Neurological

Paediatric meningococcal septicaemia — non-blanching rash with parent refusing transfer

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Pediatric · 8yr · female

Patient Information

Dispatch	You are called to the first aid post at the Perth Royal Show. A parent has brought in their 8-year-old daughter (Mia Tran) who is unwell with a headache, fever, and a rash that appeared about an hour ago.
Patient	Mia Tran — 8yr (25kg)
Incident History	Mia attended the show with her family this morning. Mum noticed she was pale and quiet around 0930, then developed a headache and fever. Mum initially thought it was heat. About an hour ago she developed a rash on her lower legs and abdomen. Mum is distressed and insisting she just needs paracetamol and rest — she does not want Mia to go to hospital.
Emergency Contact	Linh Tran (Mother) — 0412 883 047

Initial Rapid Assessment

Response	Voice
Airway	Patent. No obstruction, no stridor, no airway swelling.
Breathing	Increased respiratory rate. Shallow effort. No wheeze or crackles audible. Tachypnoeic.
Circulation	Rapid weak pulse. Skin pale, mottled lower limbs. Non-blanching petechial rash visible on bilateral lower legs and lower abdomen. Capillary refill 3 seconds centrally.
Disability	GCS 13 (E3V4M6). Oriented to person only. Drowsy, irritable when roused. Photophobia reported by mum. Pupils equal and reactive.
Exposure	Non-blanching petechial rash present on bilateral lower legs and lower abdomen. No evidence of trauma. Neck stiffness noted on assessment.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	95% (RA)	Moderate	28	138	88/60	3s (central)	13	4 4 ++	39.6	3.8 mmol/L	7
10 mins	98% (O2 NRB 15L/min)	Moderate	26	144	84/55	4s (central)	11	4 4 ++	39.6	3.5 mmol/L	8

History Taking

Treatment Response

Diagnosis

This patient is suffering from suspected meningococcal septicaemia presenting with a non-blanching petechial rash, fever, altered conscious state, photophobia, neck stiffness, and haemodynamic compromise consistent with Red Flag sepsis in a paediatric patient.

Facilitator Triggers — if trainees miss a critical step

! (If the non-blanching rash is not identified or the glass test is not performed within the first 3 minutes of assessment, mum points to the rash and asks 'Is this serious? It wasn't there this morning.' — cue trainees to inspect and perform glass test)
! (If oxygen is not applied within 3 minutes of initial assessment, GCS drops to 11 and RR increases to 32 — facilitator announces 'Mia is becoming more drowsy and her breathing is getting faster')
! (If BGL is not checked, facilitator prompts: 'You notice Mia looks pale and is not responding normally — is there anything else you want to check?')
! (If the parent refusing transfer is not addressed with de-escalation, mum states loudly 'I am taking her home, she just needs rest, you can't make me do anything' — trainees must use calm, non-confrontational communication and explain the life-threatening nature of the rash clearly and compassionately without threatening language)
! (If mum continues to refuse after explanation, trainees must escalate to CSPSOC and request ambulance dispatch Priority 1 — facilitator can prompt: 'You have explained the situation. What do you do if she still refuses?')
! (If the 10-minute vitals show deteriorating GCS and trainees have not yet requested ambulance, facilitator announces 'Mia's eyes are harder to open and she is not responding to your voice as well as before')
! (If the BGL of 3.5–3.8 mmol/L is noted but glucose gel is not considered, facilitator prompts: 'Mia's BGL is borderline — what is your threshold for treatment and is this patient able to safely swallow?' — note: at GCS 11–13 oral glucose gel safety must be assessed; if GCS drops to ≤12 it should not be administered orally)

