A recent, national study found that almost 50% of children presenting to GPs with meningococcal disease were sent home on their first visit and that these children were more likely to die. The study found that the first symptoms reported by parents of children with meningitis and septicaemia were common to many self-limiting viral illnesses. This prodromal phase lasted up to 4 hours in young children but as long as 8 hours in adolescents, followed by the more specific and severe symptoms of meningitis and septicaemia
Red Flag Signs of Early Septicaemia
In all age groups, signs of septicaemia and circulatory shut-down were next to develop – 72% of children had limb pain, pale or mottled skin, or cold hands and feet at a median time of 8 hours from the onset of illness. Parents of younger children also reported drowsiness, rapid or labouredbreathing, and sometimes diarrhoea. Thirst was reported in older children.
These tended to present later. The first classic symptom was a rash, which appeared at 8-9 hours (median time) in babies and young children, but later in older children. Although not always present, it was the most common classic feature of meningococcal disease. Meningitis symptoms (neck stiffness, photophobia, bulgingfontanelle) appeared later – 12 to 15 hours from onset. They were more common in older children and were not reliable signs in children under age 5.
NICE Guidelines on Feverish Illness in Children specify that temperature, heart rate, respiratory rate and capillary refill time should be routinely measuredand recorded in all feverish children aged under five. A respiratory rate of >60 breaths/minute is classified as ‘red’ in the NICE traffic-light system, requiring urgent referral to a paediatric specialist. NICE classifies children with RR >50 at 6-12 months of age or RR >40 at >1 year of age to be at intermediate risk of serious illness: they should be assessed face-to-face and their need for paediatric care considered.
A raised heart rate can be a sign of serious illness, particularly septic shock.
You should check capillary refill by pressing for 5 seconds on the big toe or a finger, or on the sternum, and count the seconds it takes for colour to return. Capillary refill time ≥3 seconds signals intermediate risk of severe infection1, and when prolonged to ≥4 seconds on peripheries, especially with raised heart and respiratory rates, suggests shock.
If a pulse oximeter is available you should check oxygen saturation: normal value is >95% in air.
Hypotension is an important sign in adults, but it is a late and ominous sign in children, which limits its diagnostic value. Children and adolescents can compensate for shock and maintain normal blood pressure until septicaemia is far advanced.
Drowsiness/impaired consciousness in children with septicaemia is a late and grave prognostic sign and indicates immediate action. True neck stiffness can be assessed by checking whether a patient can kiss their knees, or by assessing the ease of passive flexion in a relaxed patient. Neck stiffness signifies meningitis, but is absent in septicaemia. It is not common in young children even with meningitis, so the absence of neck stiffness in a febrile child is NEVERreassuring.
If meningococcal infection is suspected, the patient should be transferred to hospital by the quickest means of transport, usually an emergency ambulance, and parenteral antibiotics should be given at the earliest opportunity usually while arranging transport to hospital. Urgent transfer to hospital is the key priority. The evidence on effectiveness of pre-hospital antibiotics is inconclusive, because disease severity is a confounding factor. Current guidelines advise giving parenteral antibiotics for suspected meningococcal disease at the pre-hospital stage. Antibiotics can be administered IV, IM, or IO. IM antibiotics should be given as proximally as possible, into a part of the limb that is still warm (the cold area being more poorly perfused).
Choice of antibiotic:
Pre-hospital administration of Benzylpenicillin has been recommended since 1988, and expert guidelines continue to recommend that all GPs carry it and inject it unless there is a history of immediate allergic reactions after previous penicillin administration. GPs do not need to carry alternative antibiotics, but third generation Cephalosporins (Cefotaxime rather than Ceftriaxone for first line use in meningococcal septicaemia) and Chloramphenicol are recommended alternatives if available. Thamesdoc carries Benzylpenicillin, Cefotaxime and Chloramphinicol.
Paramedics have the mandate to give Benzylpenicillin for suspected meningococcal septicaemia with a non-blanching rash, and the Joint Royal Colleges Ambulance Liaison Committee and Meningitis Research Foundation have collaborated to produce a guideline for paramedics on this.
Transfer to Hospital
The patient should be transferred to hospital by the quickest means of transport, usually 999 ambulance. Ambulance control and hospital staff need to know the diagnosis, whether the patient has a non-blanching rash, and especially whether there are serious prognostic signs such as a rapidly evolving rash, shock, or impaired conscious level. A GP referring a patient to hospital should contact the on-call paediatrician/emergency personnel so that they can expect this patient. 1>