• Dr. Michelle Yee MD CCFP

Which is best: Kernig, Brudzinski, or Jolt Accentuation?


Marie is a 31 year old female who reports a one-week history of rhinorrhea, cough and generalized unwell. In the last 2 days, she has had a progressively worsening headache and photophobia. You begin to examine her with concerns around potential meningitis.

SNAP SAMP:

  1. Name THREE physical exam findings you may look for with suspected meningitis?

  2. What is your immediate NEXT STEP in management?

  3. List FOUR additional steps to your management.

  4. What are TWO most common organisms in meningitis in adults?

  5. What is ONE additional step of management that needs to completed once the diagnosis is confirmed?

Answers:

1)

  • Fever

  • Altered LOC or mental status changes (confusion, lethargy, irritability)

  • Nuchal rigidity

  • Kernig (Memory tip: K for bending the Knee)*

  • Brudzinski (Memory tip: B for bending the Back of the head / the Brain)*

  • Jolt accentuation

  • Petechiae

*Pitfall alert: These are low sensitivity, high specificity (5% and 95%) ... don't be falsely reassured if these are absent.

** Another pitfall: Better sensitivity (70%) but lower specificity (33%) than the Kernig and Brudzinski. Use your clinical judgment and especially your lumbar puncture to make the call.

2) Antibiotics! Need to be started ASAP if meningitis is suspected, even prior to CT or LP

  • For most adults, this involves Ceftriaxone (or Cefotaxime) and Vancomycin

  • This is one of the only indications in which 2g of Ceftriaxone is used

  • Consider adding Ampicillin if elderly or history of alcoholism or debilitating disease

3)

  • Airway, Breathing, Circulation

  • IV fluids

  • CT head

  • Steroids (reduces risk of neurological sequelae and hearing loss, but must be given PRIOR to antibiotics)

  • LP

  • Admit to Internal Medicine

4) Strep pneumonia & Neiserria meningitidis

  • Recall: organisms in neonates differ. Here is a memory aid - LEGS and SHIN:

  • < 1 month neonate: LEGS (and the L helps you remember it is for Less than 1 month)

  • L - Listeria

  • E - E.coli

  • GS - GBS

  • > 1 month and for children and most adults: SHIN (or SH1N to remember it's over 1 month of age)

  • S - Strep pneumonia

  • HI - Hemophilis influenza

  • N - Neiserria meningitidis

5)

  • Report disease to public health

  • Treat household contacts, child care or school contacts with prophylactic antibiotics (rifampin, ceftriaxone or ciprofloxacin)

Sources:

http://www.jwatch.org/jw200207050000002/2002/07/05/kernig-and-brudzinski-fail-perform

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357091/

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