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
How often is ceftriaxone given for
q 12 hours
How often is vanc given
q 8 hours
How often is flagyl given
q 8 hours
what cultures for abscess fluid if orbital abscess goes to OR
anaerobic culture
body fluid culture
body fluid culture (PCR) - this one comes back faster while waiting for the other which is more accurate.
med to help dry secretions
Robinul
adolescent with swollen tonsils….whats on diff
besides Strep (outside of age range)
EBV
mono
When your cell lines are down on CBC, other than onc, what else could be causing this
viral suppression
pustules on rectum….likely to be infected with
staph
If you need a bolus, what level of dehydration are you at least?
moderate
Diarrhea, what fluids should they have
D5NS + k once they have voided
resp distress worse during feeds then improves, need to think about
choanal atresia (a congenital disorder in which the nasal choanae, (i.e., paired openings that connect the nasal cavity with the nasopharynx), are occluded by soft tissue (membranous), bone, or a combination of both)
streaking is a sign of
Lymphangitis (inflammation of your lymph vessels, often complication of skin infection)
Red streaks on your skin (hallmark symptom of infection-related lymphangitis). untreated can cause sepsis
formula to calculate kcal
100kcal/kg/day
Thrombocytosis in setting of infection
platelets can be elevated due to inflammation
mottling that does not resolve when skin is warmed, can be bluish purple
cutis marmorata
Hip Pain Differentials
Septic arthritis
JIA (>6weeks)
Transient synovitis
SCFE
CRMO
Reiters syndrome (Chlamydia is most common culprit)
Disseminated Gonococcal infection (actually in hip)
Reiters syndrome is a ______ arthritis
reactive
Reiters syndrome pathogens
Chlamydia trachomatis
Chlamydia pneumoniae
E. Coli
Mycoplasma genitalium
Ureaplasma urealyticum
Pathogens that can cause epiglottitis/lymphadenitis/retropharyngeal abscess and mediastinanitis include
MSSA
MRSA
Strep
Hemophilus influenzae
Viral etiologies also possible but would be unlikely to be extending into the mediastinum
Immature platelet count acts like what other lab
retic count
Platelet counts above what number warrants consulting hematology
> 1000
High flow should be ___l/kg
2L/kg
what sizes of hfnc do we have
8L
15L
when do you obtain a lovenox level
4 hours after
____ml/kg RBC transfusion
10ml/kg
___ ml/kg platelet transfusion
5ml/kg
Bugs covered
PCN vs Nafcillin
PCN: strep, enterococcus, syphilis, anaerobe
Nafcillin: MSSA, GAS, GBS
Bugs Covered
Amp vs Amox-clav
Amp: strep, enterococcus, listeria, some GN
Amox-Clav: strep, Hflu, morax, anaerobe, pasteurel
general rule of thumb in an adult sized pt (teen) who is hypokalemic for raising potassium.
for every 10meq you can expect about .10 raise
never give more than 80meq without checking a k+ level
good med for htn thats not as big of a commitment
propanolol
rule to remember in mitochondrial kids when prescribing abx
they have ribosomes similar to bacterial so if it is harmful to bacterial ribosomes, it will affect his too.
what creatinine level should make you worry
> 1 is time to worry…
what can cause a low creatinine
muscle mass loss/malnutrition
when should you worry about AST/ALT levels
3xs upper limit
a kidney lesion that causes a decline in kidney function and is characterized by an inflammatory infiltrate in the kidney interstitium.
