Dear Colleague, 

I will be thankful to you if you could read the text below and answer four short questions

(This survey is completely anonymous)

Thanks in advance,

Itai Shavit, MD

"Lumbar punctures are contraindicated in children with focal neurologic signs, focal seizures, coma, or papilledema on fundoscopic examination until brain imaging with or without contrast medium rules-out a space occupying lesion ..... Brainstem herniation can occur in these conditions."

PEDIATRICS, Osborn, DeWitt, First, Zennel. Elsevier Mosby. 2005.

"When the clinical examination only reveals meningeal and infectious signs (60-70% of cases) lumbar puncture is the first examination to perform. ...... funduscopic examination is completely useless."

Boisson C, Arnaud S, Vialet R, Martin C.  Severe community-acquired meningitis. Crit Care. 1999; 3(4): R55–R65

These quotes represent two different approaches regarding the performance of fundoscopic examination prior to lumbar puncture in cases of suspected acute bacterial meningitis.

                                                       What is your approach?

Assuming that your patient is a 7 y/o previously healthy boy, and that this patient presented with 24 hours of fever, photophobia, and meningeal signs. He has no focal signs, no signs of septic shock, did not present with focal seizures or coma (GCS 15), and the platelets count is 350,000.  You intend to perform a Lumbar Puncture.

1. Would you perform fundoscopic examination or order CT scan prior to the Lumbar Puncture ?

Please justify your answer (provide an evidence-based explanation, if possible):

2. If you decide to perform fundoscopic examination, than please answer the following three questions:

The fundoscopic examination revealed papilledema. What is your next step?

Please justify your answer (provide an evidence-based explanation, if possible):

3. Have you ever had a case of herniation during Lumbar Puncture in a patient with acute bacterial meningitis?

If you answered YES please describe the case/s:

4. Personal details

I am a physican

Who will perform the fundoscopic examination?

I am working in

(country)

I am a Qualified Pediatrician

I am practicing Pediatric Emergency Medicine or working in a pediatric emergency department/room for

years

I am a Qualified Pediatric Emergency Physician

Would you change your decision to perform fundoscopic examination if the child was 10 months old ?

Please justify your answer (provide an evidence-based explanation, if possible):

A. NO. B. I would perform fundoscopic examination C. I would order CT scan WITHOUT contrast mediumD. I would order CT scan WITH contrast medium

A. An Ophtalmologist B. Myself

A. YES B. NO

YESNO

A. I will start with antibiotics. No Lumbar Puncture  will be performed. B. I will order a CT scan without contrast medium, and will perform the Lumbar Puncture  if this scan is normal. C. I will order a CT scan with contrast medium, and will perform Lumbar Puncture only if this scan rules out a space-occupying lesion.

YESNO

YESNO