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1
Q

pneumonic for KD

A

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)

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2
Q

age range for KD

A

Has to be <18 yrs, most frequently seen in younger than 5 yrs

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3
Q

when should you consider KD

A

-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)

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4
Q

lab and clinical findings in KD shock syndrome

A

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

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5
Q

lab findings in KD

A

-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

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6
Q

What is considered Positive echo in KD

A

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
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7
Q

Elevation of CRP is seen but should return to
normal by _____after onset of illness.

A

6-10 weeks

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8
Q

when should echo be repeated in KD

A

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.

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9
Q

dosing of IVIG for KD

A

2g/kg

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10
Q

when is 2nd dose of IVIG given in refractory KD

A

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).

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11
Q

treatment for KD

A

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

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12
Q

when can you d/c KD

A

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

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13
Q

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.

A

2.0

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14
Q

what inflammatory marker cannot be checked after IVIG

A

ESR

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15
Q

follow up care for KD

A

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

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16
Q

How long no live vaccines after IVIG

A

11 months

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17
Q

characteristics of norovirus vs rotavirus

A

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.

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18
Q

when should you suspect c-dif in a gastro picture

A

age >2 years
previous use of antibiotics
previous C. difficile infection,
and/or hospitalization within the last 30 days.

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19
Q

exclusionary criteria for gastro

A

<60 days or >17
years old
- history of underlying
conditions
- toxic appearance
- episodes of
diarrhea lasting
> 14 days

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20
Q

drinks to avoid in for gastro

A

-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

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21
Q

Inpatient SABA weaning criteria and protocols

A

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

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22
Q

inpatient discharge criteria asthma

A

Room air
CRS ≤3
SABA q3h X 2
Asthma Action Plan given
Asthma Education complete
Appropriate support system (e.g., PCP, caregivers)

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23
Q

What consults will you consider for orbital cellulitis

A

Optho
ENT
ID

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24
Q

what antibiotics are you using for orbital cellulitis and why

A

Vanc - for the CSF penetration

Flagyl - anaerobic

Ceftriaxone - Staph/strep

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25
Q

How often is ceftriaxone given for

A

q 12 hours

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26
Q

How often is vanc given

A

q 8 hours

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27
Q

How often is flagyl given

A

q 8 hours

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28
Q

what cultures for abscess fluid if orbital abscess goes to OR

A

anaerobic culture
body fluid culture
body fluid culture (PCR) - this one comes back faster while waiting for the other which is more accurate.

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29
Q

med to help dry secretions

A

Robinul

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30
Q

adolescent with swollen tonsils….whats on diff

A

besides Strep (outside of age range)
EBV
mono

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31
Q

When your cell lines are down on CBC, other than onc, what else could be causing this

A

viral suppression

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32
Q

pustules on rectum….likely to be infected with

A

staph

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33
Q

If you need a bolus, what level of dehydration are you at least?

A

moderate

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34
Q

Diarrhea, what fluids should they have

A

D5NS + k once they have voided

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35
Q

resp distress worse during feeds then improves, need to think about

A

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)

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36
Q

streaking is a sign of

A

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

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37
Q

formula to calculate kcal

A

100kcal/kg/day

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38
Q

Thrombocytosis in setting of infection

A

platelets can be elevated due to inflammation

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39
Q

mottling that does not resolve when skin is warmed, can be bluish purple

A

cutis marmorata

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40
Q

Hip Pain Differentials

A

Septic arthritis
JIA (>6weeks)
Transient synovitis
SCFE
CRMO
Reiters syndrome (Chlamydia is most common culprit)
Disseminated Gonococcal infection (actually in hip)

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41
Q

Reiters syndrome is a ______ arthritis

A

reactive

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42
Q

Reiters syndrome pathogens

A

Chlamydia trachomatis
Chlamydia pneumoniae
E. Coli
Mycoplasma genitalium
Ureaplasma urealyticum

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43
Q

Pathogens that can cause epiglottitis/lymphadenitis/retropharyngeal abscess and mediastinanitis include

A

MSSA
MRSA
Strep
Hemophilus influenzae
Viral etiologies also possible but would be unlikely to be extending into the mediastinum

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44
Q

Immature platelet count acts like what other lab

A

retic count

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45
Q

Platelet counts above what number warrants consulting hematology

A

> 1000

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46
Q

High flow should be ___l/kg

A

2L/kg

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47
Q

what sizes of hfnc do we have

A

8L
15L

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48
Q

when do you obtain a lovenox level

A

4 hours after

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49
Q

____ml/kg RBC transfusion

A

10ml/kg

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50
Q

___ ml/kg platelet transfusion

A

5ml/kg

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51
Q

Bugs covered
PCN vs Nafcillin

A

PCN: strep, enterococcus, syphilis, anaerobe

Nafcillin: MSSA, GAS, GBS

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52
Q

Bugs Covered
Amp vs Amox-clav

A

Amp: strep, enterococcus, listeria, some GN

Amox-Clav: strep, Hflu, morax, anaerobe, pasteurel

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53
Q

general rule of thumb in an adult sized pt (teen) who is hypokalemic for raising potassium.

