Lumbar Puncture
left lateral position
Hip flexion opens intervertebral spaces
Avoid neck flexion (asphyxia/uncomfortable = squirm)
?Sitting position with their hips flexed and their legs forward is associated with wider intervertebral spaces
The spinal cord ends around L3 in neonates, L2 in adults
The sub-arachnoid space ends at S2
Tuffier’s line: between the most superior aspect of both Iliac crests, crosses the body of L4
L4-L5 i.e. space just below this is ideal (L3/4 also ok)
Contraindications:
Airway compromise
Respiratory compromise
Cardiovascular compromise
Neurological compromise
Local infection
Purpura (not petechia)
EMLA
Sucrose
25g in neonates, 22g in others
Parallel to fibres
Depth = 0.03 x height (cm)
Depth (mm) = 0.4 x Weight (kg) + 20
Depth (cm) = 1.3 + 0.07 x wt
30 drops (1.5ml) safe in neonates (production: 1ml/hr, have 50ml total)
Replace stylet prior to withdrawal to minimise headache
CSF lactate >3.5 (prior to antibiotics) suggests bacterial
Protein
Glucose (pair with serum)
MCS
PCR HSV, Meningococcal, ...
Interpretation:
see meningitis guideline/RCH/compare to ratio in FBE
Hip flexion opens intervertebral spaces
Avoid neck flexion (asphyxia/uncomfortable = squirm)
?Sitting position with their hips flexed and their legs forward is associated with wider intervertebral spaces
The spinal cord ends around L3 in neonates, L2 in adults
The sub-arachnoid space ends at S2
Tuffier’s line: between the most superior aspect of both Iliac crests, crosses the body of L4
L4-L5 i.e. space just below this is ideal (L3/4 also ok)
Contraindications:
Airway compromise
Respiratory compromise
Cardiovascular compromise
Neurological compromise
- Coma
- Signs of raise ICP (normal CT doesn't exclude)
- drowsy, diplopia, abnormal pupillary responses, unilateral or bilateral motor posturing or papilloedema
- NB bulging fontanelle in isolation doesn't = raised ICP and not a contraindication
- NB Normal CT doesn't exclude raised ICP
- drowsy, diplopia, abnormal pupillary responses, unilateral or bilateral motor posturing or papilloedema
- Focal neurology > CTB
- Seizures within last 30 mins or still post ictal
Local infection
Purpura (not petechia)
EMLA
Sucrose
25g in neonates, 22g in others
Parallel to fibres
Depth = 0.03 x height (cm)
Depth (mm) = 0.4 x Weight (kg) + 20
Depth (cm) = 1.3 + 0.07 x wt
30 drops (1.5ml) safe in neonates (production: 1ml/hr, have 50ml total)
Replace stylet prior to withdrawal to minimise headache
CSF lactate >3.5 (prior to antibiotics) suggests bacterial
Protein
Glucose (pair with serum)
MCS
PCR HSV, Meningococcal, ...
Interpretation:
see meningitis guideline/RCH/compare to ratio in FBE
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