Sepsis represents a clinical diagnosis of exclusion in the ED, pending the results of cultures and treatment, because of the potential for rapid progression of disease. Obvious septic shock rarely presents a problem of diagnosis but rather of management. In more subtle cases, the combination of altered mental status and abnormal vital signs should suggest to the emergency physician the possibility of sepsis. Because of the characteristically nonspecific presentation, febrile or ill-appearing neonates should be considered septic until proven otherwise. No laboratory test is diagnostic, although a WBC greater than 20,000/pL is supportive of bacterial sepsis. However, the presence of a WBC in the "normal" range in the setting of an ill-appearing child is not reassuring. A WBC less than 5000/pL or platelet count less than 150,000/pL is a grave prognostic sign, particularly for disease due to N. meningitidis. Cultures of the blood, urine, CSF, and diarrheal stool, if present, should be obtained to identify a primary focus of infection and guide future therapy. Gram-stained smears made from CSF and petechial scrapings may provide immediate diagnostic information regarding the identity of the organism.

The differential diagnosis for a "septic-appearing" child includes infectious, cardiac, metabolic, and traumatic disease. Major focal bacterial infections, such as meningitis and pericarditis, and systemic viral disease may present with findings of fever, altered mental status, and cardiorespiratory compromise. Young infants with congenital heart disease or viral myocarditis may present in cardiogenic shock with respiratory distress and signs of poor perfusion. Toxic ingestion and congenital metabolic disease may present with altered mental status as the major complaint. Finally, child abuse with head or abdominal injury may present with altered mental status, temperature instability, and signs of poor perfusion without historical or cutaneous evidence of trauma.

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