Neisseria meningitidis is the leading infectious cause of death in childhood in the UK.1 2 There were over 2500 cases and 246 deaths in 19973 and the disease has an overall mortality of about 10%.4 5 Although mortality rises to 50% in the most severely ill patients,4-6 data from our unit suggests that early recognition,7 aggressive resuscitation, specialist advice, and transfer to paediatric intensive care8 9 can reduce this mortality to less than 5%.10

Critically ill children are best managed in a specialist paediatric intensive care unit,11 but most patients with meningococcal disease will present to a hospital without tertiary care facilities and will require transport to a specialist centre. The immediate institution of lifesaving therapeutic measures is more crucial to patient outcome than the speed and urgency with which the paediatric intensive care retrieval team arrives.9Therefore, the resuscitation and stabilisation expertise available at the referring hospital must be harnessed while the specialist intensive care team is being mobilised. Decisions on when interventions (such as tracheal intubation) should be performed can be extremely difficult even for those who care for critically ill children on a regular basis. The decision making process at the referring hospital can be greatly facilitated by early telephone dialogue with a specialist centre.

The department of paediatrics at St Mary’s Hospital in London, UK has a special clinical and research interest in meningococcal disease. Between June 1992 and September 1998, 425 critically ill children with meningococcal disease were referred to our paediatric intensive care unit from 72 different hospitals in the south east of England. The algorithm (fig 1 and 2 [AQ:1] ) presented in this article summarises our personal practice that has evolved as a result of this experience.