63.14 Meningitis follows a head injury

A stiff neck soon after an injury can be caused by meningeal bleeding, by a fracture of the patient’s cervical spine, or by soft tissue injuries, so it is not of great significance early on. Some days later a stiff neck is more serious. So do a lumbar puncture if: (1) His neck becomes stiff some days after the injury. (2) He has a positive Kernig’s sign at any time.

MENINGITIS AFTER A HEAD I NJURY

If the organisms have entered from the patient’s nose, they are probably pneumococci, and are usually sensitive to penicillin. Give him penicillin 2 megaunits immediately, and then 1 megaunit 6 hourly.

Also, give him intrathecal penicillin 20 000 units immediately, and then 10 000 units daily for 5 days. Give it in a dilution of 2000 units per ml in water for injection because stronger solutions, or larger doses, can cause severe meningeal reactions. Withdraw an equivalent quantity of CSF before you inject. At the same time give him chloramphenicol 50 to 100 mg/kg/day. Or give him sulphadiazine or sulphadimidine orally or by tube, 3 g initially, followed by 1.5 g 4 hourly, together with plenty of fluid.

If the organism is insensitive to penicillin, give him streptomycin 1 g intramuscularly, and 50 mg in 1 ml intrathecally.