Rosen & Barkin's 5-Minute Emergency Medicine Consult (447 page)

Postexposure prophylaxis needed for pre-hospital personnel in close contact with patient

• Wear mask and gloves, observe droplet precautions.
  
• Notify department of health.
  
• ABCs
  
• Immediate endotracheal intubation for severe acidosis, hypoxia, or decreased mental status:
  
  • Hyperventilate to treat acidosis (target PCO
    ₂
    about 25 mm Hg)
    
• Treat hypotension:
  
  • 0.9% normal saline bolus of 20 mL/kg; cautious rehydration with ARDS, CHF
    
  • Begin dopamine or norepinephrine (epinephrine if no response) if hypotensive after 2 L of IV fluids.
    
• Naloxone, thiamine, dextrose (Accu-Chek) for altered mental status
  
• Initiate IV antibiotics:
  
  • 1st line: High-dose penicillin (proven meningococcemia) or 3rd-generation cephalosporin (broader coverage pending definitive diagnosis)
    
  • 2nd line: Ampicillin
    
  • 3rd line: Chloramphenicol (penicillin-allergic patients)
    

• Overwhelming meningococcal sepsis
  
• Severe acidosis (pH <7–7.1 or serum HCO
  ₃
  <8–10):
  
  • Administer IV NaHCO
    ₃
    along with hyperventilation.
    
• Insert Foley catheter to monitor urine output.
  
• Place in respiratory isolation.
  
• High-dose steroids:
  
  • To protect against cranial nerve injury in the setting of ongoing infection (controversial)
    
  • Administer with adrenal gland injury.
    
• DIC treatment:
  
  • Administer fresh-frozen plasma and platelet transfusions.
    
  • Heparin is not indicated unless significant thrombotic complications are evident clinically (e.g., cyanosis or cold digits, low urine output despite adequate volume status, and blood pressure).
    
• Prophylaxis options for close contacts:
  
  • Ideally, prophylaxis should be given within 1st 24 hr.
    
  • 10-day window of observation
    
  • Serogroup-specific vaccine as adjunct only
    
• Vaccine:
  
  • Vaccine recommended in military recruits, travelers to endemic areas, complement-deficient or asplenic patients, 1st-year college dormitory residents
    
  • Vaccine recommended routinely for ages 11–18 yr
    

The safety of meningococcal vaccine is unclear in pregnancy.

• Cefotaxime: 2 g (peds: 50 mg/kg) IV q6h
  
• Ceftriaxone: 2 g (peds: 50 mg/kg) IV q12h
  
• Penicillin G: 4 MU (peds: 250,000 U/kg/24 h) IV q4h
  

• Ampicillin: 2–3 g (peds: 200–400 mg/kg/24 h) IV q6h
  
• Chloramphenicol: 50–100 mg/kg/24 h IV q6h (max. 4 g/d)
  
• Prophylaxis:
  
  • Single-dose ceftriaxone:
    
    • 125 mg IM for age <15 yr
      
    • 250 mg IM for age >15 yr
      
  • Ciprofloxacin: 500 mg PO (adults)
    
  • Rifampin: 600 mg (peds: 5–10 mg/kg) PO BID for 2 days
    
  • Azithromycin 500 mg PO single dose (not routinely used)
    
• Dexamethasone: 0.15 mg/kg IV for pediatric meningitis
  
• Dopamine: 5–20 ug/kg/min IV titrate to blood pressure (BP)
  
• Epinephrine: 2–10 ug/min IV titrate to BP
  
• Heparin: 3,000–5,000 U (peds: 80 U/kg) IV bolus followed by 600–1,000 U/h (peds: 18 U/kg/h) IV drip
  
• Hydrocortisone (Solu-Cortef): 100 mg (peds: 2 mg/kg) bolus IV for adrenal insufficiency q8h
  
• Meningococcal polysaccharide 0.5 mL IM ×1
  
• Meningococcal vaccine 0.5 mL SC ×1
  
• Norepinephrine: 0.5–30 ug/min IV titrate to BP
  
• Sodium bicarbonate: 2–5 mEq/kg (peds: 0.5–1 mEq/kg) IV over 30 min to 4 hr
  

FOLLOW-UP

• ICU admission for overwhelming sepsis with respiratory isolation
  
• Respiratory isolation admission for mild meningococcemia
  

Prophylaxis for close patient contacts

• Consider transfer to tertiary care center, as multisystem organ failure is common.
  
