30925166 - pre oxygenation chin lift position with holding oxygen mask
The case involves a female author who began feeling neck pain while traveling to promote her new book. After experiencing the neck pain for a week, she presented to the hospital with severe pain, low-grade fever, and altered mental state. The author was prescribed a muscle relaxant and a steroid for pain relief and was discharged from the hospital. The author’s condition continued to worsen over the next few days. She checked back into the hospital three days later and was immediately diagnosed with meningitis. This resulted in a prolonged and complicated ICU course for the author. She remains ventilator dependent. An infectious disease expert was sought to opine on the causality between a delay in treating meningitis and a patient’s difficult clinical course.
Question(s) For Expert Witness
- 1. How often do you treat patients with meningitis?
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2. What is the standard of care in regards to starting time sensitive antibiotic prophylaxis for suspected cases of meningitis?
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3. How would a delay in initiating antibiotics impact a patient's clinical course?
Expert Witness Response E-004446
Community-acquired bacterial meningitis is a relatively rare occurrence, with an incidence of 1-2 per 100,000 population. Because I work for a referral center, I have experience with about one case /month of confirmed bacterial meningitis. Since viruses are the most common cause of meningitis/encephalitis, separating viral from bacterial can be challenging. If a provider even considers bacterial meningitis in their differential diagnosis, antibiotics should be started within 30 minutes of that clinical suspicion, whether or not a spinal tap is done before antibiotics. Steroids are also usually given. Delays in diagnosis and proper management are usually directly proportional to adverse outcomes, including morbidity and mortality. Without seeing the records, I will comment that it is unusual to have a week of neck pain in cases of bacterial meningitis since once the bacteria infect the spinal fluid, they rapidly grow. More typically the presentation is over 24-36 hours. Also, fever is an important clue. However, it is the obligation of the provider to query as to whether the patient took antipyretics that would normalize the temperature as part of the full decision making.
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