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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

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Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Non-Blanching Rash, management in children, Paediatrics (537)

Objectives

Guidance for the diagnosis and management of children presenting with a non-blanching rash. It includes a management algorithm and photos to aid the clinician. 

Scope

Children presenting with a non-blanching rash.

Audience

Medical and nursing staff in the Emergency Department and Acute Care Environments. 

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

Management of the Child with a Non-Blanching Rash Algorithm go straight to algorithm if patient unwell.

It is not uncommon for children to present to the Emergency Department with a non-blanching rash (accounting for approx. 2% of all attendances) +/- fever and other systemic features of illness. 1, 2

The minority of children with invasive bacterial infections, such as meningococcal disease (MCD), must be distinguished from the majority of individuals presenting with a non-blanching rash secondary to a benign self-limiting illness (90% of paediatric hospital presentations with NBR  do not have MCD; furthermore petechiae can be found in up to 3% of well infants). 3, 4, 5

Meningococcal disease remains the leading infectious cause of death amongst the paediatric population within both the UK and the developed world. The highest rates of invasive infection are in children < 5yrs (particularly those under 1yr of age); a second peak occurs amongst 11 – 22yr olds. Early recognition & treatment has been shown to improve outcome. 6, 7

  • Petechiae: pinpoint-sized capillary haemorrhages (< 2mm in diameter)
  • Purpura: essentially coalesced petechiae measuring > 2mm
  • Ecchymoses: lesions of a similar appearance to purpura, but > 1cm in size (i.e. bruises) 8

If in any doubt – Treat as Meningococcal disease

Differential Diagnoses:

  1. Invasive Meningococcal Disease
  2. Sepsis with other Bacteria
  3. Trauma / Non-Accidental Injury
  4. Thrombocytopenia
  5. Viral Illness
  6. Mechanical (secondary to transient increases in vascular pressure e.g. straining, coughing or vomiting; manifestation of petechiae in the distribution of the superior vena cava – i.e. above the patient’s nipple line)

  7. The following groups are distinct diagnoses and often have specific signs and symptoms:
    1. ITP: Idiopathic Thrombocytopenia
    2. HSP: Henoch-Schönlein Purpura
    3. Acute Leukaemia
    4. HUS: Haemolytic Uraemic Syndrome 5, 8, 9

Once the above differentials have been excluded, this leaves us with a further group of children in whom we need to distinguish invasive meningococcal disease and other underlying bacterial sepsis from self- limiting viral illness or a traumatic / mechanical cause.

The algorithm in this guideline is based on observation & investigation of these children and acts as a guide to their initial assessment and management.


Management of the Child with a Non-Blanching Rash: 6, 7, 15, 16

Management algorithm

* Children who have received pre-hospital IM / IV Benzylpenicillin:

  • Follow the NBR guideline as above on initial ED presentation
  • Regardless of clinical condition → these children will require hospital admission for an observation period of a minimum of 6 – 8hrs post-antibiotic administration

**The “ILL” Criteria:

Children should be considered unwell when they have the following features:

  • Abnormal Vital Signs:
  • Tachycardia
  • Tachypnoea +/- oxygen desaturation in air
  • Increasing systolic to diastolic difference in blood pressure
    (i.e. a widening pulse pressure)

  • Poor Peripheral Perfusion:
  • Cold Extremities
  • Prolonged Capillary Refill Time > 2 secs

  • Altered Conscious State:
  • Irritability (inconsolable crying or screaming)
  • Lethargy (as reported by family or other medical / nursing staff) 5, 15

***ESSENTIAL PROCESS PRIOR TO DISCHARGE FROM RHC:

Ensure clear & appropriate indications for return advice given to child’s parent / guardian.

