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Karen Farbman wrote:
Does anyone routinely obtain a heat CT on teen-agers before the LP, as our
adult
ED colleagues do?  Outlined in Annals of Emer Med this year is a headache
CPG
which lists this as a guideline over age 14, I believe.
-
 
Karen:
 
No, I personally don't get a CT iff:
- No focal deficits on neurologic exam
- Sharp discs
- No altered sensorium
- No suspicion of a coagulopathy or IC bleed or h/s/o SAH
 
All cases of meningitis have some elevation of their ICP (which causes their
HA, emesis photophobia etc). Whether their CT shows edema or not, by
definition their opening pressures are going to be elevated! What one is
really determining with a CT is any focal pathology with "midline shift" or
significant ICP elevation from diffuse cytotoxic cerebral edema (as in
fulminant meningitis). Both these situations, I believe, can be discerned
with a careful neurologic examination and using the screening criteria I
mentioned above.
 
I am not aware, at least from the recent pediatric literature, any case of
post mortem proven herniation following an LP in a patient with suspected
meningitis who was clinically awake, without FND or papilledema. Moreover,
was the herniation from meningitis or the LP???  I will have to check the
older literature. Is there a threshold ICP beyond which the risk of
herniation increases?????
 
Which issue of Annals are you referring to? I think we will be getting a
whole lot of CT's if these CPG's are promulgated!!! My intuition makes me
disagree with this CPG.
 
Hope this helps. Will report back if I find something on a literature
search.
Jay Pershad, M.D.
"We care for wee folks"
 
 
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