Petechiae

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of children who present with petechiae.

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.

Definitions

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.

Key points

  • 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

Causes of petechiae

Viral Influenza
Enterovirus
Bacterial Neisseria meningitidis
Haemophilus influenzae
Streptococcus pneumoniae
Mechanical Vomiting, coughing - petechiae to the head and neck
Local pressure (torniquet, holding, trauma) - petechiae to site
Non-accidental injury (NAI)
Other Henoch Schonlein purpura (HSP)
Immune thrombocytopaenic 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, UEC, CRP, venous blood gas and coagulation profile (screen for DIC)
    • Meningococcal PCR, Blood Culture
    • +/- lumbar puncture (refer to Lumbar puncture to determine if appropriate)
  • Intravenous antibiotics: Ceftriaxone 50mg/kg - DO NOT DELAY
  • 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 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.

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 – HSP, ITP, 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.

Bibliography

  1. Fleisher GR, Ludwig S. Textbook of Paediatric Emergency Medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2010
  2. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elsevier 2012
  3. Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Nelson Textbook of Pediatrics: 20th Edition Publisher: Elsevier
  4. Evaluating the child with purpura. AFP  Leung, A K 2001

Endorsed by:  Emergency Department Guidelines team  Date:  May 2018


 Review date:   May 2021


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