Assessment of a febrile child with suspected meningococcal disease

If MD is suspected, the purpose of the initial assessment should be to identify whether shock or raised intracranial pressure is present and the severity of the illness.

Septicaemia will lead to shock and multiorgan failure. Shock is a clinical diagnosis. The signs are a result of circulatory failure. The underlying pathophysiology of septicaemia and the capillary leak syndrome leading to these signs are briefly summarised in the pathophysiology section.

A child in early shock may still be alert and have a normal blood pressure.

Child lucid despite advancing septicaemia

The early signs of shock include:

• Tachycardia
• Cool peripheries (CRT>4 seconds) or toe-core temperature gap of >3 degrees
• Pallor, mottling
  
  
• Decreased urine output (<1ml/kg/hr)
• Tachypnoea – secondary to acidosis and hypoxia

(In patients with meningococcal disease, signs of shock will usually co-exist with symptoms of septicaemia.)

As shock progresses further signs develop:

• Metabolic acidosis with base deficit worse than -5
  
  
• Hypoxia: PaO₂ <10kPa in air or saturation < 95% in air
  
• Increasing tachypnoea, tachycardia and gallop rhythm

Late signs of shock include:

• Drowsiness or agitation
• Hypotension: in children, blood pressure can be normal until shock is advanced