Below is a case written up by one of our EM attendings who was working at Prince's Bay.
Chief Complaint: 13 yo male c/o N, V, D.
HPI: Pt brought in for fever, weakness, intermittent N/V for 8 days, unable to ambulate, c/o weakness to right side of body, intermittent HA and blurred vision x 5 days. Homeschooled, vaccinations UTD.
PMH/PSH/SOC history noncontributory
PHYSICAL EXAM: (pertinent findinds/absences)
CONSTITUTIONAL: afebrile· Appearance: well appearing, non-toxic wdwn
ENT, Cardiac, Pulm, GI WNL
Neck supple, slight meningismus
NEUROLOGICAL: right arm and leg weakness, + drift, difficulty holding up against gravity, reflexes intact. Decreased sensation to light touch on RUE, RLE. CNs nml.
How would you approach this not so everyday presentation?
What would you order? Who (if anyone) would you call?
LABS: (pertinent/abnormal results):
WBC 15.6k (77% neutrophils)
Magnesium 2.6
CK: 16 (hah you thought myositis, right?)
ESR 103
CRP 174
EKG: unremarkable
CXR: No acute disease
CT head: no acute intracranial pathology. Sinusitis.
What would you do next?
Neuro was consulted. While awaiting response, the decision to do LP was made.
LP results: Fluid: WBC: 1399. RBC 0 (cough ...champagne... cough). Predominance of neutrophils. Glucose 21. Protein 89.
Neurology called back. Agreed that LP was appropriate (after we did it lol). Pt started on IV abx (initially Ceftriaxone, then vanco and dex added later). Pt was transferred from SIUH PB to north and was admitted.
Follow up:
CSF Cultures grew Strep Pneumo.
MRI: 1. Leptomeningeal enhancement along bilateral frontal sulci consistent with leptomeningitis.
2. Thin rim-enhancing, diffusion-restricting fluid collections over the frontal convexities extending along the cerebral falx consistent with subdural empyemas.
3. Small acute infarcts in the corona radiata / centrum semiovale.
4. Paranasal sinus inflammatory changes with near-complete opacification of the right frontal and bilateral sphenoid sinuses. Likely purulent material within the right sphenoid sinus.
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This was a crazy case. It is not your typical presentation of bacterial meningitis. Usually when you hear bacterial meningitis you think fever, severe HA, neck stiffness, altered mental status, maybe a rash. Generally, a toxic looking patient, which this child was not. You don’t usually hear about these cases having focal neurologic deficits as he had. The combination of reported fevers and URI, leukocytosis, markedly elevated CRP and ESR (highest CRP I’ve ever seen by at least double), coupled with neurologic symptoms and meningismus prompted the LP decision. I honestly thought that no way could this be meningitis, and my brain is going to some auto-immune or maybe even some oncological processes, or at the most a viral meningitis. With the S. Pneumo/Hflu/NMeningitis vaccinations, we really don’t see bacterial meningitis like we used to (thankfully).
The child was eventually discharged home with a PICC line and getting 2g Ceftriaxone x 4 weeks, visiting nurse services, and is undergoing at home PT.
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LP TIPS:
I've done a lot of LPs in my EM career. It’s not that I like them but it's one of my “favorite procedures” and I've developed a system where I can get CSF relatively quickly. Here are my LP pearls:
Tip 1: Location, location, location. I can’t stress this enough. The biggest factor for success is patient positioning. I prefer lateral recumbent positioning but sitting up is fine, just make sure it’s a very capable/cooperative patient. Obviously factors like body habitus, mental status can affect this. If in doubt, lay them on their side. The most important thing is having the patient positioned perfectly, which requires a 2nd set of hands. If laying down on their side, make sure their shoulders are lined up perfectly. This goes for adults all the way down to infants. If one shoulder is “more forward or back” than the other, then essentially their spinal column is “twisted” and you’re going to hit bone or hit kidney (no extra points for renal biopsies). Make sure their knees are upwards towards their chest.
Tip 2: Prep. Have the kit open and accessible. Have 4 tubes standing up and lids open and off. Make sure you fill tubes 1-3 with 1cc of csf, and tube 4 I usually put about 3-5cc’s in (for pcr, viral, oncological testing). Less important but something to consider…try using the smallest gauge spinal needle that’s available. Doing an LP with a harpoon versus a 20g needle will decrease the chances of a CSF leak and a spinal headache, and a bounce back for an intractable headache (for you and the patient).
Tip 3: Comfort. Yours!!! Not the patient’s (we will get to that). Get a stool and set it to the right height where you’re not leaning down or hunched over. I prefer to put a chuck down on the floor and get on my knees. I feel more stability with my approach and my back doesn’t hurt afterwards.
Tip 4: Pt comfort. Every patient I LP (except infants) I give a little squirt of Valium to. You can use Versed as well. But I find them much more relaxed and maneuverable, and half the time they didn’t even know you did it by the time you’re done. Explain everything to them. Explain the pain from the “numbing needle”. Give them a LOT of lidocaine. I make a wheel with the small gauge needle first, then I insert the larger longer (not spinal) needed and infiltrate lidocaine deep (hub it) along the path I'm going to insert the spinal needle in to. And lastly tell them they might feel a zinger down their left or right leg similar to the “funny bone” sensation when you bang your elbow. If they jump or get startled because of this (proper positioning will decrease this tremendously, see tip 1!) If they say it went down their Right leg, then reposition the spinal needle and aim more towards the other laterality. When inserting the needed, go slow. The spinal fluid isn’t that deep in thin/young patients. I go in about a cm and take out the stylet. I repeat this process until I get CSF. Usually between the 2nd and 3rd stylet removals. Aim slightly upwards from the L4-5 space towards their sternum. Lastly, you will never feel a “pop” as you enter penetrate the dura. Sorry Tintanalli/Rosen but after dozens of successful taps, I still have yet to “pop” one in.
Tip 5: Tying loose ends. The most important orders are CSF cell count, gram stain and culture. Make sure to add glucose and protein. Make sure to add HSV and Lyme where appropriate. If the patient is being admitted they will likely add about 6 million more CSF studies and having the extra fluid in tube 4 will help.
Tip 6: Failure IS an option. The LP isn’t the end all-be all. If you suspect bacterial meningitis or HSV encephalitis, and you miss the tap, dry tap, bloody tap and you don’t think you have the CSF or can’t get it…start treatment and admit. They can always have it done under flouro as an in-patient. But if you follow these tips, ESPECIALLY tip 1, I guarantee you will have >90% success rate.
Tip 7: Celebrations. If your PA/Resident gets a champagne tap, buy them a bottle of Champagne or Martinelli’s sparkling apple juice.