In patients where sepsis is not suspected but infection is a possible or probable cause of being unwell they should have some recorded assessment of respiratory rate/effort, perfusion, and cognition. They or their carers should also receive specific safety netting as to the signs of sepsis, and ideally an age appropriate Sepsis leaflet.

Assessing Children
This can present a significant clinical challenge. Children’s physiology can vary wildly according to age and their response to infection. There is no standardisation of Paediatric Early Warning Scores as yet and the values they contain are validated against different cohorts of children to those seen in Primary care. There is also no standard paediatric definition of what determines the presence or absence of sepsis.

None of this helps the General Practice clinician. Clinical assessment should include judgement as to the history and unusual signs, including rashes abnormal alertness, clinician and parental concern. It should also contain a record of an assessment of physiology, particularly their respiratory rate/distress, perfusion (capillary refill, pulse rate) and level of cognition/social interaction.  In many children this may be represented as negative findings, (no respiratory distress, pink and playing with toys, running around room or smiling appropriately). Temperature alone is a poor predictor of wellness. The more unwell the child the more formal the assessment may need to be, particularly where the judgement is to keep the child at home.

Safety netting for children needs to be better than “if they get worse come back” and should include some indication of what worse looks like. This should be supported by an age appropriate leaflet.

Verbal advice for Parents of Children with Infection
Your child has xxx infection and is likely to improve with/without treatment. Very occasionally they can get significantly worse, signs of getting worse can include:

• Becoming increasingly breathless 
• Pale and clammy “the colour someone goes when they are about to be sick”
• Unnaturally drowsy or unresponsive
• Not passing urine in the previous 12 hours.

If these occur then you should consider getting your child assessed as a matter of urgency.

Summary

• When assessing any patient with infection consider if there are features that might suggest sepsis and document their presence or absence
• Assessment of Respiratory Rate, Blood Pressure/perfusion and cognition should all be assessed and recorded for all patients with infection
• National Early Warning Score (2017) should be considered to be the bench mark for abnormal values in adults.
• Paediatric Early Warning scores and NICE Guidance vary in their contents and values but all provide an indication of abnormal values. Clinical and parental judgement remains a strong predictors
• Oximetry should be recorded using age appropriate devices and probes
• Escalation to ambulance or other services should be done by the clinician and must include the phrase “Suspected Sepsis” and give a NEWS score in adults and abnormal physiological findings in children
• Safety Netting should be sepsis specific supported by age appropriate leaflets.

Further Reading
E-Learning for Health Sepsis Modules
RCGP Sepsis: Guidance for GPs

References
1.    Hospital Episode Statistics: Health and Social Care Information Centre. 2015. http://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2015-09-16/10526/.
2.    Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Jama 2016; 315(8): 801-10.
3.    Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical care medicine 2006; 34(6): 1589-96.
4.    Daniels R. Surviving the first hours in sepsis: getting the basics right (an intensivist's perspective). The Journal of antimicrobial chemotherapy 2011; 66 Suppl 2: ii11-23.

Appendix A
NICE Guidance  

Table 1: Risk stratification tools for adults, children and young people aged 12 years and over with suspected sepsis

Table 2: Risk stratification tool for children aged 5-11 years with suspected sepsis

Table 3: Risk stratification tool for children aged under 5 years with suspected sepsis

​Signs are of limited value in excluding the diagnosis, though the presence of a transverse high lying testes or abnormal position compared with the alternate side may support clinical suspicion.

Actions
Testicular torsion is a surgical emergency with testicular salvage possible in 90-100% of cases operated on within 6 hours of onset of symptoms, this drops to 20-50% at 12 hours after onset. Orchidectomy or subsequent testicular atrophy results in 5-50%
​
Patients should be referred for urgent assessment and kept nil by mouth until a torsion has been excluded in hospital.

Summary

• Testicular torsion may be difficult to diagnose if symptoms are intermittent or atypical, but it must be considered in all cases of scrotal pain, with careful history and examination.
• Sudden, severe onset of testicular pain with tenderness should be considered as torsion and referred, unless other clinical features suggest an alternative diagnosis.
• Examine the testis for tenderness, size, shape, and position, and examine the remaining scrotal contents, comparing findings with the unaffected side.

Case Study
https://www.themdu.com/guidance-and-advice/case-studies/testicular-torsion

Learning resources.
https://bestpractice.bmj.com/topics/en-gb/506 
https://learning.bmj.com/learning/module-intro/testicular-torsion.html?moduleId=10029430&searchTerm=“testicular torsion”&page=1&locale=en_GB 

Further Reading
Testicular Torsion  
1.    Somani BK, Watson G, Townell N. Testicular torsion. BMJ (Clinical research ed) 2010; 341.

​Download the PDF.