What are the immediate steps for evaluating and managing a patient suspected of having meningococcemia?

Assessment of Meningococcemia

Stabilize airway, breathing, and circulation immediately—this takes absolute priority over all diagnostic procedures, and a senior clinician must review the patient within the first hour to determine need for ICU admission. 1, 2

Immediate Priority Actions (Within First Hour)

Airway and Breathing Assessment

• Assess airway patency and consider intubation if Glasgow Coma Scale (GCS) ≤12, as altered mental status can rapidly progress to respiratory failure. 2
• Evaluate oxygen saturation, breathing pattern, and need for supplemental oxygen or ventilatory support. 2
• Patients can deteriorate rapidly despite initially reassuring vital signs, so do not be falsely reassured by normal early warning scores. 1

Cardiovascular Evaluation

• Check blood pressure, heart rate, capillary refill time (<2 seconds is target), and peripheral perfusion (warm vs. cold extremities). 2, 1
• Calculate the National Early Warning Score (NEWS): aggregate score of 5-6 requires urgent senior review; score ≥7 requires immediate critical care team assessment. 1, 2
• A common pitfall is underestimating severity based on early vital signs—meningococcemia can progress to shock within hours. 1, 3

Neurological Assessment

• Document GCS score immediately for both prognostic value and to monitor deterioration. 1, 2
• Assess for focal neurological signs including asymmetric weakness, cranial nerve palsies, and visual field defects. 2
• Check for papilledema (though inability to visualize fundus is not a contraindication to lumbar puncture in early disease). 1

Critical Clinical Examination

Rash Assessment

• Systematically examine the entire body including mucous membranes and conjunctivae for rash—document presence or absence in all patients. 2, 1
• Characterize rash type: petechial, purpuric (non-blanching), maculopapular, or blanching. 2
• The absence of rash does not exclude meningococcemia—some patients present with sepsis before rash develops. 1
• Document whether rash is rapidly evolving, as this indicates need for immediate antibiotics without waiting for lumbar puncture. 1

Sepsis Indicators

• Record presence of pre-admission antibiotics, as this affects diagnostic yield. 1
• Assess for signs of shock: prolonged capillary refill, cold extremities, altered mental status, hypotension. 1, 2

Diagnostic Investigations (Concurrent with Resuscitation)

Blood Work

• Obtain blood cultures within 1 hour of arrival and before antibiotics, but never delay antibiotics beyond 1 hour to obtain cultures. 1, 4
• Send complete blood count, coagulation studies (to assess for DIC), lactate, and simultaneous serum glucose (for CSF comparison). 4, 5

Lumbar Puncture Decision Algorithm

If patient has predominantly sepsis or rapidly evolving rash:

• Do NOT perform lumbar puncture at this time—give antibiotics immediately after blood cultures. 1
• LP is contraindicated in shock states as resuscitation takes priority. 1

If patient has suspected meningitis without shock or severe sepsis:

• Assess for CT scan indications first: focal neurological signs, papilledema, continuous seizures, or GCS ≤12. 1, 4
• If no CT indications: perform LP within 1 hour if safe to do so, then start antibiotics immediately after. 1
• If CT indicated: start antibiotics first, then obtain CT, then LP only if no mass effect. 4

Additional Diagnostic Tests

• Obtain nasopharyngeal swabs for meningococcal PCR when diagnosis is suspected. 4
• Consider skin biopsy of purpuric lesions for Gram stain and culture if rash present. 5

Immediate Management

Antibiotic Therapy

• Administer ceftriaxone 2g IV every 12 hours (or cefotaxime 2g IV every 6 hours) within 1 hour of presentation, regardless of whether LP has been performed. 2, 4, 3
• Add vancomycin 15-20 mg/kg IV every 8-12 hours if bacterial meningitis cannot be excluded. 4
• Delays in antibiotic administration are strongly associated with increased mortality—do not wait for imaging or LP if these will delay treatment beyond 1 hour. 6, 3

Fluid Resuscitation (If Shock Present)

• Administer rapid 500 mL crystalloid bolus over 5-10 minutes and reassess after each bolus. 1, 2
• Target therapeutic endpoints: capillary refill <2 seconds, mean BP >65 mmHg, warm extremities, urine output >0.5 mL/kg/hour, normal mental status, lactate <2 mmol/L. 1, 2
• Follow Surviving Sepsis guidelines for ongoing resuscitation. 1

Adjunctive Therapy

• Administer dexamethasone 10 mg IV every 6 hours immediately before or with first antibiotic dose if bacterial meningitis suspected. 6, 3

Infection Control

• Implement respiratory isolation with droplet precautions immediately until meningococcal disease excluded or 24 hours of effective antibiotics completed. 2, 4
• Healthcare workers should use surgical masks if in close contact. 2

Critical Care Transfer Criteria

Transfer to ICU if patient has: 6, 2

• Rapidly evolving rash with hemodynamic instability
• GCS ≤12 or declining mental status
• Shock requiring vasopressor support
• Respiratory failure requiring mechanical ventilation

Common Pitfalls to Avoid

• Do not delay antibiotics for imaging or LP—treatment within 1 hour is mandatory. 1, 4, 3
• Do not be falsely reassured by low early warning scores—meningococcemia deteriorates rapidly. 1
• Do not perform LP in patients with shock or rapidly evolving rash—resuscitation and antibiotics take priority. 1
• Do not assume absence of rash excludes diagnosis—some patients present with sepsis alone. 1
• Remember to arrange chemoprophylaxis for close contacts regardless of vaccination status. 3