Tasty Morsels of Critical Care

About Tasty Morsels of Critical Care

Bite size chunks of critical care medicine targeted at fellowship exam preparation

Publisher

Andy Neill

Category

health & fitness

Language

en

Explicit

No

First episode

27 Oct 2020

Latest episode

28 Sept 2026

Latest episodes

98 episodes in the feed.

1. 

   28 Sept 2026

   Tasty Morsels of Critical Care 098 | Meningitis and Encephalitis

   Welcome back to the tasty morsels of critical care podcast (https://emergencymedicineireland.com/the-tasty-morsels). Today we cover some of the material from Oh’s manual chapter 54 on meningitis and encephalitis. This is a broad enough topic so the post will be correspondingly broad and somewhat superficial. There are a number of presentations to consider this in and you will undoubtedly commence treatment on a lot of patients who do not end up not having an acute CNS infection. And that is OK. Until you get CSF you really just can’t be sure and if it’s on the differential then in general it’s best to cover it appropriately pending appropriate investigations. Well, what are those “number or presentations” that I’ve just mentioned. There’s a whole set of pneumonocal or meningococcal meningitis that moves through the hospital at ward level care never needing us with our tubes and machines. For us in critical care we’ll typically only be getting involved in the unconscious or the seizing patient. The history of headache and fever etc is all very useful but is often not available in the context of the patients we’re seeing.  So what we’re left with is unconsciousness and seizures. Thankfully in that very common cohort there is often an easy alternate diagnosis staring you in the face like the pCO2 of 13 or the large bleed on the head CT. But in the patients for whom the diagnosis remains uncertain after the initial pieces of data then we have to consider CNS infection. While we have so far lumped meningits and encephalitis into one presentation, at this stage it’s probably worth separating them out by specific cause as that can be a helpful way to talk about risk factors and presentations First off meningitis. Most common will be bacterial, strep pneumo at top of list with meningococcal outbreaks still remaining a thing despite relatively widespread vaccination. Both are rapid and nasty, though thankfully both respond beautifully to appropriate antibiotics as long as you get them early. CSF will make the diagnosis but a +ve urinary penumococcal antigen in urine might make me consider meningitis a little stronger in the obtunded pneumoina patient if the presentation fits. In the alcoholic and elderly population listeria is a significant consideration. Encephalitis is a much trickier beast with a much more subtle presentation. Obtundation rather than florid coma may catch you out. Seizures may be focal or generalised. Fever is less obvious. CSF is less obvious. HSV is the number one diagnosis we’re worried about because the outcomes are poor and we actually have a treatment that might work in the form of aciclovir. There are much more indolent tricky to diagnose things like autoimmune encephalitidies that are in the encephalitis bucket but they are not really a 2am consideration in general. CSF as mentioned is essential. LP remains a great and safe test and too often deferred for concerns over bleeding risk or hassle factor. The British society of Haematology guidelines have a recommendation of platelets >40 and INR <1.5 as cut off for doing an LP. The guidelines suggest antiplatelets including DAPT should not preclude LP if urgent. The phrase “if urgent” is of course carrying a lot of weight in that sentence and can be interpreted in a variety of ways as you might imagine Once you’ve got CSF what patterns should you look for? This is a classic question for exams and focuses on neutrophils vs lymphocytes and what each might predict in combination with different levels of protein and glucose on CSF. Classic bacterial meningitis is high neutrophils with a low glucose. Viral tends to have lower overall white count with more lymphocytes. A raised CSF lactate seems to be a useful test in predicting or excluding bacteria in the CSF but I have not seen it done routinely. Gram stain is +ve in ~50% of bacterial meningitis but this rate of positivity massively increases in the exam scenario where the presence of gram positive bacilli allows follow up “guess the bug” type questions. (it’s listeria FYI). Encephalitis is a lot trickier on CSF, if there’s a few WCC then you end up waiting for a PCR for HSV, though a white count of zero is probably enough to exclude it without the PCR. However if the clinical picture is really worrying a repeat CSF after a number of days is probably the way to go. We can split management into a few sections. Firstly we have antimicrobials. As always this will vary with geographic region but being able to tie together your antibiotic choices with the likely bugs comes across very well in an exam scenario. In Ireland ceftriaxone is the go to cover for strep penumo and meningococcal disease. Go with the higher BD dosing for improved CSF penetration. Vanc is given routinely, theoretically to cover for resistant strep pneumo, the prevalence of which is really quite low in Ireland but still give it. Listeria in those at risk (pregnant, older, alcohol misuse) requires the use of amoxicillin in addition. In the unconscious patient HSV encephalitis is almost always on the differential and aciclovir is the drug of choice there. Usual best supportive care, while a little dull and generic is of course critical to a good outcome, with intubation and airway protection immediately relevant in most of the meningitis critical care referrals as they’re either obtunded or seizing. Steroids were somewhat novel and controversial when i first started training but now seem to be well established, with a cochrane review suggesting benefit in terms of neuro outcomes (primarily hearing) mainly in pneumococcal disease. Of course you won’t know it’s pneumococcal at the time so the recommendation is 0.15mg/kg dexamethasone at the time of or shortly after you give the antibiotics. Conversely if you’re pretty sure this is more of an encephalitis type issue then it’s hard to see why you would give steroids. Indeed a 2026 MCRCT by Solomon et al suggests no benefit to steroids in proven HSV encephalitis Raised ICP can be a real issue with meningitis but is less common in adults with brains shrunken by age and alcohol. Obtundation and the CT scan are going to be your likely clues to an ICP crisis. While it would seem reasonable to apply some of your basic neuroprotective measures like MAP targets and CO2 control and even CSF diversion in this scenario it’s by no means clear if they change outcomes and indeed without an ICP monitor it would be hard to assess response For encephalitis the major bug we’re interested in is HSV. It is common and can lead to devastating neuro outcomes untreated. Aciclovir seems to be effective with a substantial fall in mortality since its introduction even in the absence of RCTs. There are of course many other causes of encephalitis with particularly the autoimmune encephalitides being of particular relevance to critical care, however i think beyond the scope of this post. Reading Oh Chapter 54 – Dodd, K. C. et al. Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists 2026 guideline summary update. Pract. Neurol. pn-2026-005351 (2026) doi:10.1136/pn-2026-005351. – Solomon, T. et al. Safety and efficacy of adjunct dexamethasone in adults with herpes simplex virus encephalitis in the UK (DexEnceph): a multicentre, observer-blind, randomised, phase 3, controlled trial. Lancet Neurol. 25, 136–146 (2026). – Corticosteroids for acute bacterial meningitis. Matthijs C Brouwer et al 2015 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004405.pub5/full)

