A 40-year-old male presents to the ED from home with a report of fever and neck stiffness since yesterday according to a family member at bedside. On arrival he is obtunded and emergently intubated. You are concerned for bacterial meningitis. As you prepare to perform an LP, you order ceftriaxone and acyclovir to be given immediately. You later realize you forgot to order a medication known to decrease mortality if given early for cases like this. What medication should be administered next? 

A. Mannitol

B. Hypertonic Saline

C. Thiamine

D. Dexamethasone

Answer: D. This patient with fever, neck stiffness, and AMS has possible strep pneumoniae meningitis, therefore 0.15 mg/kg IV dexamethasone should be given as soon as possible either before or concurrently with antibiotics as it has been shown to significantly decrease mortality. Vancomycin is often given as well to cover for cephalosporin-resistant pneumococcus. Ampicillin may be added for listeria coverage for infants, elderly, and the immunocompromised. Although this patient has the classic triad of symptoms indicative of meningitis, your patients in real life often will not!

See this past EM Daily post discussing the evidence for steroids in meningitis: https://emdaily.cooperhealth.org/content/dexamethasone-meningitis-eviden...