Neurocritical Care

, Volume 23, Supplement 2, pp 110–118 | Cite as

Emergency Neurologic Life Support: Meningitis and Encephalitis

  • David F. GaieskiEmail author
  • Barnett R. Nathan
  • Nicole F. O’Brien
Review Article


Bacterial meningitis and viral encephalitis, particularly herpes simplex encephalitis, are severe neurological infections that, if not treated promptly and effectively, lead to poor neurological outcome or death. Because treatment is more effective if given early, the topic of meningitis and encephalitis was chosen as an Emergency Neurological Life Support protocol. This protocol provides a practical approach to recognition and urgent treatment of bacterial meningitis and encephalitis. Appropriate imaging, spinal fluid analysis, and early empiric treatment is discussed. Though uncommon in its full form, the typical clinical triad of headache, fever, and neck stiffness should alert the clinical practitioner to the possibility of a central nervous system infection. Early attention to the airway and maintaining normotension is crucial in treatment of these patients, as is rapid treatment with anti-infectives and, in some cases, corticosteroids.


Meningitis Encephalitis Critical care Emergency Central nervous system infection Neurocritical care 


  1. 1.
    van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006;354:44–53.CrossRefPubMedGoogle Scholar
  2. 2.
    Schuchat A, Robinson K, Wenger JD, Active Surveillance Team, et al. Bacterial meningitis in the United States in 1995. N Engl J Med. 1997;337:970–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Saex-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2013;361:2139–48.CrossRefGoogle Scholar
  4. 4.
    van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004;351:1849–59.CrossRefPubMedGoogle Scholar
  5. 5.
    Attia J, Hatala R, Cook DJ, Wong JG. The rational clinical examination. Does this adult patient have acute meningitis? JAMA. 1999;282:175–81.CrossRefPubMedGoogle Scholar
  6. 6.
    Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis. 2002;35:46–52.CrossRefPubMedGoogle Scholar
  7. 7.
    Seymour CW, Cooke CR, Mikkelsen ME, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehospital Emerg Care. 2010;14(2):145–52.CrossRefGoogle Scholar
  8. 8.
    Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296–327.CrossRefPubMedGoogle Scholar
  9. 9.
    Angus DC, Yealy DM, Kellum JA, ProCESS Investigators. Protocol-based care for early septic shock. N Engl J Med. 2014;371(4):386.PubMedGoogle Scholar
  10. 10.
    Peake SL, Delaney A, Bellomo, ARISE Investigators. Goal-directed resuscitation in septic shock. N Engl J Med. 2015;372(2):190–1.PubMedGoogle Scholar
  11. 11.
    Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267–84.CrossRefPubMedGoogle Scholar
  12. 12.
    Tunkel AR. Bacterial meningitis. Philadelphia: Lippincott Williams & Wilkins; 2001.Google Scholar
  13. 13.
    Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001;345:1727–33.CrossRefPubMedGoogle Scholar
  14. 14.
    de Gans J, van de Beek D. European dexamethasone in adulthood bacterial meningitis study I. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549–56.CrossRefPubMedGoogle Scholar
  15. 15.
    Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38:1045–53.CrossRefPubMedGoogle Scholar
  16. 16.
    Talan DA, Guterman JJ, Overturf GD, Singer C, Hoffman JR, Lambert B. Analysis of emergency department management of suspected bacterial meningitis. Ann Emerg Med. 1989;18:856–62.CrossRefPubMedGoogle Scholar
  17. 17.
    Jeha LE, Sila CA, Lederman RJ, Prayson RA, Isada CM, Gordon SM. West Nile virus infection: a new acute paralytic illness. Neurology. 2003;61:55–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, Harrison H, Farley MM, Reingold A, Bennett NM, Craig AS, Schaffner W, Thomas A, Lewis MM, Scallan E, Schuchat A. Bacterial meningitis in the United States, 1998–2007. N Eng J Med. 2001;364(21):2016.CrossRefGoogle Scholar
  19. 19.
    Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010;126(5):952.CrossRefPubMedGoogle Scholar
  20. 20.
    Kim KS. Bacterial meningitis beyond the neonatal period. In: Cherry JD, Harrision GJ, Kaplan SL, et al., editors. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. 7th ed. Philadelphia: Elsevier; 2014. p. 425.Google Scholar
  21. 21.
    Brouwer MC, McIntyre P, Prasad K, van de Beek D. Cortiscosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2013;6:CD004405.PubMedGoogle Scholar
  22. 22.
    American Academy of Pediatrics. Pneumococcal infections. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, editors. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village: American Academy of Pediatrics; 2012. p. 571.Google Scholar
  23. 23.
    Venkatesan A, Tunkel AR, Bloch KC, et al. Case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. Clin Infect Dis. 2013;57(8):1114–28.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • David F. Gaieski
    • 1
    Email author
  • Barnett R. Nathan
    • 2
  • Nicole F. O’Brien
    • 3
  1. 1.Department of Emergency MedicineSidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Division of Neurocritical Care, Department of NeurologyUniversity of VirginiaCharlottesvilleUSA
  3. 3.Division of Critical Care MedicineNationwide Children’s HospitalColumbusUSA

Personalised recommendations