Meningitis or encephalitis (suspected)

Any person, 4 weeks to 15 years, presenting with signs or symptoms of meningitis or encephalitis.

Escalate immediately as per local CERS protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Assess the patient in a single room or isolation Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiorespiratory monitor
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL If further fluid resuscitation is required, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL If signs of hypovolaemia/shock persist, careful fluid administration is required Do not give further fluids without a medical order

Seizure activity

Assessment

Intervention

Actively seizing

Check BGL. See glucose section Apply oxygen Note: give a maximum of 2 doses of benzodiazepines in any seizure episode, inclusive of out of hospital treatment Select: IV access No IV access IV access Give midazolam 0.15 mg/kg IV, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg No IV access Give: midazolam 0.15 mg/kg IM once only. Maximum dose 10 mg or midazolam 0.3 mg/kg intranasal/buccal, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg Escalate as per local CERS protocol for second-line seizure management

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline If altered level of consciousness, observations every 5 minutes Continue neurological observations every 15 minutes until consciousness returns to normal
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment Non-opioid options have better outcomes in headaches. Consider simple analgesia, such as paracetamol or ibuprofen

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities Assess for a non-blanching petechial or purpuric rash Assess for neck stiffness: Place chin to chest (flexion) Look up to the roof (extension) Look left and right (right and left rotation) Ear to shoulder (right and left lateral flexion)

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
NBM	Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Focused assessment

Complete neurological focused assessment.

Precautions and notes

• It is difficult to distinguish between bacterial and viral meningitis. Treat patients with the first dose of empirical antibiotics without delay until a diagnosis is confirmed.
• Fever with a petechial or purpuric rash is highly suggestive of meningococcal disease.
• The younger the child the more non-specific and subtle symptoms may be.
• Over or under-hydration is associated with adverse outcomes in children with meningitis. Careful fluid management is critical.
• Steroids may reduce the risk of hearing loss in children.

Interventions and diagnostics

Antibiotic management

• Give antibiotics within 60 minutes of starting this protocol, if a medical or nurse practitioner is unavailable.
• Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

Select:

• No known allergies
• Life-threatening or uncertain penicillin allergy

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

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Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

• FBC, UEC, blood cultures, LFT, coags, glucose, CRP/procalcitonin, VBG with lactate
• Urinalysis:
  • Patient who can void in the toilet: mid-stream urine
  • Patient who is not toilet trained: clean catch or catheter urine
  • If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au