A

for every 10meq you can expect about .10 raise

never give more than 80meq without checking a k+ level

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54
Q

good med for htn thats not as big of a commitment

A

propanolol

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55
Q

rule to remember in mitochondrial kids when prescribing abx

A

they have ribosomes similar to bacterial so if it is harmful to bacterial ribosomes, it will affect his too.

56
Q

what creatinine level should make you worry

A

> 1 is time to worry…

57
Q

what can cause a low creatinine

A

muscle mass loss/malnutrition

58
Q

when should you worry about AST/ALT levels

A

3xs upper limit

59
Q

a kidney lesion that causes a decline in kidney function and is characterized by an inflammatory infiltrate in the kidney interstitium.

A

Acute interstitial nephritis (AIN)

60
Q

what fluids should not be given to a kid with mitochondrial history

A

LR due to risk of lactic acidosis

61
Q

meds for diuresis

A

HCTZ before lasix

62
Q

Gram positive cocci

A

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

63
Q

antibiotic coverage for MRSA and MSSA

A

vanc covers both
Nafcillin for MSSA

64
Q

abx coverage for strep pneumo

A

penicillin/amoxicillin

65
Q

Gram + clusters

A

Staph (think staff gather)

66
Q

Gram + pairs and chains

A

strep (think strip)

67
Q

Drugs that cover MRSA

A

Vanc
Linazolid
Daptomycin (not good lung penetration)
Doxy

68
Q

Daptomycin doesnt have good penetration where?

A

lung

69
Q

Outpatient oral meds for MRSA coverage

A

Linazolid (van equal) - risk of cytopenias

Clindamycin (skin soft tissue)

Bactrim
Doxy

70
Q

These 2 antiepileptics have what cardiac side effects

A

Vimpat - PR changes
Fosphenytoin - Prolonged QT

71
Q

what med in a seizure RRT can you not give without going to picu

A

Fosphenytoin

72
Q

what physical exam finding helps distinguish facial palsy from intracranial

A

incracranial can move forehead, facial palsy cant move it

73
Q

prednisolone 5 day dosing

A

1mg/kg/dose BID

74
Q

more sensitive lab to malnourishment?
can be falsely elevated if what lab is elevated

A

prealbumin
CRP

75
Q

how long does it take for a directed donation

A

72 hours
look on giveblood.org through gulf coast

76
Q

murmur grading

A

I/VI - softer than heart sounds

II - same as heart sounds

III louder than heart sounds

IV thrill

77
Q

facial palsy vs intracranial cause

A

if able to move forehead, likely intracranial, if full palsy of side of face then likely peripheral palsy

78
Q

only reason neb is >MDI

A

humidified air

79
Q

broadening from ceftriaxone to cefepime also covers what

A

pseudomonas

79
Q

When you order steroid and Ibuprofen, you will also need

A

PPI

80
Q

gram neg rods

A

pseudomonas

80
Q

when your considering running H.Pylori, cannot be taking what med

A

PPI

81
Q

what oral antibiotic is equal to vanc

A

linazolid

82
Q

linozalid causes

A

cytopenias

83
Q

Clindamycin is good for _________ and covers ______ but resistant to ______

A

skin and soft tissue
MRSA
resistant to MSSA

84
Q

MRSA coverage IV

A

Vancomycin
Linozalid
Daptomycin (not good lung penetration)
Doxy

85
Q

what are important physical exam findings to comment on for hyperbili neonates

A

Presence/absence of hematomas (can falsely elevate bili level)

-what level of jaundice

86
Q

Kramer’s jaundice zones

A

1- face (5mg)
2- upper trunk (10)
3- lower trunk and thighs (12)
4- arms and lower legs (15)
5- palms and soles

87
Q

When a RBC is broken down by a macrophage, what happens

A

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)

88
Q

what causes elevated Unconjugated bilirubin and what happens

A
  1. Extravascular hemolytic anemias
  2. 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

  1. 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.

  1. 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
  2. Crigler Najjar syndrome - NO UGT at all
    super high UCB in blood causing kernicterus. usually fatal.
89
Q

Increase conjugated Bili

A
  1. 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
  2. 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

90
Q

increase of CB and UC bili in blood

A

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

91
Q

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

A

Bactrim
Keflex

92
Q

Protein in CSF: what would you expect in TB, viral and bacterial
neonate subnote

A

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

93
Q

you have xanthochromia in a neonate’s csf…what is this from?

