How to manage a 46-year-old female patient with decreased level of consciousness, post-traumatic amnesia (PTA), sudden onset of vomiting, slurred speech, seizure, and hypertension, tachycardia, hyperthermia, and impaired oxygenation on room air, with a Glasgow Coma Scale (GCS) score of 9?

Management of 46-Year-Old Female with Decreased Sensorium, Seizure, and Hyperthermia

This patient requires immediate endotracheal intubation without delay, aggressive cooling measures, empiric broad-spectrum antibiotics plus acyclovir for suspected meningoencephalitis, and urgent neuroimaging after airway stabilization. 1, 2

Immediate Airway Management (First Priority)

Intubate immediately using rapid sequence induction—do not delay for any reason. 2, 3

• With a GCS of 9 (E4V2M3), this patient meets the absolute threshold for intubation (GCS ≤12 in suspected meningitis, GCS ≤8 in general critical care), and her recent seizure with ongoing altered mental status mandates airway protection. 1, 2
• The combination of vomiting, decreased sensorium, and recent seizure creates extreme aspiration risk that cannot be managed without a secured airway. 2, 4
• Maintain mean arterial pressure >80 mmHg and systolic blood pressure >110 mmHg during the peri-intubation period to ensure adequate cerebral perfusion. 2, 3
• Use waveform capnography immediately after intubation to confirm correct tube placement—never rely on auscultation alone. 2

Simultaneous Resuscitation and Stabilization

While preparing for intubation, obtain two large-bore IV lines and draw blood cultures immediately. 1

• Blood cultures must be obtained within 1 hour of arrival and before antibiotics are administered. 1
• Target hemodynamic endpoints: capillary refill <2 seconds, normal blood pressure for age (MAP >65 mmHg), warm extremities, urine output >0.5 ml/kg/hour, and normal mental status. 1
• The hypertension (160/100) and tachycardia (117) likely represent a physiologic response to increased intracranial pressure or systemic infection—do not treat the blood pressure acutely unless it exceeds 220 mmHg systolic. 3, 4

Aggressive Fever Management

Initiate immediate cooling measures for the temperature of 40°C, as hyperthermia is a secondary brain insult that worsens neurological outcomes. 1

• Use physical cooling methods (cooling blankets, ice packs to groin/axilla/neck, cold IV fluids) to target normothermia (36-37°C). 1
• Hyperthermia in the setting of meningitis/encephalitis significantly increases morbidity and mortality. 1

Empiric Antimicrobial Therapy

Administer empiric antibiotics immediately after blood cultures are drawn and within 1 hour of arrival—do not wait for lumbar puncture or CT scan. 1

• Give vancomycin PLUS ceftriaxone (or cefotaxime) to cover resistant Streptococcus pneumoniae, Neisseria meningitidis, and Listeria monocytogenes. 1
• Add acyclovir empirically given the seizure and fever, as herpes simplex encephalitis must be covered until excluded. 1
• The combination of fever, seizure, and altered mental status creates high suspicion for meningoencephalitis, which is a neurologic emergency requiring immediate treatment. 1

Seizure Management

Administer a benzodiazepine (lorazepam 0.1 mg/kg IV or diazepam 0.15-0.2 mg/kg IV) if seizure activity recurs, followed by loading with fosphenytoin or levetiracetam. 1

• Continuous or uncontrolled seizures are an absolute contraindication to lumbar puncture until controlled. 1
• Post-ictal state may partially explain the decreased sensorium, but given the fever and vomiting, infectious etiology must be assumed. 1

Neuroimaging Decision

Perform CT head immediately after airway is secured but BEFORE lumbar puncture, as this patient has multiple contraindications to immediate LP. 1

• Absolute contraindications to LP before CT in this patient: GCS ≤12, recent seizure activity, and focal neurological signs (slurred speech suggests possible focal deficit). 1
• CT is needed to exclude significant brain swelling, mass effect, or shift that would predispose to cerebral herniation post-LP. 1
• Do not delay antibiotics waiting for CT or LP—give antibiotics first, then image, then LP if safe. 1

Post-Intubation Ventilator Management

Maintain strict normocapnia (PaCO₂ 4.5-5.0 kPa or 34-38 mmHg) and adequate oxygenation (PaO₂ ≥13 kPa or ≥98 mmHg). 2, 3, 4

• Avoid hyperventilation except as a brief life-saving measure for impending herniation—it reduces cerebral blood flow and worsens outcomes. 1, 2
• Avoid prolonged hyperoxia, which may worsen neurological outcomes. 2, 3
• Use continuous capnography to maintain target PaCO₂. 2

Ongoing Monitoring and Assessment

Perform serial neurological examinations every 30 minutes for the first 2 hours, then hourly. 1

• Document GCS with all three components (eye, verbal, motor) separately, and assess pupillary size and reactivity. 1, 5
• A decrease of ≥2 points in GCS or deterioration in motor score warrants immediate repeat CT. 1
• Place arterial line for continuous blood pressure monitoring and frequent blood gas analysis. 3, 4
• Insert urinary catheter to monitor urine output as a marker of adequate resuscitation. 1

Critical Pitfalls to Avoid

• Never delay intubation to obtain CT scan—secure the airway first, as losing the airway while attempting imaging would be catastrophic. 2, 3
• Never perform LP before CT in a patient with GCS ≤12, seizures, or focal signs—risk of herniation is unacceptably high. 1
• Never delay antibiotics waiting for LP or imaging—bacterial meningitis mortality increases dramatically with each hour of delayed treatment. 1
• Never allow hypotension during intubation—this can precipitate cerebral herniation in patients with elevated intracranial pressure. 2, 3
• Never assume this is "just" post-ictal confusion—the fever and vomiting mandate treatment for meningoencephalitis until proven otherwise. 1

Disposition

This patient requires ICU admission with critical care monitoring and should be reviewed by a senior clinician immediately (within 1 hour of arrival). 1

• The National Early Warning Score would be ≥7 in this patient (tachycardia, fever, altered consciousness), mandating urgent assessment by a team with critical care competencies. 1
• Consider neurology and infectious disease consultation once stabilized. 1