As a paramedic attending a patient it is important that all presenting conditions, signs and symptoms are adequately assessed using the tools available to paramedics. Along with the assessment a thorough history must be obtained to identify the main presenting problem so appropriate management and treatment can be implemented.
Through the limited information provided it has been determined that the patient is presenting with signs and symptoms of meningococcal disease.
Patient presentation of meningococcal disease will generally present with typical triad of symptoms such as fever, intense headache and altered conscious state. However one of the clearest and most important signs of meningococcal is the petechial or purpuric rash on the trunk and limbs. Other signs and symptoms of meningococcal are joint pain, photophobia, general malaise and lethargy, hypotension and/or tachycardia (Victorian Department of Health, 2009).
Meningococcal disease has two main clinical presentations which are meningitis which is an inflammation or infection of the meninges and affects the cerebrospinal fluid within the subarachnoid space. The second presentation is septicaemia which is a systemic infection present in the blood caused by an infection which started in another part of the body (Harris, Nagy & Vardaxis, 2006).
Meningococcal disease can occur at any age with babies and young children under the age of five at most risk, it should be noted that susceptibility decreases with age however there can be a secondary peak of infection which occurs in adolescents and young adults aged between 15 – 24 years of age (Victorian Department of Health, 2009).
As our patient is presenting with the classic signs and symptoms of meningococcal disease and is within the relevant age group for increased susceptibility it is important that as paramedics we treat the patient in accordance with the clinical practice guidelines keeping the “pay off” principle in mind. Meningococcal disease can result in death from cardiovascular failure or increased intracranial pressure.
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Treatment of meningococcal in accordance with Ambulance Victoria Clinical Practice Guidelines is to confirm meningococcal septicaemia by confirming a purpuric rash, headache, fever, joint pain, altered conscious state, hypotension and/or tachycardia. Ceftriaxone is to be given either intramuscularly or intravenously and is considered as a chemoprophylaxis for meningococcal as it has excellent activity against Neisseria species. Neisseria meningitides is the bacteria which causes meningococcal infection (Ambulance Victoria, 2009).
Encephalitis – is a viral infection of the brain which may occur after an infection such as chickenpox, measles or influenza. Clinically there is little difference between encephalitis and meningococcal disease as they both present with a headache, fever and altered conscious state, however a patient with encephalitis will have seizures and paralysis and no purpuric rash. Further investigations at hospital such as a CT scan, lumbar puncture and spinal fluid analysis is required to definitively diagnose a patient with suspected encephalitis. (Cameron, Jelinek, Kelly, Murray, Brown, 2009)
Subarachnoid haemorrhage – a patient presenting with a subarachnoid haemorrhage will be complaining of a severe headache and may present with an altered conscious state with lucid intervals, neck stiffness and abnormal pupils. Syncope and seizures are common along with hypertension and bradycardia. As our patient is not presenting with seizures, abnormal pupils, hypertension or bradycardia then as paramedics we may be able rule out a subarachnoid haemorrhage however it is strongly recommended that further investigations at hospital occur to definitively rule out a subarachnoid haemorrhage (Caterino & Kahan, 2003).
Heat Stroke – is when the body’s core temperature is above 40°C. A patient will present with an altered conscious state, high body core temperature, tachycardia and anhidrosis. A rash may be present due to the blockage of sweat glands. Based on the information provided our patient is exhibiting a fever and further investigation such as obtaining a detailed history of activities (prolonged heat exposure) and taking a tympanic temperature would need to undertaken to rule out possible heat stroke (Caterino & Kahan, 2003).
CVA/Stroke – there are two classifications of stroke. The most common stroke is the ischemic stroke which occurs when cerebral blood flow is interrupted and the second most common is hemorrhagic stroke. The patient will present with a headache, decreased conscious state, progressive deficits such as parethesias, visual disturbances and numbness. Information provided indicates that our patient does not have progressive deficits however as paramedics we would rule out stroke by referring to using the FAST stroke assessment on the patient (Kahan & Ashar, 2009).
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Anaphylaxis – is a severe overwhelming systemic allergic reaction which presents with urticaria, angiodema, nausea and vomiting, respiratory distress, poor perfusion and altered conscious state leading to loss of consciousness. A thorough history from the patient would indicate any past history of allergies or anaphylactic reactions. As our patient has no past history and limited clinical presentations of anaphylaxis, then treatment of the patient should be in accordance with the main presenting problem (Caterino & Kahan, 2003).
Migraine/headache – a patient suffering from a migraine will present with dull and deep pain which is exacerbated during movement of the head. The patients’ conscious state is not affected and the patient will often have a past history of the illness (Cameron et al., 2009).
Kernig’s sign and Brudzinski’s sign are to be used in conjunction with each other in determining meningism. However it should be noted that these signs are only present in 50% of suspected adult cases. Kernig’s sign is performed with the patient lying supine with legs raised and the knee is to be extended. Failure to extend the knees is considered to be a positive sign of meningism due to the spasming of the hamstrings. Brudzinski’s sign is when the head is flexed causing the thighs and knees to also flex. These signs are thought to be caused by irritable motor root nerves which pass through the inflamed meninges causing tension in the roots (Cameron et al., 2009).
The Meningitis Research Foundation and the Joint Royal Colleges Ambulance Liaison Committee in the United Kingdom have developed an identification and management protocol of meningococcal septicaemia for ambulance personnel. The protocol starts with the assessment of airway, breathing, circulation and conscious state and then includes exposure and observation which is a simplistic secondary survey that primarily looks for a rash. The protocol states that the rash will be purpuric and will not fade or blanche if a glass is pressed firmly against rash, the rash will remain visible through the glass. Other signs and symptoms are given such as raised respiratory effort, tachycardia, poor capillary refill, vomiting/nausea, painful joint and limbs as often not all signs and symptoms will be present. Management of the patient with suspected meningococcal septicaemia in accordance to the protocol is as follows:
- High flow oxygen (assisted ventilations as required)
- Load patient and transport to nearest hospital.
- Give benzylpenicillin in transit (Infant 300mg, small child 600mg, large child & adult 1200mg)
- Treat for shock during transport with a bolus of crystalloid (children 20ml/kg and adult 250ml bolus). Re-assess vital signs before repeating dose. It should be noted that no more than 3 boluses of crystalloid for children and a maximum of 2 litres for adults.
- Alert hospital of patient and give relevant history.
Benzylpenicillin commonly known as penicillin G is used as it is an antibiotic considered to be the “gold standard” of penicillin to be used for the treatment of group B streptococci, non- Î² lactamase producing staphylococci (Meningitis Research Foundation, 2008).
As paramedics this assignment highlights the importance of obtaining a thorough past history, current history and chief complaint, vital sign statistics and any other relevant information such as temperature, medications and secondary surveys to ensure that an accurate assessment of the patient can occur. A thorough assessment allows the paramedic to implement the right management and treatment for the patient until they reach definitive care and treatment at a hospital.
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