17.2 Meningococcal Septicaemia Flashcards
A 4-year-old child is admitted to the emergency department with suspected meningococcal septicaemia.
You are asked to help resuscitate the patient prior to transfer to a tertiary centre.
a) List the clinical features of
meningococcal septicaemia. (35%)
- Nonspecific symptoms and signs:
Fever, nausea and vomiting, lethargy,
irritable/unsettled, ill-looking, anorexia,
headache, muscle ache/joint pain,
respiratory symptoms and difficulty
breathing, chills, shivering,
rapid deterioration in illness.
- More specific symptoms and signs:
Non-blanching rash,
altered mental state,
capillary refill time greater than two seconds,
unusual skin colour,
shock, hypotension, leg pain,
cold hands/feet,
unconsciousness, toxic/moribund state.
b) Outline the initial management of this patient? (45%)
Meningococcal septicaemia is a medical emergency and so I would assess and manage the patient simultaneously following an ABCDE approach.
Request senior help and
give ceftriaxone 80 mg/kg intravenously
without delay.
Initiate communication with
paediatric retrieval service and download
guidance to assist with drug dosing.
A: Assess airway patency –
consider need for immediate intubation for either
respiratory compromise or moribund state
.
B: Assess respiratory rate, oxygen saturations, give 100% oxygen.
C: Intravenous access,
ideally two cannulae.
Obtain intraosseous access if
intravenous access not immediately feasible.
Assess for signs of shock:
» Capillary refill time greater than 2 seconds.
» Unusual skin colour.
» Tachycardia and/or hypotension.
» Cold hands/feet.
» Toxic/moribund state.
» Altered mental state/decreased conscious level.
» Poor urine output.
Treat shock with up to
three boluses of 20 ml/kg 4.5% human albumin solution
or 0.9% sodium chloride each over 5–10 minutes.
At the third bolus,
intubate and ventilate the child,
ensuring a cardiostable induction
with ketamine (up to 2 mg/kg)
and rocuronium (1 mg/kg).
Ensure that emergency drugs are ready.
Further fluid boluses may be required: consider using blood.
Consider contributing causes to shock:
acidosis, extravasation of fluids.
Initiate vasoactive support as per retrieval team guidance.
D: Continue to monitor the
child’s mental state
(GCS or AVPU scoring) and
need for intubation.
Assess for signs of meningism.
E: Examine child, look for rash,
check capillary blood glucose.
Send investigations as detailed in section (c).
c) Which investigations will guide care? (20%)
> > Full blood count:
blood administration may be required especially
after resuscitation with crystalloid.
Elevated white cell count supports
diagnosis of meningococcal disease,
although may be normal or even
low.
Low platelets may contraindicate lumbar puncture.
> > Coagulation screen:
management of disseminated intravascular
coagulation may be required. Results may contraindicate lumbar puncture.
> > Glucose:
hypoglycaemia may occur due to
resuscitation with non-sugar
fluids and critical illness,
supplementation may be required.
> > Electrolytes:
must be managed due to
administration of large quantities
of intravenous fluids.
> > CRP:
usually elevated in meningococcal disease,
supports diagnosis, but may be normal.
> > Arterial blood gas:
guides need for intubation and
adequacy of ongoing ventilation.
Acidosis may require treatment
if shock is persistent despite
fluids and vasoactive drugs.
> > Neisseria meningitidis whole blood PCR:
confirms diagnosis if positive.
If negative, CSF should be tested
for N. meningitidis and
Streptococcus pneumoniae PCR.
> > Blood culture:
may confirm infective organism,
therefore guiding
antimicrobial treatment.
> > CT brain: may indicate different diagnosis
or may contraindicate lumbar
puncture if features of raised
intracranial pressure are present.
> > CSF: PCR or culture may be
diagnostic of underlying cause if negative
for meningococcus.
Causative bacteria determine
the choice and
duration of antibiotics.
