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To be out cold

When a person is unconscious, they are completely unaware of themselves and their surroundings. They have no control over body functions or movement. Usually they are not able to recall or remember any of the time spent in an unconscious state.

There are many causes of unconsciousness, including stroke, epilepsy, diabetic coma, head injury, alcohol intoxication, poisoning, heart attack, bleeding, electrocution and shock.

What you can do if someone has lost consciousness

Check for breathing. If necessary, open the airway and begin rescue breathing.

Check pulse. If no pulse, begin CPR.

Call for emergency medical assistance.

Keep the person warm unless you suspect heat stroke.

Lay the person down face up, with their head below their heart level. Move them as little as possible and only to provide life support or safety. Do not move person if you suspect a head or neck injury.

If there is vomit in the mouth, turn person on their side to allow fluids to drain out.

Look for medical identification or possible cause of unconsciousness.

Do not give anything to eat or drink.

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Steroid Use

Given that many of the damaging sequelae of acute bacterial meninges are due to the host’s inflammatory response, several studies have looked at the role of steroids as an adjunctive measure. Many of the studies have been done in children, and steroids have been shown to decrease the incidence of hearing loss in cases of H. influenzae meningitis in this population. Corroborating retrospective studies, a recent randomized double-blinded study from the Netherlands found significant mortality and morbidity benefit with the use of dexamethasone during the first 4 days of therapy for acute bacterial meningitis, convincingly for pneumococcal meningitis. The authors used doses of 10 mg IV every 6 hours for 4 days, commencing before or concomitant with the first dose of antibiotics. While they did not demonstrate better outcomes with steroids for non-pneumococcal meningitides, the number of non-pneumococcal cases was too small to reach a conclusion. Early steroid use should strongly be considered when the clinical picture with or without CSF data points to bacterial meningitis.

Supportive Care

Each patient’s neurologic status should be monitored closely and vigilantly for clinical deterioration, and, if this occurs, the practitioner should consider prompt reimaging, the use of modalities to lower intracranial pressure, and neurosurgical consultation for placement of a ventricular shunt or other neurosurgical intervention. While debate has surrounded intravenous fluid administration and cerebral edema, it is now generally accepted that fluids are often needed to maintain an adequate mean arterial pressure to provide sufficient cerebral perfusion pressure.

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The lumbar puncture is critical to the diagnosis of acute bacterial meningitis. Several case series have looked at the presence of various CSF abnormalities of the lumbar puncture in cases of acute bacterial meningitis. Opening pressure is typically greater than 18 cm H20 and can be very high when cerebral edema is present. Generally, 80% of the time, the fluid is turbid. Gram stain is positive in 50% to 60% of cases. CSF cultures are positive in 65% to 75% of cases, although less often if antibiotics precede the lumbar puncture. The CSF cell count often exceeds 1000 cells/mm3. Neutrophilic predominance, with more than 80% neutrophils, is present in 80% of cases, although there are cases of lymphocyte predominance, seen most commonly with Listeria infection. The total protein usually exceeds 45 mg/dL in more than 95% of cases and is greater than 200 mg/dL in more than 50% of cases. The CSF glucose level is less than 50 mg/dL in approximately 70% of cases. However, these initial indices can be relatively normal in immunocompromised and neutropenic patients, and excluding the diagnosis of acute bacterial menigitis may necessitate a follow-up lumbar puncture. Partial antibiotic treatment, which is defined as the administration of intravenous antibiotics within 6 hours, oral antibiotics within 12 hours, or a prior recent course of antibiotics, does not usually not have a significant effect on CSF indices. Bacterial antigen tests in the CSF have been shown to have sensitivities of less than 75% and cannot be used to rule out disease. CSF analysis, combined with blood culture data, determines the diagnosis of acute bacterial meningitis.

Gram stain and culture of the CSF results should be performed immediately after the lumbar puncture and can direct antibiotic therapy. Since blood cultures are positive in more than 50% of cases of acute bacterial meningitis, two sets of blood cultures should be drawn prior to the administration of any antibiotic therapy.

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