work work work Flashcards
pneumonic for KD
CRASH & Burn
5 days fever (usually high 102-104)
Conjunctivitis (bilat and non-exudative)
Also limbic sparing is a big clue - red eyes with clear halo around pupil
Rash -maculopapular, diffuse erythroderma, or erythema multiforme-like (often worse in groin)
(not vesicular or bullous)
Adenopathy (must be at least one lymph node in the anterior chain at least 1.5 usually unilateral)
Strawberry tongue (and/or oral mucosa changes - fissured lips, injected pharynx)
Hands and feed swelling (acute phase)/periungual desquamation (convalescent phase)
age range for KD
Has to be <18 yrs, most frequently seen in younger than 5 yrs
when should you consider KD
-younger than 18
-fever >=5days with >=2 criteria for incomplete (<1yr at greater risk) or >=4 criteria for complete
consider in infants with fever >=7days without other explanation
(resp viruses does not exclude dx of KD - ie) RSV, metapneumovirus, coronaviruses, parainfluenza, influenza)
lab and clinical findings in KD shock syndrome
Laboratory findings
Higher levels of inflammatory markers
Lower albumin levels
Anemia
Consumptive coagulopathy
Bandemia
Hyponatremia
Clinical Findings
More severe skin rash
Myocardial dysfunction
More severe coronary artery
involvement
Poor response to IVIG
lab findings in KD
-Leukocytosis (acute stage) with predominance of immature and mature granulocytes. About 50% have wbc >15,000
-Anemia with more prolonged active inflammation
-Thrombocytosis (rare in 1st week but may be seen in 2nd week and will peak in 3-4th week)
-Hyponatremia can be seen
-mild to moderate elevation in transaminases (<40% of pt)
**Liver enzymes (AST, ALT and albumin abnormal results associated with IVIG resistance)
-mild hyperbili in 10%
-Hypoalbuminemia (for severe prolonged)
-Elevated CRP, ESR
-Pyuria in 33% (cath samples may not reveal this)
-elevated D-dimer - may help predict coronary artery involvement bc it signifies endothelial damage and fibrinolysis that is associated with systemic vasculitis
-NT-pro BNP can be used as an adjunctive marker to assist with dx of pt in acute phase of KD
What is considered Positive echo in KD
if any of 3 conditions are met:
- Z score of LAD or RCA ≥2.5
- Coronary arteries meet criteria for aneurysms
- 3 other suggestive features exist, including decreased LV function, mitral regurgitation, pericardial effusion, or Z scores in
LAD or RCA of 2 – 2.5
Elevation of CRP is seen but should return to
normal by _____after onset of illness.
6-10 weeks
when should echo be repeated in KD
For uncomplicated patients, echocardiography should be repeated at both 1 to 2 weeks and 4 to 6 weeks after initiation of therapy.
For patients with important and evolving coronary artery abnormalities (Z score >2.5) detected during the acute illness, more
frequent echocardiography (at least twice per week) should be performed until luminal dimensions have stopped progressing to
determine the risk for and presence of thrombosis.
dosing of IVIG for KD
2g/kg
when is 2nd dose of IVIG given in refractory KD
Administration of a second dose of IVIG (2 g/kg) for patients with refractory Kawasaki disease (patients with persistent or
recrudescent fever at least 36 hours after the end of the first IVIG infusion without other concerning features, such as coronary abnormalities and/or Kawasaki shock).
treatment for KD
Pulse steroids (30mg/kg, max 1g) - up to 3 days
IVIG (2g/kg)
can repeat if still have fever after 36 hours
Infliximab (Remicade)
aspirin (ASA) upon diagnosis of Kawasaki disease at a dose of 7.5-12.5 mg/kg/DOSE every 6 hours until the
patient is afebrile for 72 hours and then transition to 3-5 mg/kg/DOSE once daily for 6 to 8 weeks until the echocardiogram
demonstrates a lack of coronary artery abnormalities
when can you d/c KD
patients are afebrile for at least 24 hours following IVIG therapy, are clinically improved AND have
a normal initial echo. For high risk patients, consider discharge if patients are afebrile for at least 36 hours following IVIG therapy,
show clinical improvement AND have a normal initial echo
Patients with coronary artery dilation (z-score >__) should
be followed with a repeat echocardiogram at least twice a
week until dimensions stabilize; additional antiinflammatory therapy should be considered.
2.0
what inflammatory marker cannot be checked after IVIG
ESR
follow up care for KD
1) labs and imaging (echocardiogram) in 7 to 14 days from discharge OR 14 to 21 days from initial
fever, whichever occurs sooner.
2)Return to EC if fever > 38.0 or recurrence of KD symptoms before follow up with PCP, Cardiology or Rheumatology
- Education on side effects of low dose aspirin (i.e., bruising, gastrointestinal bleeding)
- Patient received inactivated flu vaccine if during flu season; no live vaccines x 11 months;
- Avoid exposure to anyone with the flu or chicken pox to avoid the risk of Reye’s syndrome, which has been linked to
aspirin use in these illnesses
- Recommend a low-fat, heart healthy diet, regular exercise and avoid exposure to secondhand cigarette smoke.
- Physical activity
How long no live vaccines after IVIG
11 months
characteristics of norovirus vs rotavirus
Rotavirus disease typically begins abruptly. Vomiting often
precedes the onset of diarrhea.
Norovirus is characterized by acute onset of nausea, vomiting, abdominal cramps, and diarrhea. Vomiting can appear alone in norovirus illness.
when should you suspect c-dif in a gastro picture
age >2 years
previous use of antibiotics
previous C. difficile infection,
and/or hospitalization within the last 30 days.
exclusionary criteria for gastro
<60 days or >17
years old
- history of underlying
conditions
- toxic appearance
- episodes of
diarrhea lasting
> 14 days
drinks to avoid in for gastro
-Avoid caffeine (tea, energy drinks)
- Avoid all carbonated (bubbly drinks such as sodas, carbonated waters)
- Avoid any sweet drinks (fruit juice, lemonade, fruit punch, even diluted beverages)
- Avoid sports drinks
Inpatient SABA weaning criteria and protocols
Criteria for weaning:
CRS 3-6 and improving, VS stable, and weaning
from O2
Previous Treatment Level: Wean To:
SABA or MDI 8 puffs → 6 puffs and continue to taper
Continuous SABA → q2h
q1h → q2h
q2h → q3h X 2, then q4h
inpatient discharge criteria asthma
Room air
CRS ≤3
SABA q3h X 2
Asthma Action Plan given
Asthma Education complete
Appropriate support system (e.g., PCP, caregivers)
What consults will you consider for orbital cellulitis
Optho
ENT
ID
what antibiotics are you using for orbital cellulitis and why
Vanc - for the CSF penetration
Flagyl - anaerobic
Ceftriaxone - Staph/strep