A

Jaundice can turn the csf yellow

94
Q

In children, Bacterial meningitis scoring. If they do not have these, they are at very low risk for bacterial meningitis.

A

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

95
Q

for a nicu transfer, who do you call

A

TLC doc

96
Q

sign of hormonal resistance to breastfeeding

A

bra size didnt change during pregnancy

97
Q

neonate with sepsis type fever, birth history + for maternal fever and scabbing to head from monitors, think about what

A

HSV

98
Q

unconjugated bili turns into conjugated bili which is ________ so can be _____
If conjugated bili is elevated, what does it mean?

A

water soluble
excreted
think cholestatic…body cant excrete

99
Q

what ratio can you use to determine if bili is cholestatic, hepatocellular or mixed?

A

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

100
Q

House fire…..pt has cherry red flushed skin, vomiting, tachycardia, tachypnea, HTN….what should you think of

A

Cyanide poisoning

101
Q

How do you treat for cyanide poisoning

A

Hydroxocobalamin & sodium thiosulfate

102
Q

does HSP rash blanch

A

non-blanching

103
Q

what antibiotic is helpful for inflammatory component of asthma

A

azithromycin

104
Q

what should you cover for in setting of flu if concern for effusion on xray

A

MRSA

105
Q

drug fever is usually from what antibiotics? even though can be any (dx of exclusion)

A

PCNs

106
Q

what virus causes tachycardia

A

Influenza

107
Q

Does influenza normally cause thrombocytopenia?

A

no

108
Q

What platelet level should you avoid nsaids?

A

Less than 100,000

109
Q
A
110
Q

Nephrotic syndrome, what age would make you concerned for genetic disorders

A

Younger than 1yr

111
Q

Nephrotic syndrome with abd pain and fever. What is highest on differential

A

Strep pneumonia peritonitis until proven otherwise

112
Q

.2-2 urine protein
Vs
>2 urine protien

A

Nephritic
Nephrotic

113
Q

Why is c3, c4 a helpful test in nephrotic syndrome

A

Low levels points to another cause
Minimal change disease these are normal

114
Q

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

A

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)

115
Q

scenario….kiddo with orbital cellulitis and pansinusitis on vanc and unasyn…..what are you going to transition to for PO

A

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

116
Q

Staph scalded skin is usually from what organism?

A

MSSA

117
Q

for SSS what antibiotic choices/ pros and cons

A

Cefazolin vs Nafcillin

Cefazolin you can change to Keflex to easier to discharge
Nafcillin you still change to Keflex but not technically equivalent coverage

118
Q

Treatment of ringworm

A

Oral + topical, get culture ….treatment is 6 weeks of oral therapy

119
Q

Antibiotic treatment in suspected pyelo. Note: US is not super sensitive for pyelo

A

10-14 days

120
Q

What lab derangement does azithromycin cause

A

leukopenia

121
Q

how many ml/hr is considered trophic feeding to keep gut moving

A

5-10

122
Q

clear nutritional feeds that we have

A

Boost Breeze
Ensure Clear

123
Q

labs to be aware of when iron (ferric carboxymaltose) transfusion is required

A

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

124
Q

what bili is elevated in biliary atresia vs breastmilk causes of hyperbili

A

conj bili -> biliary atresia
unconj bili -> breastmilk

125
Q

what does MOCA evaluate (done by speech)

A

how cognition is affecting speech

126
Q

encephalopathy vs meningitis
which is emotional lability most characteristic of

A

Encephalopathy

127
Q

Elbow I&D what cultures

A

Anaerobic culture
Bacterial body fluid pcr
Body fluid culture
Cell count body fluid

128
Q

Congestion, bloody suction cannister. What can you use to help

A

> 18 mos Afrin for 3 days
<18 mos phenylephrine for 3 days

129
Q

what is it called if you see focality in the triangular space on lat xray

A

spine sign

130
Q

in pertussis what causes the constant coughing

A

sloughing of esophagus

131
Q

clindamycin is __% effective for MSSA/MRSA + _____
Bactrim is __% effective for MSSA/MRSA and would have to add what for cellulitis

A

70% MSSA/MRSA + strep
Bactrim is 90% but does not cover strep
so would have to also add amox or cefazolin

132
Q

when is lovenox trough drawn

A

4 hours after initiation of dose
if changing dose, wait 2 doses, then 4 hours post

133
Q

What lab is tracked for eosinophilia

A

IgE

134
Q
A

clinicals (8 decks)

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