A pupuric rash in a child evokes a huge amount of fear in both parents and health professionals. The exclusion of septicaemia particularly meningococcal sepsis is a priority in these cases but other diagnoses should also be considered

PAP4– Blood Disorders

EM Curriculum: (click to view)

Background

Thanks to the public health campaigning surrounding meningitis and meningococcal sepsis the majority of parents are acutely aware of the potential seriousness of a non-blanching rash.

However most children presenting with such a rash will not have a life-threatening cause and it is important to be able to distinguish the well vs unwell child with petechiae & purpura and manage them accordingly.

Parents may require significant reassurance and explanation if you are wishing to discharge their child home due to fears about potential serious diagnoses. Bruising is the most common finding in cases of physical child abuse with head and neck being the commonest sites.

However children also sustain bruises as a result of simple accidents so it is important to be able to distinguish between the two [1].

A pupuric rash in a child evokes a huge amount of fear in both parents and health professionals. The exclusion of septicaemia particularly meningococcal sepsis is a priority in these cases but other diagnoses should also be considered

Diagnoses to consider in a child with a purpuric rash:

  1. Septicaemia esp Meningococcal disease

  2. Viral illness

  3. Trauma/NAI

  4. Idiopathic thrombocytopaenia

  5. Henoch Schonlein Purpura

  6. Acute leukaemias

  7. Haemolytic Uraemic Syndrome

References:

  1. Maguire S et al. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child 2005; 90: 182-186

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Recall the common presentations and complications of sickle cell crisis.

  • Be able to prescribe appropriate analgesia and fluids to manage a patient in sickle cell crisis.

  • Summarise the causes of purpura in children.

  • Recognise patterns of bruising suggestive of NAI.

LEARNING OUTCOMES FROM FACE-TO-FACE TEACHING

  • Recognise features in children with purpura suggesting a serious cause.

  • Evaluate and manage patients with life threatening causes of purpura.


TASKS

Complete the following before the face to face session:

TASK 1: Evaluation of purpura in children

Duration: 40 mins

Read the follow entries from UpToDate® (requires subscription) and Don't Forget the Bubbles (#FOAMed).

Task 2: Sickle Cell Crisis

Duration: 30 mins

Seen in both adults and children, sickle crisis is not only painful but it is also likely to be recurring, this makes the management more than just fluids, oxygen and analgesia. There are also some specific complications to look out for. Read this entry from LitFL to provide an initial overview of the topic.

Task 3: Henoch Schonlein Purpura

Duration: 20 mins

HSP: What is it and what do you need to look for? This eMedicine article gives a good grounding in what you need to consider.

Task 4: ITP – Immune Thrombocytopenia / Idiopathic Thrombocytopenia Purpura

Duration: 10 mins

Listen to this podcast from Brad Sobolewski (@PEMTweets), the PEMBLOG website has lots more content and is well with checking out. Bear in mind it is american and you need to know that a CBC is a FBC.


#EM3 Content

Lightning Learning:

Simblog:


CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

A 14 year old girl with known sickle cell disease presents with chest pain. She has had a cough for a few days but no other symptoms.
A 15 year old boy is brought in by his parents who are very concerned about a rash that has appeared today which is shown in the picture below.

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse?

This review by the Welsh Child Protection Systematic Review Group aimed to answer the above question. This article in conjunction with their website Core Info provides a detailed review of the world literature available on this topic.

PEDIATRIC EM MORSELS

PEDS CASES


COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: