluids were administered as signs of physiological shock were evident with the decreasing amount of circulation blood as circulatory collapse was advancing -NICE Clinical Guidelines 2010. The patient was shivering and cold to touch, had rapid shallow breathing and a decreasing level of consciousness. Intravenous fluids were also administered to ensure circulating blood flow was maintained and dehydration corrected. The amount of fluids were titrated to how the patient presented, as the patient's condition did not improve, blood pressure continued to decline, level of consciousness remained the same and perfusion did not improve. Boluses of fluids were given 20ml/Kg over the 5-10 minutes-JRCALC 2006 and the patient's condition was reviewed and fluid administered until patient handed over to the receiving clinician.
For pre-hospital clinicians it is crucial they are aware of the signs and symptoms and collating an accurate history in order to treat effectively. It is reported than 10% of cases of meningitis results in death and 15% are left with permanent disabilities-Health Protection Agency as a result of the disease such as hearing loss, sight loss and brain damage. Hopefully the recovery of the patient in this case study is a hopeful one. Detail has been removed from this case description to ensure anonymity.