See this parent information leaflet for additional guidance on return advice

Important Points:

Indicators of meningococcal disease (or other serious bacterial infection) include:

  • The unwell child (see above NBR treatment algorithm + ILL criteria)
  • Purpura > 2mm diameter (unless clinical picture suggestive of HSP)
  • Abnormal blood indices (of which WCC & CRP are most often appraised)

Evidence is based on both retrospective and prospective observational studies; the salient points include:

  • It is highly unlikely significant bacteraemia is present if the non-blanching rash is localised to an SVC distribution and is not spreading
  • No single serological factor (i.e. FBC or CRP) can rule-out significant bacterial illness on its own
  • If observation is required → a period of 4hrs is recommended
  • The presence of purpura make meningococcal disease more likely 4, 5, 6, 7

 

Idiopathic Thrombocytopenia: 


Click to view larger version of image

  • Most common haematological cause of a non-blanching rash
  • Affected children are typically well (with an absence of fever / other signs of infection)
  • Majority present between the ages of 2 – 5yrs
  • 60% have a preceding viral infection                     
  • Petechiae, purpura and bruising are often present in sites of frequent mild trauma
  • Physical examination is usually otherwise unremarkable (i.e. no hepatosplenomegaly)
  • Caused by destruction of circulating platelets by IgG-based platelet antibodies
  • The platelet level at which petechiae appear spontaneously is usually ≤20 x 109/L
  • Suspicion of ITP always necessitates taking a FBC + Blood Film (demonstrating isolated thrombocytopenia with an otherwise normal blood film appearance)
  • A self-limiting disorder overall; > 80% spontaneously resolve within 6 – 8 weeks 8, 10

Henoch-Schönlein Purpura:


Click to view larger version of image

  • An IgA-mediated systemic small vessel vasculitis
  • Classical symmetrical distribution of palpable purpura - predominantly over the child’s buttocks, lower limbs and ankles
  • Often associated with arthritis, peripheral oedema and colicky abdominal pain
  • May have associated renal involvement (with haematuria +/- proteinuria)
  • Diagnosis is uncommon < 2yrs of age; usually manifests between 3 – 10yrs
  • Incidence peaks throughout the winter months; often preceded by an URTI
  • If clinical diagnosis uncertain: Take blood for: FBC (platelet levels should be within normal range), Coagulation Screen, U&Es and Bone Profile (to monitor renal profile)
  • Blood Pressure & patient's height measurement taken (determine BP centile based on child’s sex, age + height)
  • Urinalysis; plus send urine samples to quantify protein : creatinine ratio and for microscopy, culture & sensitivity
  • Most cases have a benign course with remission occurring within ~ 6 weeks 8, 10, 11

See RHC Clinical Guidelines for further information regarding initial assessment and management

Acute Leukaemia:

  • Most common paediatric malignancy → accounts for 1/3rd of all childhood cancers
  • Typically short history (manifesting over days-to-weeks)
  • Consider in children with: hepatosplenomegaly, lymphadenopathy, easy bruising, petechiae (in absence of trauma), pallor, fatigue, weight loss, bone + / - joint pain etc.
  • Diagnostic tests: Baseline Bloods (including: FBC, Blood Film, U&Es, Bone Profile, LFTs, LDH); CXR (to exclude mediastinal mass)
  • Discuss any suspected new diagnoses with on-call consultant haematologist 9, 10

Haemolytic Uraemic Syndrome:  

  • Rarely causes petechiae or purpura
  • Commonest cause of acute renal failure in Scotland
  • Usually follows a diarrhoeal prodrome (often bloody)
  • Most cases due to verotoxin-producing Escherchiae coli
    (0157:H7 most prevalent subtype)       
  • A triad of:
    1. Microangiopathic Haemolytic Anaemia
    2. Thrombocytopenia                                                                  
    3. Acute Renal Failure
  • Mainstay of management involves acute assessment of patient’s intravascular status with subsequent fluid resuscitation as appropriate
  • Correction of electrolyte abnormalities thereafter
  • Avoidance of NSAIDS e.g. Ibuprofen
  • See link to HUS guideline below for preliminary tests and further management 10, 12

See RHC Clinical Guidelines for additional information

 

Further Considerations:

Viral Cause:

