10 month old boy. Taken to GP with h/o sudden onset of fever, vomiting and lethargy for 4 hours. Mother very anxious about child. GP referred child to walk-in clinic at hospital.
History on admission: Feverish and drowsy – sudden onset. 2 episodes of vomiting, 1 soft stool, no rash.
Assessment on admission: Drowsy and pale, dark rings around eyes.
Temp 37.7
CVS: P 181, BP 120/52, CRT 4 secs. Child peripherally shutdown.
RS: RR 32 breathing laboured and child cyanosed.
SaO2 100% in oxygen.
NS: GCS10 then 9, no neck stiffness.
Fine blanching rash on abdo/chest. 1 petechial spot on abdo.
Diagnosis: meningococcal septicaemia
QUESTIONS ON CASE 5
Q 2 of 11: Adequate examination?
Yes No
CORRECT : Examination was comprehensive enough to show what was wrong with this child. ABC thoroughly assessed as well as conscious level and neck stiffness. Rash carefully examined, including extent and whether blanching, petechial or purpuric. Checking pupil size/reaction would complete assessment.
Capillary refill time or toe-core temperature gap
Standard technique for measurement of CRT is to press for 5 seconds on a fingertip or toe, or on the centre of the sternum, and count the seconds it takes for colour to return. (Capillary refill shown here on dorsum of foot to facilitate capture on film.)
Oxygen saturation measurement (normal value is >95% in air)
If rash present record whether it is blanching, extent of rash, speed of development and whether it is petechial or purpuric (Petechial <2mm diameter, purpuric >=2mm diameter). Purpura are highly predictive of meningococcal disease and should be treated as an emergency, with immediate antibiotics and admission. Petechiae alone are less predictive, but must be taken very seriously and especially in combination with other features of septicaemia should provoke urgent action.
