Menningococcal Septacaemia

[jmac]

air,

what i was speaking about was dust referencing TB, he is right, but we do not admin AB treatment for TB, we have cases here also, previously eradicated versions that have not been seen since the 50's and 60's , but the difference is that Meningococcal Septicaemia is a rapid killer, therefore AB admin in the field is important while TB, just as much a killer but slower.

This is a thread about admin of AB's and recognition for admin of said AB's. while infection control is of the utmost importance, it should in my opinion be a done deal, it is here. It is the doc's here that called for pre-hosp admin of AB's, we have our own guideline on recognition and admin and is part of our training, also we are licenced practitioners and the onus for continued medical education is on ourselves as professionals, to the delight of management, and we have a requisite amount of hours training per year, not a couple of hours in a firehall as dust says. (thats a quote dust not a slag off)

To us it makes sense, i am all for education, actually have some myself, but the approach is different here, and the recognition, different strokes for different folks, i have respect for all my fellow professionals in the states at all levels, but things changed here, it seems by all acoounts in discussion that things are not changing in the states, and if there are some, they are not across the board and vary from state to state, though the US started pre-hosp care, countries outside have picked up the flag and are trying to carry it forth, gone are cook-book medics and big overflowing drugbags, today its more if it looks like a duck, walks like a duck and quacks like a duck....hit it with both barrels and break out the plum sauce, back to basics and build on it........agree to differ here.

[air.stump]

Jmac, I'm with you on this one. I understand the pathophysiology of meningitis and can understand the need for field AB. Under what other circumstances do you guys start field AB therapy?

[jmac]

none air,

strictly a once off, may change in the future but now just suspected cases men-sep, AB's and fluids, the thinking is to get it started because of the wait in A&E, better to have it started.

[Dustdevil]

Jmac, agree with everything you just said. No disagreement at all from me.

I understand the pathophysiology of meningitis and can understand the need for field AB.

Sure, but are you still willing to stake your reputation and life on the assumption that "most EMS providers of all levels" understand as well as you do? That's really the crux of my contention.

[air.stump]

I would not stake my reputation on the assumption that most EMS persons have the same understanding as I do. I do feel that they have the ability to learn and come to the understanding of what it is, what it looks like and how to competently treat it.

[chbare]

Hmm, hard to say. It can fool us in the hospital as well. I know many people have CT's to rule out SAH prior to receiving their LP. Multiple conditions can masquerade as meningitis. At this point, I am still concerned that many providers would simply shot gun patients with ABO therapy.

Take care,

chbare.

[Doczilla]

Regarding meningitis:

N. Meningitidis is decreasing in incidence. The petichial rash is more typical of n. meningitidis than other agents. Strep pneumo comprises the majority of meningitis cases in the US. Rocephin (ceftriaxone) and vancomycin are the standard first line drugs here. An important point is that steroids (usually decadron [dexamethasone]) should be administered with the first dose of antibiotics to blunt the inflammatory cascade that comes from mass bacterial killing, and studies show reduced morbidity with meningitis when this is done. The lumbar puncture and cultures are helpful, but have to be balanced against the need for early treatment. Antibiotics may kill off bacteria evident on CSF gram stain, but may not eliminate the eventual culture of the organism, and will not mask the evidence of bacterial infection in the CSF (high protein, WBCs, low glucose), allowing the diagnosis to be reliably made. Therefore, cultures and LP should not delay treatment.

As far as giving antibiotics in the field, there is far more to this than just "can we do something to help?"

Adding any medication to a medic's armamentarium includes substantial risk and cost. There is the cost of stocking the medication, monitoring and replacing it when it expires, and initial and ongoing training. There is then the risk, not only of improper application of the medication, but of the chance of medication errors (selection of the wrong medication when they meant to administer something else, wrong dose, etc.).

Based on the number of patients with clinically obvious bacterial meningitis who present to our ER (86 beds, 100,000 pts/year), I do not expect that most medics would see this patient in their career. I have yet to see one like that, though I have seen several cases of meningitis. Patients who fit this description are rare enough in our area that they constitute an "interesting case", that when they do occur, they are discussed with some interest among the EM, IM, and ID docs (emergency med, internal med, infectious disease).

So with the rarity of this patient presentation, the minimal benefit of administering the antibiotic only slightly earlier, and relatively high chance of an error of medics having a drug that they administer extremely rarely, I don't think it's worth it in the systems I work with.

'zilla