• Late neurologic, cardiovascular, and orthopedic complications may necessitate follow-up with specialists.
  

• Complete antibiotic course.
  
• Respiratory precautions may be discontinued after 24 hr.
  
• All close contacts need prophylaxis.
  

• Notify department of health in any suspected case.
  
• Watch for late development of pericardial tamponade.
  
• Do not wait to give antibiotics.
  

• Apicella M.
  Neisseria meningitidis
  . In: Mandell GL, Bennett JE, Dolin R, eds.
  Principles and Practice of Infectious Disease.
  7th ed. Philadelphia, PA: Churchill Livingston Elsevier; 2010:2737–2752.
  
• Cramer JP, Wilder-Smith A. Meningococcal disease in travelers: Update on vaccine options.
  Curr Opin Infect Dis.
  2012;25(5):507–517.
  
• Pace D, Pollard AJ. Meningococcal disease: Clinical presentation and sequelae.
  Vaccine.
  2012;30(suppl 2):B3–B9.
  
• Rosenstein R, Perkins BA, Stephens DS, et al. Meningococcal disease.
  N Engl J Med.
  2001;344(18):1378–1388.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Meningitis
  
• Sepsis
  

CODES

036.2 Meningococcemia

BASICS

Mercury:

• 3 forms: Elemental, inorganic salts, and organic
  
• Reacts with sulfhydryl groups, causing enzyme inhibition and alterations in cellular membranes
  
• Binds to phosphoryl, carboxyl, amide, and amine groups of enzymes
  

• Exposure is usually through the GI tract and inhalation and less frequently dermal exposure.
  
• Exposure through manufacturing of chlorine and caustic soda, diuretics, antibacterial agents, antiseptics, thermometers, batteries, fossil fuels, plastics, paints, jewelry, lamps, explosives, fireworks, vinyl chloride, and pigments
  
• Exposure through taxidermy, photography, dentistry, mercury mining
  
• Contaminated seafood
  

DIAGNOSIS

• Naturally occurring mercury is converted into 3 primary forms, each with its toxicologic effects:
  
• Elemental mercury:
  
  • Symptoms from inhalation occur within hours:
    
    • Cough and dyspnea, which may progress to pulmonary edema
      
    • Metallic taste, salivation
      
    • Weakness, nausea, diarrhea, fever, headaches, visual disturbances
      
  • Subcutaneous deposits may present as granulomas or abscesses.
    
  • IV exposure presents with symptoms consistent with pulmonary embolization.
    
  • Relatively nontoxic from oral ingestion, although appendicitis has been reported
    
• Inorganic mercurial salt ingestion:
  
  • Caustic GI injury:
    
    • Abdominal pain with nausea, vomiting, and diarrhea
      
    • Metallic taste, sore throat
      
    • Hemorrhagic gastroenteritis with hematochezia and hematemesis
      
  • Acute tubular necrosis
    
  • Acrodynia (pink disease):
    
    • Idiosyncratic, occurs mainly in children
      
    • Painful extremities
      
  • Pink discoloration with desquamation
    
• Organic mercury ingestion:
  
  • Historically, infants exposed in womb are most severely affected (e.g., Minamata Bay, Japan)
    
  • May see GI symptoms acutely
    
  • Delayed CNS toxicity predominates and may take weeks to months to manifest:
    
    • Paresthesias
      
    • Ataxia
      
    • Paralysis
      
    • Visual field constriction
      
    • Dysarthria
      
    • Hearing loss
      
    • Mental deterioration
      
    • Death