Serious complications can develop rapidly and include cerebral edema, hydrocephalus, hemorrhage, ventriculitis, cerebral infarction, and cerebral abscess formation. Cerebral abscess, such as subdural empyema, can be seen in as many as 13 percent of cases of neonatal meningitis.4 It is a life-threatening condition, causing up to 25 percent of all intracranial infections, with a mortality rate of 4.4–24 percent.5 Signs and symptoms in a neonate include mental status changes, vomiting, and irritability. Treatment should include surgical drainage and triple antibiotic therapy with nafcillin or vancomycin, plus a third-generation cephalosporin and metronidazole. Prognosis is dependent upon the time to surgical intervention as a delay in surgery of 72 hours has been shown to result in 70 percent disability rate as opposed to 10 percent when surgery is performed within 72 hours.6 Complications associated with subdural empyema include seizures, increased intracranial pressure, cerebral infarction, and hydrocephalus.
Explore This IssueACEP Now: Vol 36 – No 03 – March 2017
In the process of diagnosing neonatal meningitis, it is important to keep in mind the possibility of abnormal laboratory studies. A 2006 evaluation of 9,111 neonates with culture-proven bacterial meningitis was performed to determine the correlation between CSF parameters and blood tests. This study demonstrated that 17.3 percent of the 8,312 neonates who had CBC data available had white blood cell (WBC) counts that were within normal parameters (3,000–10,000/mm3) and that the use of peripheral WBC count as a predictor for meningitis had a positive likelihood ratio of 7
Neonatal meningitis is a devastating infection that is often difficult to diagnosis due to physical signs being fairly subtle in the neonate. Therefore, lumbar puncture must be performed promptly to confirm the diagnosis.2 However, obtaining consent for lumbar puncture in the pediatric population can sometimes be problematic. Arguably one of the most difficult scenarios experienced in the emergency department is parents declining consent to procedures that are in the best interest of their child. Research has been pursued to determine the initial reasons behind parental dissent. A qualitative analysis in two hospitals in the United Arab Emirates published in 2012 involving 55 families found that 24 families (44 percent) refused lumbar puncture. The primary reasons for refusal included fear of paralysis as a result of the procedure, pain, perception of the lumbar puncture being unnecessary, and a distrust of motives behind the consent.8
Both the American Academy of Pediatrics and ACEP endorse the principle that treating a minor for an emergent condition should not be delayed solely due to difficulties in obtaining consent.9 An approach described in the Textbook of Pediatric Emergency Procedures suggests a discussion on the need for the procedure, the relatively low risk of the procedure, and the reasons parents have for dissent. If discussion fails to convince parents to consent to the procedure, consider notifying the hospital attorneys, as the hospital could pursue protective custody and obtain a court order to perform the procedure.9