From the Guidelines
An emergent lumbar puncture in the ER is required when there is suspicion of bacterial meningitis, subarachnoid hemorrhage without diagnostic CT findings, or certain cases of increased intracranial pressure requiring therapeutic drainage, and should be performed immediately after blood cultures are drawn and empiric antibiotics administered, without delay for a CT scan unless there are clinical signs suggestive of a shift of brain compartments, such as focal neurological signs and a reduced GCS, as indicated by a Glasgow Coma Score of ≤12 1. The decision to perform an emergent lumbar puncture is based on the potential for severe neurological damage or death if the underlying condition is not promptly diagnosed and treated.
- The most common conditions requiring an emergent lumbar puncture include:
- Bacterial meningitis
- Subarachnoid hemorrhage without diagnostic CT findings
- Certain cases of increased intracranial pressure requiring therapeutic drainage Before performing the procedure, it is essential to ensure that there are no contraindications, such as:
- Increased intracranial pressure with risk of herniation
- Infection at the puncture site
- Coagulopathy
- Thrombocytopenia (platelets <50,000) A fundoscopic exam should be performed to check for papilledema, and if increased intracranial pressure is suspected, a CT scan should precede the lumbar puncture, as indicated by clinical signs suggestive of a shift of brain compartments, such as focal neurological signs and a reduced GCS, as indicated by a Glasgow Coma Score of ≤12 1. The urgency of the lumbar puncture is justified by the potential for severe neurological damage or death if the underlying condition is not promptly diagnosed and treated, and the benefits of prompt diagnosis and treatment outweigh the risks of the procedure, as supported by studies showing that delays in antibiotics can lead to increased mortality 1.
From the Research
Conditions Requiring Emergent Lumbar Puncture (LP) in the Emergency Room (ER)
- Bacterial meningitis is a medical emergency that requires prompt antibiotic treatment and may necessitate an emergent LP 2
- Severe bacterial meningitis may benefit from lumbar drainage as adjuvant therapy, in addition to standard treatment with antibiotics and steroids 3
- Patients suspected of bacterial meningitis should receive empirical treatment with antibiotics before undergoing a CT scan or LP, as delays in antibiotic administration can worsen outcomes 4
- In children under 18 months, LP is indicated if signs suggestive of meningitis are present, or if the child has had a complex febrile seizure, prior antibiotic treatment, or is not properly vaccinated against Haemophilus and Streptococcus pneumoniae 5
- In critically ill patients, LP for suspected meningitis is likely to change management, particularly if meningeal signs are present or if the patient is already on antibiotics 6
Key Considerations for Emergent LP
- Prompt antibiotic treatment is crucial in cases of suspected bacterial meningitis 2, 4
- CT scans should not delay antibiotic treatment, but may be necessary in selected patients to rule out contraindications to LP 4
- Lumbar drainage may be a useful adjunctive therapy in severe bacterial meningitis 3
- Clinical symptoms and signs, such as meningeal signs and complex febrile seizures, can guide the decision to perform an emergent LP 5, 6