Case Summary

You transport Jack to the nearest Emergency Department, providing a radio report of an unwell male child, history of coughing and runny nose for a few days.

 

ED Assessment:

• Febrile child, listless, irritable and drowsy.

• Pyrexial and drowsy, unknown cause, referral to paediatric team.

• One-and-a-half hours later Jack is admitted to the paediatric observation ward.

Nursing assessment:

• Temp 38.6C, HR 170, RR 42, BP 110/52.

• Small maculopapular rash on abdomen and thorax.

 

Resident on-call reviews Jack:

• Sleepy but rousable, no signs of meningeal irritation or photophobia.

• No rash evident.

• Chest clear.

 

Diagnosis: viral URTI.

 

Jack is sent home with his mom, with instructions to keep him hydrated and to give him paracetamol prn for fever control. Jack re-presents 9 hours later via ambulance in uncompensated shock, with a widespread petechial rash and unfortunately dies despite resuscitation attempts.

 

Your colleague John, another Intensive Care Paramedic, who brought Jack in the second time, asks you

 

"Why didn't you consider meningitis?"

 

Learning points:

• Children with septicaemia often have rigors.

• Children in early stages of septicaemia may look reasonably well and remain relatively alert.

• Isolated pinprick spots may appear where the rash is mainly maculopapular so it is important to search the whole body for small petechiae especially in a febrile child with no focal cause.

• The early rash in meningococcal disease can be very diverse in appearance.

• The septicaemic rash does not necessarily develop at the same rate as the septicaemia. Always examine the child for the clinical signs of shock.

• Neck stiffness and photophobia are uncommon in a young child even if they have meningitis and their absence should not be reassuring.