Acute interstitial nephritis (AIN)
what fluids should not be given to a kid with mitochondrial history
LR due to risk of lactic acidosis
meds for diuresis
HCTZ before lasix
Gram positive cocci
clusters ->staph which could be CONS or S. Aureus. -> could be MSSA or MRSA
diplococci -> strep pneumoniae
Pairs/chains ->group A/B strep, other streps, Enterococcus
antibiotic coverage for MRSA and MSSA
vanc covers both
Nafcillin for MSSA
abx coverage for strep pneumo
penicillin/amoxicillin
Gram + clusters
Staph (think staff gather)
Gram + pairs and chains
strep (think strip)
Drugs that cover MRSA
Vanc
Linazolid
Daptomycin (not good lung penetration)
Doxy
Daptomycin doesnt have good penetration where?
lung
Outpatient oral meds for MRSA coverage
Linazolid (van equal) - risk of cytopenias
Clindamycin (skin soft tissue)
Bactrim
Doxy
These 2 antiepileptics have what cardiac side effects
Vimpat - PR changes
Fosphenytoin - Prolonged QT
what med in a seizure RRT can you not give without going to picu
Fosphenytoin
what physical exam finding helps distinguish facial palsy from intracranial
incracranial can move forehead, facial palsy cant move it
prednisolone 5 day dosing
1mg/kg/dose BID
more sensitive lab to malnourishment?
can be falsely elevated if what lab is elevated
prealbumin
CRP
how long does it take for a directed donation
72 hours
look on giveblood.org through gulf coast
murmur grading
I/VI - softer than heart sounds
II - same as heart sounds
III louder than heart sounds
IV thrill
facial palsy vs intracranial cause
if able to move forehead, likely intracranial, if full palsy of side of face then likely peripheral palsy
only reason neb is >MDI
humidified air
broadening from ceftriaxone to cefepime also covers what
pseudomonas
When you order steroid and Ibuprofen, you will also need
PPI
gram neg rods
pseudomonas
when your considering running H.Pylori, cannot be taking what med
PPI
what oral antibiotic is equal to vanc
linazolid
linozalid causes
cytopenias
Clindamycin is good for _________ and covers ______ but resistant to ______
skin and soft tissue
MRSA
resistant to MSSA
MRSA coverage IV
Vancomycin
Linozalid
Daptomycin (not good lung penetration)
Doxy
what are important physical exam findings to comment on for hyperbili neonates
Presence/absence of hematomas (can falsely elevate bili level)
-what level of jaundice
Kramer’s jaundice zones
1- face (5mg)
2- upper trunk (10)
3- lower trunk and thighs (12)
4- arms and lower legs (15)
5- palms and soles
When a RBC is broken down by a macrophage, what happens
https://youtu.be/gIACp5js4MU?si=izu1hzUssm2Himri
Globin down to amino acids
Heme to iron and Protoporphyrin which is broken down into unconjugated bilirubin
Albumin in blood then binds to unconjugated bilirubin and takes it to the liver where it is taken up by hepatocytes where it is conjugated by uridine glucuronyl transferase (UGT) turning it water soluble conjugated bilirubin
The conjugated bili is then secreted into bile canaliculi then drains to the bile ducts to the gallbladder for storage as bile.
when eat something like a donut….The bile secretes bile with conjugated bilirubin in it and moves through common bile duct to duodenum of small intestines where it is converted into urobilinogen by microbes in the gut
Some of the UBG is reduced to stercobilin (responsible for brown color in feces)
Also UBG is reabsorbed into blood and spontaneously oxidizes into Urobilin (UB) which is sent to liver and kidneys. From kidneys its excreted in urine (responsible for yellowness of urine)
what causes elevated Unconjugated bilirubin and what happens
- Extravascular hemolytic anemias
- Ineffective hematopoiesis
both of these causes macrophages to break down RBCs. Hepatocytes can get overwhelmed (cant keep up). Excess stays in blood. As liver cells max out. Increased conjugated bili in bile which increases risk for pigmented gallstones
also have increase conjugated bili duodenum which increases UBG (urobilinogen) which is reabsorbed into blood spontaneously converts to urobilin (UB) then excreted in kidneys causing urine to darken up.