Treatment Objectives

1. Ensure scene and FAP safety — don appropriate PPE including gloves and mask given potential infectious aetiology
2. Perform Primary Survey — airway patent, breathing tachypnoeic, circulation compromised with mottling and weak rapid pulse
3. Apply high-flow oxygen via non-rebreather mask at 10–15 L/min — titrate to SpO2 94–98%
4. Perform glass test on petechial rash — confirm non-blanching; identify this as a Red Flag sign for meningococcal septicaemia
5. Perform full Vital Signs Survey including GCS, RR, HR, BP, SpO2, temperature, BGL, CRT, and pain score
6. Assess BGL — result 3.8 mmol/L; patient currently GCS 13 and oriented to person; do NOT administer oral glucose gel at this time as conscious state is insufficient (GCS <15) and is deteriorating — monitor BGL closely and reassess
7. Identify Red Flag sepsis criteria: altered mental state (GCS 13), tachycardia (HR 138), tachypnoea (RR 28), hypotension (BP 88/60), reduced SpO2 (95% RA), non-blanching rash — document Red Flag sepsis on ePCR
8. Activate Priority 1 ambulance via CSPSOC immediately — do not delay for any treatment steps; meningococcal septicaemia is a time-critical emergency
9. Pre-notify receiving facility (Perth Children's Hospital preferred for paediatric patient) — advise suspected meningococcal septicaemia, Red Flag sepsis, non-blanching petechial rash, GCS 13, haemodynamic compromise
10. De-escalate parent (Linh Tran) using calm, empathetic, non-confrontational language — acknowledge her concerns, explain clearly that the non-blanching rash is a sign of a life-threatening condition that requires immediate hospital care, and that time is critical for Mia's survival and outcome
11. If parent continues to refuse, escalate to CSPSOC for guidance — document refusal attempts and escalation clearly; do not use threatening or coercive language; involve event management if available for additional support
12. Position Mia semi-recumbent or in a position of comfort — do not lay flat given altered conscious state and risk of vomiting/aspiration
13. Monitor GCS, RR, HR, BP, SpO2, CRT, and BGL every 5 minutes given time-critical status — document all observations
14. Prepare suction and BVM at bedside — anticipate potential deterioration in conscious state and airway compromise
15. Do NOT administer paracetamol — this is outside EHS scope as an IV medication and the oral route is not appropriate given the patient's deteriorating conscious state and risk of vomiting
16. Maintain continuous reassurance to both Mia and her mother throughout — keep environment calm, dim lighting where possible given photophobia
17. Await ambulance; prepare IMISTAMBO handover including: name/age/weight, suspected meningococcal septicaemia, non-blanching rash location and distribution, time of rash onset, current GCS, vital signs trend, Red Flag sepsis documented, parent initially refused transfer, oxygen applied, ambulance pre-notification made
18. Scenario ends on arrival of ambulance and IMISTAMBO handover
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Disturbed & Abnormal Behaviour · Unconsciousness · Seizures · Primary Survey · Blood Glucose Monitor · Oxygen Delivery · Glucose Oral Gel · Glasgow Coma Scale (GCS) · Secondary & CNS Survey · Tympanic Thermometer · Pulse Oximetry

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Signs/Symptoms	Severe headache, high fever, photophobia, neck stiffness, drowsiness, non-blanching petechial rash on lower legs and abdomen, pallor, mottling.
Allergies	Nil known drug allergies.
Medications	Nil regular medications. Nil paracetamol or ibuprofen given today — mum wanted to speak to the first aid team first.
Pertinent History	Mia is otherwise well. No recent illness in the family. Vaccinations: Mum is unsure if Mia received her Year 7 meningococcal ACWY booster — she is only in Year 3. No overseas travel. No known immunodeficiency.
Last Oral Intake	Small breakfast at approximately 0730. Nil oral intake since. No vomiting yet but complaining of nausea.
Events Leading	Family arrived at the Perth Royal Show at 0830. Mia was well on arrival. Gradually became quiet and pale around 0930. Sat down at a bench and did not want to walk or play. Mum noticed the rash while changing Mia's top approximately 1 hour ago and brought her to the FAP.
Treatment Prior	Nil treatment prior to EHS arrival. Mum applied a cold wet cloth to her forehead.

Onset	Unwell since approximately 0930 this morning — approximately 2 hours ago. Rash appeared approximately 1 hour ago and has been spreading.
Pain	Severe headache — rated 7/10 by mum on Mia's behalf. Mia states 'my head hurts really badly'. Neck pain on movement.
Quality	Constant, generalised headache. Does not want bright lights. Neck feels stiff.
Radiates	Nil radiation of pain.
Severity	7/10