2. 

   31 Aug 2026

   Tasty Morsels of Critical Care 097 | Infective Endocarditis – Management

   Welcome back to the tasty morsels of critical care podcast (https://emergencymedicineireland.com/the-tasty-morsels). This is part 2 of infective endocarditis, this time covering the highlights of endocarditis management from the ICU perspective. Once the diagnosis is made and checked that the diagnosis is solid (remember there are published criteria about how to reach the diagnosis) then you should be reaching for some antibiotics. The guidelines have multiple, tedious tables describing antibiotic combos for native and prosthetic valves all guided by knowing what bug you are dealing with. If you are at the stage where you know what bug it is you will almost have a specialist in infection giving advice so I think this is somewhat beyond the scope of the ICU exam setting. Having a broad overview that of what bugs are gram +ve and gram -ve I think is key and will allow you to put together an appropriate reigime in any septic scenario, not just IE. As such i’m not going to go into detail. I suspect the more relevant scenario for us will be the crashing patient with an eaten out valve lesion at 2am and we’re the first person to be considering the diagnosis and have no micro to guide us. If you find yourself in such a situation then ceftriaxone and amoxcillin and some vancomycin will cover all the bases included prosthetics for the first 12 hours till help is available. This will cover all the commonest bugs of staph, strep, e faecalis and prosthetics. If you want to cover the weird culture -ve bugs then I have one, somewhat predictable word for you – doxycycline. If they’re in crit care they’ll almost undoubtedly be septic and any of your arsenal of sepsis interventions is probably appropriate and again beyond the scope of this post. The major modifiable part of your sepsis resus here will be determined by the echo. Are you dealing with severe, torrential AR then keeping the BP a little lower and diastolic period a little shorter with a tachycardia might be in your benefit. Have you got torrential MR from a perf or flail – then a balloon may be helpful. Again, the physiological management of a bad valve pending surgery is great fun but also beyond the scope of this post. So perhaps time would be better spent thinking about surgical indications in IE. The guidelines again have fairly clear indications here but many patients fall foul of the usual problem of having surgical disease when they are not surgical candidates. You can split surgical indications into 3 categories heart failure – this is the commonest indication and is driven by the degree of valve destruction and the heart’s ability to compensate for this. Cardiogenic shock and pulmonary oedema are obvious signs here. control of infection – the guidelines suggest surgery indicated if cultures not clear at 7-10 days or appropriate therapy. But these surgeries are often sensibly deferred to avoid putting what should be a life long valve into an infected patient. Persistent septic shock (even if cultures cleared) is another similar indication control of emboli – the guidelines would suggest very large vegetations (>30mm) should be operated on, even smaller veg (>10mm and other indications) could have surgery. However the risk of surgery is highest in few days before and after starting antibiotics and tails off signficantly at 2 weeks. As such you can imagine that many feel more comfortable with conservative management in this scenario. Be aware that the guidelines use the words “urgent” and “emergency” differently from what we might expect with “emergency” not meaning “right now” but “within 24 hrs”. There are often multiple good reasons for deferring theatre when there is the opportunity to optimise someone for a challenging bypass run. Intracranial emboli with bleeds also pose a big challenge when you’re proposing giving someone 30000 units of heparin. Lots of painful but necessary MDT discussion needed. Finally a common question appears regarding whether or not you anticoagulate to prevent the emboli causing strokes. . We do it when we find clot in the heart so why not veg (which inevitably have clot and infection in them). The guidelines give a reasonably clear answer with anticoagulation not recommended as a prophylaxis strategy.  To give a direct quote from the ESC guidance “To date, no data support initiation of either antithrombotics nor anticoagulants for treatment or prevention of stroke in IE.” In distinction  continuing anticoagulation in someone on it for pre existing reasons (eg a fib) does not seem especially high risk. Reading: – Fowler, V. G. et al. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clin. Infect. Dis. 77, 518–526 (2023). – Delgado, V. et al. 2023 ESC Guidelines for the management of endocarditis. Eur. Hear. J. 44, 3948–4042 (2023).