The unconjugated bili is not excreted bc its not water soluble
- Physiologic jaundice of the newborn
newborn liver have lower amount of UGT to convert unconjugated bilirubin
also after birth unconjugated bili levels can be high due to natural process of macrophages destroying fetal RBCs causing increase serum UCB
UCB collects in basal ganglia of brain (kernicterus) which can cause brain damage or death
phototherapy uses light to induce structural changes to bilirubin molecule by absorbing the light which changes its shape which are more soluble and can be excreted in urine.
- Gilbert’s syndrome - UGT activity is low and has a hard time cranking up when needed. Infection, stress and starvation can increase hemolysis which overwhelms the hepatocytes
- Crigler Najjar syndrome - NO UGT at all
super high UCB in blood causing kernicterus. usually fatal.
Increase conjugated Bili
- Dubin-Johnson syndrome
AR disorder deficiency in MRP@ (transporter protein deficient) Conjugated bili builds in hepatocytes bc it cant go anywhere. thought that this upregulates MRP3 which drives CB into blood instead of bile canaliculi causes build up into blood and excretes into urine by kidneys - Obstructive jaundice
blocks flow of bile (gallstones, pancreatic +cholangio carcinoma, Liver fluke (parasite)
Pressures rise in bile ducts
causes bile to leak through tight junctions between hepatocytes that line walls of bile ducts
bile salts, acids and cholesterol also leak causing pruritis, cholesterolemia, xanthomas
bili leaks into urine causes dark urine
cant absorb fat well - steatorrhea
cant absorb as many fat soluble vitamins
increase of CB and UC bili in blood
1) viral hepatitis
hepatocytes get infected and start to die off
lose ability to conjugate bili so increase UCB into blood. also bc hepatocytes line the bile ducts, when they die bile is leaked into blood so increase in conjugated bili in blood as well. Conjugated bili will cause darker urine
When you transition a pt off of vanc to a PO…what could you use? However, you need to add what because you loose GAS coverage
Bactrim
Keflex
Protein in CSF: what would you expect in TB, viral and bacterial
neonate subnote
TB would be 200s…very disproportionate to WBC in csf (keep in mind WBC indicates inflammation)
Bacterial meningitis: elevated but not as much as TB
Viral meningitis: no elevation
in a neonate you can have elevated protein 100-115 and be normal. also bloody tap can elevate protein
you have xanthochromia in a neonate’s csf…what is this from?
Jaundice can turn the csf yellow
In children, Bacterial meningitis scoring. If they do not have these, they are at very low risk for bacterial meningitis.
Positive cerebrospinal fluid Gram stain
Cerebrospinal fluid absolute neutrophil count ≥1000 cells/μL
Cerebrospinal fluid protein ≥80 mg/dL
Peripheral blood absolute neutrophil count ≥10 000 cells/μL
History of seizure before or at the time of presentation
for a nicu transfer, who do you call
TLC doc
sign of hormonal resistance to breastfeeding
bra size didnt change during pregnancy
neonate with sepsis type fever, birth history + for maternal fever and scabbing to head from monitors, think about what
HSV
unconjugated bili turns into conjugated bili which is ________ so can be _____
If conjugated bili is elevated, what does it mean?
water soluble
excreted
think cholestatic…body cant excrete
what ratio can you use to determine if bili is cholestatic, hepatocellular or mixed?
R ratio
Alt value +ALT Upper level of normal
divided by
alkaline phosphatase value + alkaline phosphatase upper level of normal
R ratio of >5 is hepatocellular
R ratio <2 is cholestatic
R ratio 2-5 is mixed pattern
House fire…..pt has cherry red flushed skin, vomiting, tachycardia, tachypnea, HTN….what should you think of
Cyanide poisoning
How do you treat for cyanide poisoning
Hydroxocobalamin & sodium thiosulfate
does HSP rash blanch
non-blanching
what antibiotic is helpful for inflammatory component of asthma
azithromycin
what should you cover for in setting of flu if concern for effusion on xray
MRSA
drug fever is usually from what antibiotics? even though can be any (dx of exclusion)
PCNs
what virus causes tachycardia
Influenza
Does influenza normally cause thrombocytopenia?
no
What platelet level should you avoid nsaids?