  • Petechial rash may be associated with viral illnesses (of which, enterovirus & adenovirus are the most prevalent causes)
  • Presentation is often with an URTI +/ - ‘flu-like symptoms or gastroenteritis
  • In a study of 69 children with a petechial rash in Germany: Schneider et al. (2013) found that petechial rashes restricted to an SVC distribution + a CRP value within normal parameters (quantified as < 6mg/L) did not have Invasive Meningococcal Disease 5, 8, 9, 13

Trauma:  

Where there are concerns that a NBR may be due to non-accidental injury:

  • Address safeguarding concerns & discuss with Senior Medic / Consultant
  • See existing Child Protection Guideline for further details regarding appropriate management: 4, 5, 8, 14

Editorial Information

Last reviewed: 10/12/2024

Next review date: 30/06/2025

Author(s): Dr Aoife Ryan (Paediatric Medicine Trainee, RHCG).

Version: 2

Approved By: Paediatric Emergency Medicine & Acute Paediatric Medicine Clinical Governance Groups

Reviewer name(s): Paediatric Clinical Effectiveness & Risk Committee .

Document Id: 537

References
  1. Wells LC, Smith JC, Weston VC, et al. The child with a non-blanching rash: how likely is meningococcal disease? Arch Dis Child 2001; 85 : 218 – 22.
  2. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr 1997; 131 : 398 – 404.
  3. Brogan P, Raffles A. The management of fever and petechiae: making sense of rash decisions. Arch Dis Child2000; 83: 506 - 507.
  4. Riordan F.A. et al. Non-Blanching Rash Audit Group. Validation of two algorithms for managing children with a non-blanching rash. Archives of Disease in Childhood 2016:101(8): 709 - 713.
  5. Barnetson L et al. Petechial rash in children: a clinical dilemma.Emergency Nurse: The Journal Of The RCN Accident And Emergency Nursing Association 2016: 24(2): 27 - 35.
  6. NICE Clinical Guideline [Internet]. Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. National Institute for Health and Clinical Excellence; 2010: CG102. [updated Feb. 2015; cited 2018 March 28th 2018]. 
  7. SIGN National Clinical Guideline [Internet]. Management of invasive meningococcal disease in children and young people. Scottish Intercollegiate Guidelines Network; 2008: CG102. [cited March 28th 2018]. 
  8. May N. Don’t Be Rash: Petechiae in well kids at St. Elmyn’s [Internet]. Manchester; 2003. [cited March 28th 2018]. 
  9. Waterfield T, Dyer E.M, Lyttle M. D. Fifteen-minute consultation: the child with a non-blanching rash. Archives of Disease in Childhood - Education and Practice. 
  10. Tasker R.C, McClure R.J, Acerini C.L, editors. Oxford handbook of paediatrics. 2nd Oxford (UK): Oxford University Press; 2013.
  11. Royal Hospital for Children. Clinical Guideline on: Henoch-Schonlein Purpura (HSP); renal management on presentation with. [Internet] GG&C Guidelines [updated Feb. 2017; cited March 28th 2018]. 
  12. Royal Hospital for Children. Clinical Guideline on: Haemolytic Uraemic Syndrome; investigation and management of. [Internet] GG&C Guidelines [updated Oct. 2016; cited March 28th 2018]. 
  13. Schneider H, Adams O, Weiss C et al. Clinical characteristics of children with viral single and co-infections and a petechial rash. The Pediatric Infectious Disease Journal 2013; 32 (5): 186 - 191.
  14. Royal Hospital for Children. Clinical Guideline on: Child Protection Protocol. [Internet] GG&C Guidelines [updated Oct. 2016; cited March 28th 2018]. 
  15. Royal Children's Hospital. Clinical Practice Guideline on: Fever and petechiae – purpura. [Internet] Melbourne, Australia. [cited March 28th 2018]. 
  16. Thomas A.E, Baird S.F, Anderson J. Purpuric and petechial rashes in children: initial assessment. [Internet] BMJ Best Practice [cited March 28th 2018].