Medical Advanced

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

Pediatric · 8yr · male

Patient Information

Dispatch: You are called to the First Aid Post at the Perth Royal Show. A parent has brought in an 8-year-old male (Lachlan Nguyen) who is unwell with fever and a rash that appeared in the last hour.
Patient: Lachlan Nguyen — 8yr (26kg)
Incident History: Lachlan's mother brought him to the FAP after noticing he had become increasingly unwell during the day — started with a headache and fever this morning, now has a rash on his arms and legs. Mum states he seemed fine at breakfast. She is refusing ambulance transfer as she believes he just has a viral illness and does not want to disrupt the family's day.
Emergency Contact: Thanh Nguyen (Mother (present on scene)) — 0412 387 651

Initial Rapid Assessment

Response: Voice
Airway: Patent. No airway obstruction. No stridor. Mouth moist.
Breathing: Increased work of breathing. RR elevated. No audible wheeze or crackles. Bilateral chest rise present.
Circulation: Rapid, weak radial pulse. Skin warm and flushed centrally. Non-blanching petechial rash visible on bilateral forearms and lower legs. CRT 3 seconds.
Disability: GCS 13 (E3V4M6). Drowsy and irritable. Not fully oriented to time or place. Photophobia present — patient turns away from light.
Exposure: Non-blanching petechial/purpuric rash visible on bilateral forearms, lower legs and beginning to appear on trunk. No obvious external haemorrhage. Neck stiffness noted on passive assessment — patient resists neck flexion.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	94% (RA)	Moderate	28	136	88/56	3s	13	4 4 SL	39.8	3.6 mmol/L	7
10 mins	98% (O2 NRB 15L/min)	Moderate	30	144	84/52	4s	11	4 4 SL	40.1	3.4 mmol/L	8

History Taking

Treatment Response

Diagnosis

This patient is suffering from suspected meningococcal septicaemia (meningococcal disease) presenting with septic shock, non-blanching petechial/purpuric rash, meningism, and haemodynamic compromise meeting Red Flag sepsis criteria.

Facilitator Triggers — if trainees miss a critical step

! (If the non-blanching rash is not assessed or the glass tumbler test is not performed within the first 3 minutes of assessment — the rash visibly spreads to the trunk and mum points it out in distress, prompting reassessment.)
! (If oxygen is not applied within 3 minutes of initial assessment — SpO2 drops to 91% on RA and patient becomes more obtunded, GCS drops to 11.)
! (If the trainee fails to identify Red Flag Sepsis criteria or does not initiate CSP contact — facilitator prompts: 'Mum asks you, is this serious? Should we call an ambulance?' — trainee must now clearly escalate.)
! (If the trainee does not attempt de-escalation with the mother and simply moves to treatment without addressing her refusal — the mother physically steps between the trainee and Lachlan and states: 'I said NO ambulance. He just needs to rest.' Trainee must use calm, clear communication to explain the non-blanching rash significance and the risk to Lachlan's life.)
! (If de-escalation fails and the mother continues to refuse after the trainee clearly explains the non-blanching rash is a medical emergency — facilitator advises the trainee to contact CSP/Duty Manager immediately for support and escalation guidance, and document the refusal.)
! (If BGL of 3.6 mmol/L is not acted upon — at 10 minutes BGL drops to 3.4 mmol/L and patient becomes more drowsy — trainee must reassess and consider glucose oral gel if GCS remains 15 after reassessment; note current GCS is 13 so oral gel is NOT safe to administer — this is an advanced learning point: oral glucose is contraindicated below GCS 15.)
! (If paracetamol is considered — trainee must check last dose time: mother gave 240mg chewable tablets 3.5 hours ago, which is within the 4-hour minimum interval. Paracetamol is CONTRAINDICATED until at least 4 hours have elapsed from last dose — correct trainee if they attempt to administer it.)
! (If the patient vomits during assessment — trainee must immediately apply lateral position to protect airway, suction if required, and reassess airway/breathing.)

