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PED-EM-L  June 1998

PED-EM-L June 1998

Subject:

Re: CT before LP in meningitis???

From:

Harvey Louzon <[log in to unmask]>

Reply-To:

Harvey Louzon <[log in to unmask]>

Date:

Tue, 23 Jun 1998 00:54:13 -0400

Content-Type:

text/plain

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Parts/Attachments

text/plain (135 lines)

In the 'typical' cases of meningitis the literature provides compelling
evidence that LP without CT is a safe procedure.  Archer (1) did a
literature review spanning the years 1965-1991 on just this issue and
concluded that there were "no case reports, clinical trials or references=
 
of any sort supporting a causal relationship between lumbar puncture and
poor outcome in meningitis."
 
Citing a 1959 study on LPs performed on unselected patients with
papilledema or documented ICP > 240 the rate of adverse outcome was only =
 
6%.  The reported rates of adverse outcomes in all patients with
papilledema following LP has ranged from 0 to 6% and this includes
patients who were subsequently found to have intracranial mass lesions.
The risks in patients with a diffuse increase in ICP such as meningitis i=
s
considerably less than this.  The author points out that the mere presenc=
e
of increased ICP is not enough to cause coning. rather an elevevated ICP
AND the presence of subarachnoid block which prevents the pressure in
the supratentorial space and thecal sac from eqiluibrating (creating a
pressure 'cone') is the deciding factor.  Patients with markedly raised
ICP such as those with pseudotumor cerebri are routinely subjected to
diagnostic and therapeutic lumbar puncture without incident.
 
In summary he suggests that 1) CT is not indictaed prior to LP in
suspected meningits UNLESS a) unconsciousness b) focal findings c)
papilledema or d) atypical features are present and 2) no sucessful
litigation (at least
in Canada over the past 15 years) has resulted from failure to procure CT=
 
prior to LP.
 
Of course, it may be true that LP is safe in meningitis but can it be
reliably distinguished clinically, a priori, from other CNS disturbances
that might have a higher risk of adverse outcome from LP such as SAH?  In=
 
many cases the answer is yes.  In the adult population SAH may present in=
 a
manner very similar to meningitis with fever, photophobia, headache
and meningismus. This is not likely to be a confounding factor in the =
 
pediatric age range, however. The likelihood of an adverse outcome by
not performing a CT initially is likely to be vanishingly small. First of=
 
all patients presenting with this constelllation of findings will
overwhelming =
 
have meningitis as a final diagnosis.  Secondly even those who do not
have a low (6%) (but admitedly) finite risk of complications. My own
experience in adults performing LPs on patients with unanticipated
rises in ICP (because of either unavailablity or misinterpretation of
the scan) has been uniformly good.  This includes one patient with =
 
a posterior fossa abscess, metastastic disease to the brain and one
patient with an opening pressure of over 600 with meningeal =
 
carcinomatosis and unappreciated hydrocephalus.
 
With respect to the original query about performing an LP in the =
 
first place in situations felt to be representative of viral meninigitis
I would make the following observation:  it is folly to rely upon
such weak epidemiological evidence as the time of year (summer)
that the patient presents to reliably exclude serious disease
and thus obviate the need for LP.
 
Secondly EVERYONE presenting with these findings should recieve =
 
antibiotics either coincidant with or prior to LP since you can not predi=
ct
 
what the CSF will actually show and you cannot afford to be wrong about
that.  =
 
 
What if the CSF shows a lymhocytic pleosctosis and normal protien and
glucose?
I treat initially (remmeber before the LP is done) and admit all of these=
 
as well.
Aseptic meninigitis is NOT synonymus with viral meninigits and a 23 hour
admission during which time the clinical picture will become clearer as t=
he
patient
is rehydrated and treated with analgesics (many have considerable HA pain=
 
in my
experience--that's what prompted the LP in the first place) is appropriat=
e.
Whether antibiotics are continued in hosptial in these cases of aseptic
meningitis until culture results are available is left up to the floor
service's
discretion.
 
Furthermore those who would keep the child in the ED and repeat the tap
in 6 hours in those presenting initially with a PMN pleocytosis have
simply too much time on their hands. It's either THAT or a reflection of
managed care interfence with good clinical practice.
 
So, in summary 1) NO CT in the absence of the indications ennumerated abo=
ve
 2) =
 
antibiotics PRIOR to LP in ALL patients with a compatible clinical pictur=
e
and
 3) hospital admission for everyone with an abnormal CSF.
 
And, incideantally, I have a very low thresh-hold for performing LP in th=
e
first place.
I have had pediatric floor residents question why I even performed an LP =
on
a =
 
patient that I have admitted for aseptic meningitis as  (they tell me)
"I saw several patients in clinic today with similar complaints and sent
them all =
 
home without LP."
 
 
h
 
 
 
(1) Archer  Computed Tomagraphy Before Lumbar Puncture in Acute
Meningitis: A Review of the Risks and Benefits.  Can Med Assoc J
1993;148:961-965
 
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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