(Acknowledgements to the Clinical Excellence Commission, NSW Health, for original title – 2017)
This article is not a criticism of care and should not be used or interpreted as such. Full consent has been given by family and medical teams to share for learning purposes, with names changed for privacy.
Recognising a child who is septic or critically ill isn’t always easy, even for the most experienced of clinicians. Countless sepsis screening tools, scholarly publications, guidelines and scoring systems have been proposed and refined over the years to great fanfare and hope. Yet all too often, a media article surfaces where sepsis or critical illness wasn’t recognised early enough, with devastating consequences. ‘Lessons will be learnt’ gets trumpeted and ‘safeguards put in place’. Yet quietly and depressingly we know it will probably happen again, somewhere…
Grace was a 5-year-old girl with no prior medical issues, up-to-date immunisations, and deeply loved.
After a few days of fever, rash, otalgia and diarrhoea, Grace wasn’t herself, and her parents booked an appointment with a practitioner at their General Practice (GP), who was concerned and sent her to the local Emergency Department (ED).
After a dose of Calpol brought down her temperature, Grace passed a fluid challenge. A viral upper respiratory tract infection was diagnosed, and she was discharged home with general safety netting advice. So far, so good, a ‘run of the mill’ case.
But, dear reader, you know something happens otherwise you wouldn’t have read this far.
‘It’s always viral, until it isn’t.’
Grace continued to not be herself and her parents brought her back to their GP for review. The same symptoms were present, and her family reassured her that this was a nasty virus.
A couple of days later, she was still febrile and lethargic and again presented to her GP.
This was Grace’s third attendance at a healthcare provider for the same illness and is what’s colloquially known as ‘the hat trick’, with multiple presentations a common theme in paediatric critical illness and death.
When reviewing a child who has presented 3 or more times to singular or multiple healthcare providers for the same illness, one really questions the initial diagnosis.
Is there diagnostic anchoring?
Have/are we missing something more subtle?
At a minimum, these children require bloods (including lactate) and a senior decision-maker review.
A few hours after her third GP attendance, Grace’s parents decided to attend their local ED (day 7 of illness).
A cough, a blanching rash, and a red throat were noted, along with elbow pain and swelling.
Grace had fallen awkwardly on her trampoline at the start of the illness, and clinicians wondered if there was an injury on top of an infection.
Tachycardia (80-120 = normal range) at 172 and 166 (1hour later) in the absence of fever was also present.
As Grace wasn’t febrile at triage, she did not trigger the sepsis screening tool.
She appeared pale and confused and didn’t want to be touched.
X-ray imaging of her arm was requested with referral to the orthopaedic team for a possible supracondylar fracture.
For the uninitiated/enlightened, this may feel reasonable, and 99% of the time, nothing untoward may occur. However, back in 2021-22, this article gave a synopsis for why ‘persistent tachycardia’ is something to take seriously, and one could argue that it was present at discharge from the first medical review 4 days prior, when her lowest HR was 157.
‘Persistent tachycardia is a red flag for critical illness.‘
Persistent tachycardia (PT):
No agreed definition currently exists for PT, but it can be simply defined as ‘…a continued pulse rate above baseline for a sustained period of time’. Fever/pain/anxiety are absent from this definition as they do not generally cause a persistently high pulse rate. Explaining away tachycardia due to these or other reasons (‘she’s just sick’) is a perilous road…
But what about the evidence? Limited but increasing. PT has been shown to be present in 60% of paediatric cases involving critical illness and death, with a recent paper proposing 2-4 hours as an appropriate timeframe to become ‘persistent’. And yet, other papers note that tachycardia at discharge is not associated with increased risk, as discussed previously. However, tachycardia at discharge is not necessarily the same as persistent tachycardia and yet the two are clearly related…
Back to Grace, whose arm imaging looked pretty normal to the ED doctors.
The orthopaedic team felt cellulitis or a septic joint was most likely.
Unfortunately, some delays occurred in administering antibiotics and in specialist review, but of real note was that Grace’s pulse remained persistently high throughout (7+ hours).
‘The trend is your friend’
Grace continued to deteriorate with hypotension (BP initially normal) and rising lactates despite fluid boluses, antibiotics and inotropes, and her arm became increasingly painful and swollen.
The local Plastics team did not feel there were signs of necrotising fasciitis, but all agreed Grace was severely unwell, requiring Paediatric intensive care support.
Events from this point are best summarised in this detailed case report with Grace and her family enduring indescribable heartache, limb amputation, cardiac arrest, prolonged ICU stay, multiple surgeries and eventual survival.
Both Grace and her parents have visible and invisible scars from this heartbreaking journey. Many will heal and lessen over time, and others may not.
The key learning from this case is not necessarily the final rare diagnosis, but that the lead-up and backstory are anything but.
Better sepsis screening?
In both ED presentations, Grace did not trigger the local sepsis tool, and applying the recently internationally agreed Phoenix sepsis criteria (which include BP but not pulse), she would not have triggered even on her final presentation.
Medicolegally you could argue ‘What else could be done?’ but that ignores the argument Grace had persistent tachycardia and therein lies the rub.
Can we learn?
What if Grace had blood tests on her first ED presentation? Would they have been abnormal, and would earlier antibiotics have changed the course of events? We just don’t know. However, the lessons from Grace and the common themes they share could one day save a child’s life.
The hat trick – multiple presentations in the same illness, what are we missing?
Ignore persistent tachycardia at your peril – Grace was discharged home with persistent tachycardia with a delayed system-level response on reattendance.
Persistent tachycardia is probably the most powerful and underappreciated physiological sign in a septic child. You may change the course of a life by recognising and acting on it.
References
Should you care about persistent tachycardia? – Don’t Forget the Bubbles
Aldridge P, Baldock AJ, Baird J, Elson A, McGregor S. Recurrent themes from paediatric mortality and morbidity: a network perspective 2021–2023. Archives of Disease in Childhood. 2024 Apr 1;109(4):354-5.
Mutic A, Tan E, Fahey M, Callander E, Haskell L, George S, Borland M, Loftus N, Kasza J, Furyk J, Phillips N. Australian Emergency Department Doctors and Nurses’ Perspectives on the Duration of Persistent Tachycardia in Children. Emergency Medicine Australasia. 2025 Aug;37(4):e70118.
Wittmann S, Jorgensen R, Oostenbrink R, Moll H, Herberg J, Levin M, Maconochie I, Nijman R. Heart rate and respiratory rate in predicting risk of serious bacterial infection in febrile children given antipyretics: prospective observational study. European Journal of Pediatrics. 2023 May;182(5):2205-14.
Yusuf S, Carter MJ, Woodruff J, Kalu P, Wormald JC, Sethu C. Paediatric case of invasive group A streptococcal necrotising myositis: diagnostic challenges and lessons learned. The Lancet Infectious Diseases. 2025 Aug 14.
Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024 Feb 27;331(8):665-74.