Treatment Objectives

1 Don appropriate PPE — gloves and eye protection minimum for all patient contact.
2 Perform Primary Survey — assess ABCDE systematically, correct immediate life threats as found.
3 Identify non-blanching petechial rash — perform glass tumbler/blanching test on rash: press a clear glass or finger firmly against rash and observe — rash does NOT blanch under pressure. This is a Red Flag finding requiring immediate escalation.
4 Apply high-flow oxygen via non-rebreather mask at 10–15 L/min — titrate to achieve SpO2 94–98%.
5 Position patient in position of comfort — semi-recumbent or supine, avoid unnecessary movement.
6 Apply pulse oximetry and monitor SpO2 continuously.
7 De-escalate with mother (Thanh Nguyen) — use calm, non-confrontational language. Clearly explain: 'The rash Lachlan has is a type that does not go away when pressed. This is a sign of a serious infection in the blood that is a medical emergency. He needs to go to hospital right now by ambulance. Every minute matters.' Allow mother to voice concerns, acknowledge them, but be clear and direct about the urgency and risk to life.
8 Contact CSP immediately — advise of suspected meningococcal septicaemia with non-blanching rash, paediatric patient, haemodynamic compromise, and parent initially refusing transfer. Request Clinical Support Paramedic guidance and urgent ambulance via CSP dispatch.
9 Identify Red Flag Sepsis criteria: altered mental state (GCS 13), hypotension (BP 88/56 — check against paediatric threshold: SBP < [70 + 2×8] = 86 mmHg — borderline), tachycardia (HR 136), tachypnoea (RR 28), SpO2 94% on RA, non-blanching rash. Document Red Flag Sepsis on ePCR.
10 Perform full Vital Signs Survey — GCS, BGL, SpO2, HR, RR, BP, temperature, CRT. Record on ePCR.
11 Assess BGL of 3.6 mmol/L — note this is above 4 mmol/L treatment threshold; do NOT administer glucose oral gel. Monitor BGL closely and reassess at 10 minutes.
12 Do NOT administer paracetamol — last dose given 3.5 hours ago (240mg chewable tablets). Minimum interval is 4 hours. Paracetamol is contraindicated until at least 4 hours from last dose have elapsed. Facilitator note: even if the interval had elapsed, trainee should confirm GCS is 15/15 for safe oral administration — current GCS 13 makes oral paracetamol unsafe.
13 Do NOT administer ondansetron — GCS is 13 and sublingual administration is unsafe at this level of consciousness. If vomiting occurs, position the patient laterally to protect the airway and escalate to CSP immediately.
14 If patient vomits — immediately place in lateral position, suction airway as required, reassess airway and breathing.
15 Prepare for rapid deterioration — have BVM, suction, OPA/NPA, and AED immediately available at bedside.
16 Minimise on-scene time — do not delay urgent ambulance via CSP while awaiting ambulance. Ensure continuous monitoring.
17 Record full observations every 5 minutes given time-critical status.
18 Pre-notify receiving hospital (paediatric ED — Perth Children's Hospital if practicable given transport) — suspected meningococcal septicaemia, paediatric male 8yo 26kg, non-blanching purpuric rash, GCS 13, haemodynamically compromised, urgent ambulance via CSP.
19 Document parent's initial refusal and subsequent consent (or ongoing refusal) accurately on ePCR — include exact words used in de-escalation and mother's response.
20 Scenario ends on arrival of ambulance and IMISTAMBO handover.
21 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Seizures · Unconsciousness · Hypoglycaemia · Oxygen · Ondansetron · Paracetamol (Childrens Chewable Panadol) · Disturbed & Abnormal Behaviour · Primary Survey · Secondary & CNS Survey · Blood Glucose Monitor · Glasgow Coma Scale (GCS) · Pulse Oximetry · Tympanic Thermometer · Lateral Position · Suction · Oxygen Delivery

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