Do not perform lumbar puncture; nil by mouth

  • ABC & high flow oxygen (minimum 10 l/min) by face mask
  • Insert 2 large IV cannulae (or IO)
  • Take bloods:
    • for blood gas (bicarb, base deficit), lactate, glucose, FBC, U&E, Ca++, Mg++, PO4, clotting, CRP, blood cultures, whole blood (EDTA) for PCR, X-match.
    • Take Throat swab.
    • If limited blood volume, prioritise blood gas, lactate, glucose, electrolytes, FBC, clotting.
  • Give 0.25g/kg bolus of 20% mannitol or 3ml/kg hypertonic saline (3% or 2.7% as available) over 5 minutes
  • Treat shock if present

Call anaesthetist and contact PICU:

  • Intubate and ventilate to control PaCO (4-4.5 kPa)
  • Urinary catheter and monitor output, NG tube
  • Do not perform lumbar puncture

Neuro-intensive care

  • 30˚ head elevation, midline position
  • Avoid internal jugular lines
  • Repeat mannitol or hypertonic Saline (3% or 2.7% as available) if indicated
  • Sedate (muscle relax for transport)
  • Cautious fluid resuscitation (but correct coexisting shock)
  • Monitor pupillary size and reaction
  • Avoid hyperthermia
  • Once patient is stabilised, consider CT scan to detect other intracranial pathology if GCS  below 9, fluctuating conscious level or focal neurological signs.

Stepwise treatment of seizures

  • IV lorazepam (0.1 mg/kg) or midazolam (0.1 mg/kg) bolus
  • Consider paraldehyde (0.4 ml/kg PR)
  • Phenytoin (18 mg/kg over 30 min IV with ECG monitoring)

If persistent seizures:

  • Thiopental (thiopentone) 4 mg/kg in intubated patients (beware of hypotension)
  • Midazolam/thiopental infusion

Perform delayed LP when stable and no contraindications.

Bacterial meningitis algorithm

Go to Management of bacterial meningitis in children and young people algorithm.