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RACP DWE Paediatrics study materials
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The 2-Year-Old With a Seizure and a Rash

RACP DWE Paediatrics · Put your knowledge to work in context.

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The 2-Year-Old With a Seizure and a Rash

A 2-year-old boy is brought to the emergency department after a 4-minute generalised tonic-clonic seizure at home. He has had 3 days of fever, coryza, and cough. He is now drowsy but rousable, temperature 39.2°C, HR 160, RR 40, SpO2 96% in air, capillary refill 3 seconds, and cool peripheries. There is a blanching erythematous rash on the trunk and a few petechiae on the lower limbs. He has not had vaccinations since 12 months because the family moved repeatedly. He is not on any regular medication and has no known allergies.

1. What is your immediate assessment and management priority?

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This is a febrile child with a seizure, a rash, and signs of shock - cool peripheries, capillary refill of 3 seconds, tachycardia, and tachypnoea. The priority is to treat as suspected meningococcal sepsis until proven otherwise.

Immediate assessment:

  • Airway: patent, but reassess continuously.
  • Breathing: RR 40, SpO2 96% - give high-flow oxygen if SpO2 falls below 94% or if there is respiratory distress.
  • Circulation: HR 160, CRT 3 seconds, cool peripheries - signs of compensated shock. Obtain IV access (or IO if IV fails within 2 attempts or 2 minutes).
  • Disability: drowsy but rousable; check blood glucose immediately - hypoglycaemia can cause seizures and must be corrected.
  • Exposure: examine the rash fully. Petechiae and a blanching rash in a febrile child are a red flag for meningococcal disease.

Management priority - resuscitation first:

  1. Glucose: check and treat hypoglycaemia (e.g., 2 mL/kg 10% dextrose IV).
  2. Fluid bolus: 10–20 mL/kg of 0.9% saline over 10–20 minutes, reassessing after each bolus. In septic shock, be cautious with large volumes if there are signs of cardiac dysfunction or raised ICP; reassess frequently.
  3. Antibiotics: give IV ceftriaxone (or cefotaxime) immediately after access is obtained - do not delay for LP or imaging. Add vancomycin if there is concern about resistant pneumococcus, per local protocol.
  4. Seizure management: if the seizure recurs or is ongoing, treat with a benzodiazepine (e.g., lorazepam or midazolam) at the appropriate dose, then a second-line agent if needed.
  5. Senior help and transfer: call for senior paediatric and anaesthetic support; arrange urgent transfer to a paediatric intensive care unit.

Do not perform a lumbar puncture before antibiotics if there is any concern about raised intracranial pressure or instability. Antibiotics come first.

2. The parents ask whether the rash could be a simple viral rash and whether the vaccines are to blame. How do you respond, and what public health actions are needed?

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Responding to the parents:

  • Be honest but calm: "The rash could be caused by a virus, but the combination of fever, a rash that includes small bleeding spots, and poor circulation means we have to treat for a serious bacterial infection until we know otherwise. The treatment is safe and starting it early saves lives."
  • Explain that the petechiae (small non-blanching spots) are the concerning feature, not the blanching part of the rash.
  • Address the vaccine question: the child has not been fully vaccinated, which increases the risk of serious infections including pneumococcal and meningococcal disease. Vaccines do not cause meningococcal sepsis. Do not blame the parents; explore barriers to vaccination (mobility, access, language) and offer catch-up vaccination once he has recovered.
  • Explain that a febrile seizure can occur with any fever and is not necessarily a sign of brain infection, but the rash and shock mean we must treat aggressively.

Public health actions:

  • Notify the local public health unit immediately of suspected meningococcal disease - this is a notifiable disease in most jurisdictions.
  • Public health will arrange chemoprophylaxis (usually rifampicin, ciprofloxacin, or ceftriaxone) for close household contacts and advise on exclusion from childcare.
  • The child should be excluded from childcare until 24 hours after starting appropriate antibiotics.
  • Ensure the family is given written information and a contact number for public health.
  • Document the notification and the advice given.
  • Consider whether other children at the same childcare or household need prophylaxis, and follow public health guidance.