Paediatric Acute care Guidelines PMH Emergency Department

Petechiae:  Pinpoint (1-2 mm) red or purple non-blanching spots on the body
Purpura:  Larger (> 2 mm) red or purple non-blanching spots on the body
Fever:    > 38°C in the > 1 month age group
                > 37.5°C in the < 1 month age group

Background

  • The cause of petechiae and fever is difficult to diagnose on presentation
  • Always err on the side of caution and obtain senior medical advice early
  • This guideline is for Princess Margaret Hospital internal use only

General

  • In Australia, most cases of meningococcal disease occur in winter or early spring.
  • Less than 10% of children with petechiae and fever will have meningococcal disease.
  • Early recognition and treatment is paramount.
  • Mortality risk is high at approximately 10%. Furthermore 10-20% of patients who survive will develop permanent sequelae.
  • Well children with petechiae confined to the area of the distribution of the superior vena cava (SVC) (above the nipple line) are unlikely to have a diagnosis of meningococcal disease.
  • Consider: investigation and treatment of children who may have received partial treatment with antibiotics

Assessment

Differential diagnoses

Causes Of Petechiae:

Viral Influenza
Enterovirus
Bacterial Neisseria meningitidis 
Haemophilus influenzae
Streptococus pneumoniae
Mechanical  Vomiting, coughing – petechiae to head and neck
Local pressure – (tourniquet, holding, trauma) – petechiae to site
Non-accidental injury (NAI)
Other Henoch Schonlein purpura (HSP)
Immune thrombocytopenic purpura (ITP)
Systemic lupus erythematosus (SLE)
Leukaemia

Management

  • All patients with petechiae need to be reviewed by an Emergency Department Senior Doctor
  • No discharge home between midnight and 8am

Initial management

Temperature > 38oC and looks unwell: 

  • Investigations:
    • FBC, U&E, CRP, venous blood gas (+/- coagulation profile to screen for DIC)
    • Meningococcal PCR, Blood Culture
    • +/- lumbar puncture (See ED guideline: Lumbar Puncture to determine if appropriate)
  • Intravenous antibiotics: Ceftriaxone 50mg/kg
  • Consider intravenous fluids: 0.9% saline 20mL/kg, repeat if signs of shock
  • Hourly observations: temperature, heart rate, respiratory rate, blood pressure, capillary refill, AVPU
  • Medical review hourly including skin (for spreading petechiae)
  • Admit to ward under General Paediatric Team
  • Consider PICU referral

If looks well :

  • No Investigations until reviewed by ED consultant (in hours)
  • If after midnight,
    • Admit to Emergency Short Stay Unit (4E) until consultant review
    • Consider investigating and treating as above for the unwell child if patient has abnormal vital signs
    • Hourly observations: temperature, heart rate, respiratory rate, blood pressure, capillary refill, AVPU
    • Medical review hourly including skin (for spreading petechiae)
  • If on review child looks unwell, has spreading petechiae or has developed abnormal vital signs – investigate and treat as above for the unwell child.I

 History of mechanical cause

  • Consider differential diagnoses:  ITP, HSP
  • If suspected non-accidental injury refer to Child Protection Unit (CPU)
  • Consider investigations for underlying aetiology – HSPITP, SLE, non-accidental injury

Discharge criteria

No signs of deterioration or progression of rash:

  • Emergency Department Senior Doctor must review the patient prior to discharge 
  • Follow up: General Practitioner within 24 hours

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