Less than 100,000
Nephrotic syndrome, what age would make you concerned for genetic disorders
Younger than 1yr
Nephrotic syndrome with abd pain and fever. What is highest on differential
Strep pneumonia peritonitis until proven otherwise
.2-2 urine protein
Vs
>2 urine protien
Nephritic
Nephrotic
Why is c3, c4 a helpful test in nephrotic syndrome
Low levels points to another cause
Minimal change disease these are normal
When using Afrin and Flonase with NS rinses…..kiddo saw this on had orbital cellulitis with pansinusitis. Used bc of pansinusitis….what is the order
Give Afrin first, then wait 15 min before the Nasal saline rinses: nasal rinse with 4oz Neilmed bottle on each side (2 total). Additional rinse at mid-day. Flonase BID after AM and PM rinses. The saline rinse orders is Saline sinus rinse pediatric kit (Neilmed)
scenario….kiddo with orbital cellulitis and pansinusitis on vanc and unasyn…..what are you going to transition to for PO
Unasyn will be Augmentin
Vanc is Clinda but rising MRSA clinda resistance
Bactrim would be a good choice but does not cover GAS and not great for sinus coverage. Augmentin does cover sinus well and covers GAS.
So Augmentin and Bactrim
Staph scalded skin is usually from what organism?
MSSA
for SSS what antibiotic choices/ pros and cons
Cefazolin vs Nafcillin
Cefazolin you can change to Keflex to easier to discharge
Nafcillin you still change to Keflex but not technically equivalent coverage
Treatment of ringworm
Oral + topical, get culture ….treatment is 6 weeks of oral therapy
Antibiotic treatment in suspected pyelo. Note: US is not super sensitive for pyelo
10-14 days
What lab derangement does azithromycin cause
leukopenia
how many ml/hr is considered trophic feeding to keep gut moving
5-10
clear nutritional feeds that we have
Boost Breeze
Ensure Clear
labs to be aware of when iron (ferric carboxymaltose) transfusion is required
Causes severe renal wasting of phosphate resulting in severe hypophosphataemia.
Pre-existing vitamin D deficiency, low calcium levels, low phosphate levels or raised parathyroid hormone levels may be risk factors, and these should be evaluated and corrected before administering intravenous iron.
Patients may require phosphate and vitamin D replacement along with monitoring for a long period after iron infusion-induced hypophosphataemia.
repeat iron levels in 2 weeks
what bili is elevated in biliary atresia vs breastmilk causes of hyperbili
conj bili -> biliary atresia
unconj bili -> breastmilk
what does MOCA evaluate (done by speech)
how cognition is affecting speech
encephalopathy vs meningitis
which is emotional lability most characteristic of
Encephalopathy
Elbow I&D what cultures
Anaerobic culture
Bacterial body fluid pcr
Body fluid culture
Cell count body fluid
Congestion, bloody suction cannister. What can you use to help
> 18 mos Afrin for 3 days
<18 mos phenylephrine for 3 days
what is it called if you see focality in the triangular space on lat xray
spine sign
in pertussis what causes the constant coughing
sloughing of esophagus
clindamycin is __% effective for MSSA/MRSA + _____
Bactrim is __% effective for MSSA/MRSA and would have to add what for cellulitis
70% MSSA/MRSA + strep
Bactrim is 90% but does not cover strep
so would have to also add amox or cefazolin
when is lovenox trough drawn
4 hours after initiation of dose
if changing dose, wait 2 doses, then 4 hours post
What lab is tracked for eosinophilia
IgE
Bacterial meningitis shows what on csf
Elevated protein
Decreased glucose
Neutrophilic pleocytosis
