emDOCs Podcast – Episode 17: Sick Meningitis, POCUS for Pneumoperitoneum, and Treatment of CHS

Today on the emDocs cast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER) we cover three posts: the sick meningitis patient, ultrasound for pneumoperitoneum, and treatment of cannabiniod hyperemesis syndrome.

Part 1: The Sick Meningitis Patient

Key Points from the Podcast and Post:

– Neisseria meningitides is one of the most dreaded and serious etiologies of meningitis and sepsis.  Even with early identification and IV antibiotics, there is a 10-15% mortality associated with this infection.

– Patients will typically report at least 1 of the classic symptoms of meningitis (fever, neck stiffness, headache) and also have severe myalgias in nearly all reported cases. Rash can be the presenting symptom.

– Early identification and antibiotics save lives. Have a low threshold to start antibiotics, particularly if the patient is unstable.

– Petechial rash can quickly spread to full-blown purpura fulminans. If this is suspected, antibiotics and FFP/Protein C as well as emergent consultation with general surgery is indicated.

– Three separate clinical features are associated with adverse outcomes such as death and permanent neurologic deficits: hypotension, altered mental status, and seizures. Two potentially life-threatening complications in the ED due to meningitis include seizures and elevated intracranial pressure (ICP)

– When patients arrive with suspected meningitis and they are toxic appearing, immediate intervention is necessary. Steroids should be a part of initial management concurrent with the first dose of antibiotics to help minimize elevations in ICP and the complications that come along with it.

– Do not forget the basics when it comes to managing elevated ICP in the ED. Elevate the head of the bed to at least 30 degrees, administer hypertonic saline or mannitol, and provide analgesia. Should intubation be necessary, the most experienced physician should intubate, as repeated attempts will increase sympathetic response to laryngoscopy.

From Dr. Katy Hanson at Hanson’s Anatomy:

Part 2:  Ultrasound for Pneumoperitoneum

Key Points from the Podcast and Post:

– Pneumoperitoneum can be seen on ultrasound with the enhanced peritoneal stripe sign (EPSS) and reverberation artifact (A-lines) in the abdomen. Other findings of free air include comet-trail reverberatory artifacts and air bubbles in ascitic fluid.

– Differentiate pneumoperitoneum from intra-luminal air. Check for movement of A-lines with peristalsis.

– The sensitivity and specificity for pneumoperitoneum by means of POCUS is 92% and 53% respectively. This may serve as a useful adjunct to diagnosis.

– The most likely obstacle encountered when performing this exam will be mistaking intraluminal bowel gas for free air. Look for peristalsis of the air as a marker for being within the bowel wall. One way to try and prevent this is by looking at the RUQ. The anterior aspect of the liver is adjacent to the anterior abdominal wall and is not occupied by bowel.

– Departments can be busy; utilize POCUS at the bedside to help guide treatment plans and expedite decision-making for advanced imaging and formal consults.

Part 3: Treatment of Cannabinoid Hyperemesis Syndrome

Key Points from the Podcast and Post:

– Cannabinoid Hyperemesis Syndrome is increasing in frequency in the United States.

– CHS is characterized by nausea, vomiting, abdominal pain, and chronic cannabis use.

– Consider CHS diagnosis in patients with recurrent presentations and negative abdominal pain work-ups.

– Avoid opiates for CHS treatment.

– Consider capsaicin cream, benzodiazepines, antiemetics and antipsychotics for treatment of CHS.