What is the appropriate course of action for a non-blanchable (non-blanching) rash?

Non-Blanching Rash: Immediate Assessment and Management

A non-blanching rash requires urgent evaluation for meningococcal disease, with immediate antibiotic administration if sepsis is suspected, based on clinical risk stratification using NEWS2 scoring and specific high-risk features.

Immediate Risk Assessment

Evaluate for life-threatening meningococcal sepsis immediately when a non-blanching petechial or purpuric rash is present, as this represents a medical emergency with significant mortality risk if treatment is delayed 1.

High-Risk Features Requiring Immediate Action

Consider the patient at high risk of severe illness or death from sepsis if any of the following are present 1:

• Mottled or ashen appearance
• Non-blanching petechial or purpuric rash (the key finding in your case)
• Cyanosis of skin, lips, or tongue
• NEWS2 score ≥7 (indicating high risk)

Clinical Assessment Algorithm

Calculate a NEWS2 score to stratify risk systematically 1:

• NEWS2 ≥7: High risk of severe illness or death from sepsis
• NEWS2 5-6: Moderate risk
• NEWS2 1-4: Low risk
• NEWS2 0: Very low risk

Important caveat: The presence of a non-blanching rash alone elevates risk assessment independent of NEWS2 score 1. Clinical judgment must interpret NEWS2 in context of the patient's underlying physiology and comorbidities 1.

Immediate Management Based on Risk

For High-Risk Patients (Non-Blanching Rash Present)

Administer antibiotics within 1 hour of presentation 1:

• Give intravenous ceftriaxone immediately after obtaining blood cultures and meningococcal PCR 2
• Do not delay antibiotics for diagnostic procedures 1
• Pre-hospital antibiotic administration is widely advocated and makes good clinical sense, even though randomized controlled trial evidence is lacking due to ethical constraints 1

Ensure senior clinician review immediately 1:

• Children with suspected meningococcal infection should be reviewed and treated promptly by a senior and experienced clinician 1
• Discuss early with paediatric intensive care staff for progressive disease 1

Reassessment Intervals

Re-calculate NEWS2 and re-evaluate risk periodically 1:

• Every 30 minutes for high-risk patients
• Every hour for moderate-risk patients
• Every 4-6 hours for low-risk patients

Differential Diagnosis Considerations

While meningococcal disease is the most critical diagnosis to exclude, other conditions can present with non-blanching rash 3, 2:

Other Serious Causes to Consider

• Henoch-Schönlein purpura (HSP): Palpable purpura typically on lower limbs and buttocks, may have associated joint swelling 2
• Acute haemorrhagic oedema of infancy (AHOI): Large purpuric lesions with limb oedema in infants, benign course 2
• Vasculitis: May present with purpuric rash, requires complement levels and autoimmune screening 2, 4
• Drug hypersensitivity syndrome: Can progress to toxic epidermal necrolysis with systemic involvement 5

Key Distinguishing Features

For meningococcal disease 1, 3:

• Classic non-blanching petechial or purpuric rash with fever
• Rapid progression of rash
• Systemic signs of sepsis (tachycardia, hypotension, altered consciousness)
• May present initially with non-specific symptoms or blanching rash before petechiae develop

Common diagnostic pitfalls 1:

• Half of children with meningococcal disease are sent home at first presentation
• Children may present with fever, diarrhea, and/or vomiting but without rash initially
• Children may present with a blanching rash that later becomes non-blanching

Critical Management Principles

Do not wait for diagnostic confirmation before initiating treatment in suspected meningococcal disease 1:

• Blood cultures and meningococcal PCR should be obtained but must not delay antibiotic administration 2
• An experienced clinician's assessment is better than any tests in evaluating febrile children for serious illness 1

Ensure appropriate supervision and escalation 1:

• Failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure to administer adequate inotropes were independently associated with increased risk of death in meningococcal disease 1

Monitor for deterioration 1:

• Consider risk as higher than NEWS2 score suggests if condition is deteriorating or has not improved since previous assessment or interventions 1