3. 

   17 Aug 2026

   Tasty Morsels of Critical Care 096 | Infective Endocarditis – Diagnosis

   Welcome back to the tasty morsels of critical care podcast (https://emergencymedicineireland.com/the-tasty-morsels). For the next couple of posts we’re going to focus on infective endocarditis. We have had something of a run of these over the past few months with every other cardiac surgery seemingly being done for IE. Not all of this will be relevant to every intensive care unit but as I work in an ICU with lots of cardiac surgery we will be covering the relevant aspects. This episode we’ll look at the diagnostic process and next time we’ll look at management. IE is a common consideration in patients with infection being admitted to the hospital. But we’re going to very much focus on what the ICU presentation might look like. Often they’ll be coming in with the diagnosis already made but a lot of the time you’ll be looking after a generically sick patient and only over time does the the diagnosis of IE raise its head. 3 main types of presentations of undiagnosed IE may present themselves to the critical care doctor (and there are of course others) sepsis. this is of course bread and butter to us in ICU but IE needs to remain in the differential for septic patient in the ICU, rather than just pinning it on the first minor infiltrate we see on the CXR the embolic presentation. The most common would be an intracranial event, either stroke or intracranial bleeding from a mycotic aneurysm or embolus. Certainly anything suggesting embolic stroke (like bilateral strokes for example) should you make you consider IE (along with of course, the much more common LAA thrombus in A fib). Outside the brain the main emboli that might show up for us will be obvious on CT scans with splenic and renal infarcts in left sided disease or cavitating pulmonary lesions in right sided valve disease. You will also get the occasional dramatic bleeder where some intrabdominal vessel has a mycotic lesion that bleeds dramatically needing an IR intervention heart failure. this is usually because the vegetation has eroded through something important like a valve leaflet and now there is torrential insufficiency of this valve. these tend to be fairly dramatic presentations with wet lungs and cardiogenic shock in the left sided lesions. How do we formally make the diagnosis of IE? Well, especially as this is exam focussed we need to be able to drag out Duke’s criteria. There have been some recent updates in 2023 and while it would seem unfair to expect a trainee to regurgitate all the details it would be helpful to have an overview. You will probably have in your memory something about major and minor criteria. Major criteria can be split into imaging major criteria – with a vegetation on echo still being the main sign and TOE preferred over TTE. But CT has some important findings that can fit in here too micro major criteria – growing certain common IE bugs in the blood would be the commonest here though it does allow for some serologies of the weird culture -ve bugs in this category surgical major criteria – if, at operation the surgeon sees vegetation or abscess or perforation consistent with IE then that counts as a major criteria The minor criteria include many less specific features that I’m not going to go through here. A bit like failing your driving test you can get IE by having 2 major criteria , or 1 major and 3 minors or even 5 minors on their own can make the diagnosis. There are pathological criteria which are considered the gold standard and that involves isolating the bug from tissue, typically a valve removed at surgery but typically that’s a diagnostic standard that most patients will not reach I think it is helpful to have an idea of the common bugs involved. From European wide data it seems we could give the following prevalence of bugs Staph Aureus (30%) oral streps (17%) coag -ve Staph (11%) e faecalis ( remember 95% faecalis, 5% faecium) Of note bacteraemia is constant (you do not need cultures just at time of fever) and most cultures should be +ve when IE is the cause. Most culture -ve IE is due to the patient already being on antibiotics. You can expect blood culture -ve IE in ~10% but the vast majority of this are just standard bacteria in patients that someone had already started on antibiotics and now you can’t grow it. For the true “culture -ve” crowd  the following bugs should be on your list (and this is not a complete list coxiella burnetti [Q fever] bartonella, brucella When it comes to imaging TOE remains the test of choice as it just gives you much better pictures. Even if you can see a vegetation on TTE then the guidelines recommend that most patients should still have TOE to properly assess valve complications and other valve involvement not obvious on TTE. The exception to this might be a TV endo with good images. Vegetation size has some prognostic implications and should be measured in its longest plane. But we should also be thinking about other tests. CT in particular has a role in looking at aortic root abscesses, especially in prosthetics. PET scan is also becoming a more important test but i find getting this for an ICU patient somewhat impractical. In terms of what bacteraemias should trigger an echo, the guidance would suggest staph aureus, e faecalis and classic streps as an indication. But not every bug in the blood needs an echo which I think is a message worth communicating. Reading: – Fowler, V. G. et al. The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clin. Infect. Dis. 77, 518–526 (2023). – Delgado, V. et al. 2023 ESC Guidelines for the management of endocarditis. Eur. Hear. J. 44, 3948–4042 (2023).

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