‏ intro ‏ case ‏ background ‏ making diagnosis ‏ pathophysiology ‏ Management Principals ‏ Management Algorithm ‏ Development ‏

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CASE HISTORY


2.5 year old boy admitted with purpura and fever.


Paediatric assessment:
Temp 39.3, Pulse 134, RR 40, CRT 6 seconds, BP unrecordable, femoral pulses present but weak.
Cyanosed, Saturation 75% in air.  Widespread creps.
GCS 9/15, Neck stiffness+
Purpuric rash on chest.
Bloods sent for FBC, clotting, U&E, and culture


Diagnosis:Meningococcal meningitis.


Treatment:Antibiotics intravenously.
Fluids 40 ml/kg colloid in 2 boluses and 10 ml/kg crystalloid over 1 hour, then maintenance fluids.


Some improvement of CRT so left on the ward.


  help

QUESTIONS ON CASE 3


   Q 1 of 14: Adequate assessment?

Yes <correctNo

CORRECT : A full assessment would have recorded pupil size/ reaction. However this assessment was comprehensive enough to provoke urgent action, and provided enough information about the child's condition that a clear picture of what was wrong should have been evident.
Further Information

The following clinical signs must be measured and recorded to complete a full assessment:

  • Temperature
  • Heart rate
  • Respiratory rate
  • Blood pressure

  • 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)

  • Assessment of conscious level (AVPU)
  • Pupil size and reaction
  • 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.


image
Full-blown non-blanching haemorrhagic rash*

Normal values of vital signs
Age HR/min RR/min Systolic BP
<1 110-160 30-40 70-90
1-2 100-150 25-35 80-95
2-5 95-140 25-30 80-100
5-12 80-120 20-25 90-110
Over 12 60-100 15-20 100-120

From Advanced Paediatric Life Support—the Practical Approach. 30


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