18:15 hours paediatric registrar and SHO
History taken as above; rash noted to be purpuric.
Initial examination (in oxygen): airway clear, good saturations, equal breath sounds, no crepitations. Heart rate fast at 143, capillary refill time 6 seconds at feet. Heart sounds: gallop rhythm. BP 114/72. Rash is spreading, now on legs as well. Responding to voice, no neck stiffness, equal pupils. Blood gas taken to assess the degree of metabolic acidosis: pH = 7.2, BE= - 9.

Case History
12 year old boy referred to hospital by his GP. He was found to be febrile & drowsy with a few non-blanching spots. The GP gave a dose of intra-muscular penicillin and sent him into hospital as an emergency.

18:00 hours ED triage
Fever for a day, generally unwell with headache, regular paracetamol during day. No urine output since very early morning. No neck stiffness or vomiting. Temperature not coming down, new rash on back, increasingly drowsy.

Observations: temp 39.5, pulse 148, RR40, Cold hands and feet. Sats 92% in air. Conscious level is V (AVPU scale). Widespread non- blanching rash on trunk

Nursing actions: probable meningococcal disease, put out emergency call for paediatrics. High-flow oxygen started via facemask. BM done = 6.5.