phuluong2k
Forum Fanatic
Topics: 714
Posts: 2,008
|
8 month old male, 3 days a go has otitis media treated with oral amoxicillin
Brought to ED with vomitting, decrease urine output. PE/ T = 40°C, P = 80/mn, RR = 40/mn, irregular, BP = 100/60, lethargic, arousable only to painful stimuli, full & tense anterior fontanel, red & pulging tympanic membranes.
What is the next step of management ?
A. Lumbar puncture
B. IV amoxicillin
C. CT scan of brain
D. Start cefotaxime
|
| nisha
Forum Guru
Topics: 146
Posts: 919
|
D pt. sounds pretty toxic so begin treatment?
___________________
IM resident
|
| pgn
Forum Senior
Topics: 8
Posts: 35
|
yes i too feel the same start iv.ceftraixone
|
| frontal
Forum Guru
Topics: 53
Posts: 421
|
What do you all think has happened and how do you explain the decreased urinary output? Vomitting leading to dehydration, ?toxemia leading to shock (?endotoxic shock) or something else? 
|
| drvic
Forum Elite
Topics: 10
Posts: 181
|
you have to do a CT first because of raised ICT and the possibility of
(i) Cerebral venous sinus thrombosis sec to dehydration (due to vomiting)...
(ii)since an ear infection is pre-existing, CT would also help rule out an associated brain abscess....that brain abscess could have ruptured causing acute deterioration, increased ICT and Vomiting...leading to dehydration...progressing towards shock and pre-renal failure....
LP is definitely contraindicated with raised ICT here...do a CT first.
the other two choices pertain to the choice of antibiotics - IV amox is out of consideration straightaway - its not good enough for meningitis treatment. about IV cefotax, one may consider on the basis of clinical impression of meningitis...but CT is more important right now to rule out other things....
decreased urine output would be seondary to dehydration leading to diminished perfusion of the kidneys - giving fluid boluses would restore circulatory insuffieciency and correction of dehydration would improve the urine output, if not - its pre-renal type of renal failure...secondary to dehydration and sepsis.
___________________
say what you mean... and mean what you say...
|
| chemamr
Forum Hero
Topics: 703
Posts: 4,462
|
i go with D, too.
___________________
Any time something is written against me, I not only share the sentiment but feel I could do the job far better myself.
|
| phuluong2k
Forum Fanatic
Topics: 714
Posts: 2,008
|
The given answer is D IV cefotaxim with explanation that can not delay antibiotics due to CT & lumbar punction.
I' ve done this q wrongly, Does the delay time due to CT scan & lumbar puncture can alter the prognosis of this presumed bacterial meningitis ?
|
| Renegade
Forum Elite
Topics: 18
Posts: 171
|
frontal wrote:What do you all think has happened and how do you explain the decreased urinary output? Vomitting leading to dehydration, ?toxemia leading to shock (?endotoxic shock) or something else?
Toxemia. Notice: if he was THAT dehydrated, there's no way the fontanel could have been not only tense but also full. Basic dehydration sign.
I do think there's more than what meets the eye here. Seems there's a case of otititis going meningitis. I wonder if the mother did the treatment as she was told... if NOT (maybe social case, she couldn't afford the medicine or sumthin) then the suspicion of Strep pneumo meningitis isn't low at all, right? With otitis in the background? Either that or a very nasty strain of Strep pneumo... Should these be the case, I'd go for Vanco myself, which might be advised for all severe meningitis with S p suspicion.
___________________
«The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.» W. Osler
|
| frontal
Forum Guru
Topics: 53
Posts: 421
|
I agree that treatment should be commenced immediately. drvic has appropriately pointed out the contraindication for LP. The disease has progressed despite treatment with oral amoxicillin so there's no point in trying the same drug again even if you have doubts regarding which of the two mentioned drugs is preferable in a case of meningitis.
Will meningitis cause bulging fontanels even in the face of such severe dehydration as pointed out by Renegade? Toxemia is certainly possible.
|
| Dot
Forum Senior
Topics: 1
Posts: 168
|
I think Next step in management here is I.V Cefotaxim.After that pt should betaken for CT scan as pt hs raised ICT(buldging frontenelle) so LP is contraindicated.Toxemia is certainly possible here as per information in this qus.
___________________
have fun
|
| d_raza1
Forum Senior
Topics: 32
Posts: 92
|
I think although raised intracranial pressure is a C/I for LP but with few exceptions (one is meningitis). It can be done cautiously, after giving mannitol and CSF not allowed to come out freely rather very slow withdrawl will be ok.
|
| aitzaz141
Forum Newbie
Topics: 0
Posts: 3
|
drvic u r forgetting something here whenver u have raised icp and sometime before ct u go for 3rd generation cephalosporins and then go for ct so i ll go for choice D
|
| doc26inder
Forum Elite
Topics: 32
Posts: 97
|
this is from Oxford hand book
" if u suspect ur patient has Meningitis and are outside hospital , nothing must delay blind therapy with IV/IM benzypenicilllin 1.2 g while awaiting transport . If possible do bld culture first . In hopital bld cultures and bld glucose are essential for accurate diagnosis but must not delay emperical Antibiotic therapy . Do not wait for the ward round , expert advice or test results : delay may be fatal . Act now don't worry about future cricisim : you may end up with live patient on your side "
|
| dr.vasim
Forum Senior
Topics: 4
Posts: 61
|
HI frnds .. THE ANSWER was TOOOOOOOOOOOOO eazy .... n i dont know whaz worryin U guys so much .. NO MATTER WHETHER THE KID IS VOMITING, NO MATTER WHETHER HE IS IN SHOCK, etc etcccccccccc...... as soon as U see the patient with this PE n HX, just start IV cephalosporins .. this is what I hv learnt from My practise in PEDIATRICS since 2yrs
anywez good discussion ... Keep it UP !
___________________
with Almighty GOD life is simple & everything Possible.
|
|
| |
| | | | | | | | | | | | | | |
