Meningitis and encephalitis: SAQ

This preschool child has fever, neck stiffness, and a reduced conscious state — the adult-literature triad elements — plus a non-blanching petechial rash that is a NICE red flag for meningococcal disease. Delayed capillary refill marks early shock. This is a time-critical resuscitation and first-hour antibiotic scenario, not a wait-for-the-tap scenario. ^[2]

Question 1 (10 marks)

Outline your immediate assessment and investigation plan, including whether lumbar puncture should be done before antibiotics. ^[2]

Begin with airway, breathing, and circulation and an overall sick-or-well judgement. Record heart rate, blood pressure, capillary refill, oxygen saturation, and a paediatric Glasgow Coma Scale. Confirm that the rash is non-blanching with the glass test, and look for focal neurology and signs of raised intracranial pressure. ^[1]

Obtain intravenous access at once. Draw a blood culture, full blood count, C-reactive protein, glucose, electrolytes, and a coagulation screen. NICE: antibiotics start within 1 hour of hospital arrival. Do not delay the first dose for imaging or lumbar puncture if either would cause a clinically significant delay. Auburtin (adult ICU pneumococcal meningitis) found an interval of more than 3 hours independently associated with death — not an "every hour doubles mortality" rule. ^[2][4]

Her GCS is 14, so NICE's "GCS of 9 or less" lumbar-puncture deferral is not met on coma score alone. Do not perform lumbar puncture if there is extensive or rapidly spreading purpura, new focal neurology including seizures or posturing, or a GCS of 9 or less. Take bloods, give antibiotics, and stabilise before imaging. Measure blood glucose immediately before any lumbar puncture so the cerebrospinal fluid to blood glucose ratio can be calculated. Send fluid for cell count, glucose, protein, Gram stain, culture, and meningococcal polymerase chain reaction. ^[2]