Tuberculosis by Dr. Marks
Incidence decreasing in the US
Latent TB infection approx. 5% in US. 25% in world
PPD screening:
If >5 mm PPD and immunocompromised = positive
If >10mm and been to high risk country, healthcare worker, or IVDU =positive
Otherwise >15mm = positive
Primary TB usually asymptomatic,
If suspect TB, isolate
Sputum PCR
Gold standard is cultures (6-8wk turnaround)
For latent TP rifampin+isoniazid +pyridoxine for 3 moths
For active TB:
RIPE therapy 8 weeks
Rifampin , (orange urine, CP450 induction)
isoniazid, (B6 deficiency, seizures)
pyrazinamide (hepatotoxicity, hyperuricemia)
Ethambutol (optic neuritis)
Then rifampin/isoniazid for 18 more weeks
TB meningitis- RIPE + dexamethasone
Potts- RIPE + source control
Syphilis by Dr. Coffman
Incidence increasing since 1990.
Increasing in women. Congenital cases increasing.
Primary, Secondary, Tertiary
Painless ulcer on mucus membranes, rash involving hands and feet +nonspecific symptoms,
Jarisch Herxheimer reaction – treat symptoms with tylenol.
PEM: Endocrine by Dr. Magloire
DKA: defined by hyperglycemia, metabolic acidosis, and ketosis
30-40% are new onset T1DM
Risk factors include age <5, reduced access to medical care
Anorexia, N/V, abdominal pain, hyperventilation, dehydration
Often precipitated by missed insulin, acute illness, medications (steroids, antipsychotics)
Assume fluid deficit of 5-10%
Initial fluid bolus then 2 bag method over 24-48
Beware of cerebral edema. Treat with mannitol if developing
Avoid central lines due to increased risk of DVTs
Hypoglycemia:
Children and infants can have quicker shifts in glucose due to high metabolic demand and difference in gluconeogenesis.
If conscious, give 15 g of carbs (juice, glucose tabs etc)
IV D10 bolus if needed
If altered give 2-5ml/kg of D10 bolus, repeat and start infusion if needed
Adrenal Crisis:
Consider in known CAH, hypothalamic axis disorders, prolonged corticosteroid use, other autoimmune disorders, critically ill patients unresponsive to pressors, or neonates with atypical genitalia electrolyte abnormalities, hypoglycemia, hyperpigmentation, cushingoid features
Hyponatremia, hypoglycemia, hyperkalemia
Treat with hydrocortisone 50-100mg/m2 (25mg if <3yo, 50mg if 3-12 yo, 100mg if 12+yo)
Treat hyperkalemia if needed.
Tick-Borne Disease by Dr. Buchanan
Prevention is best
DEET and permethrin
DEET on skin, permethrin on clothes (last 6-8 weeks)
Combination of both decreased mosquito bites by 99%
Remove ticks >36hrs just use forceps.
Lyme – erythema migrans, vector is Ixodes, classic “target” rash. Disseminated disease in 60% if untreated
If bilateral bell’s palsy, treat for Lyme disease
If high clinical suspicion, can use IFA or EIA for testing
IgG +IgM if <1 month from exposure
Doxy+ceftriaxone if neuro symptoms
STARI – southern tick associated rash illness
Causative organism unknown. Lone Star Tick
Probably best to treat as Lyme
Rocky Mountain Spotted Fever –
Maculopapular rash involving hands and palms. Flu like symptoms
Hyponatremia, transaminitis, thrombocytopenia
Rickettsia Rickettsii
Dermacentor sp. (wood tick or dog tick)
Clinical diagnosis, confirmed with IFA/EIA
Rickettsia Parkeri Rickettsiosis-
Inoculation eschar. Similar labs findings. Less severe disease. Gulf coast ticks
Erlichiosis- Erlichia sp.
Lone star tick
Flu-like symtpoms
Leukopenia, hyponatremia, transaminitis
Whole blood PCR (most sensitive if <1week).
Otherwise IgG trending
Anaplasmosis –
Ixodes tick. More northeast than erlichiosis
Tick-borne relapsing Fever
Leukoytosis, thrombocytopenia, elevated bilirubin
recurring fevers. Every reccurence less and less severe
Borrelia sp.
Soft shell ticks are the vector. Western US.
Diagnoses with peripheral blood smear. Best checked during a fever.
Treatment for all the above is doxycycline
Babesiosis
Babesia microti. Vector is ixodes tick.
Fever, body aches, Scleral icterus, dark urine,
Transaminitis, anemia, thrombocytopenia, hyperbilirubinemia
Peripheral smear with intracellular organsisms, (maltese cross)
Treatment atovaquone +azithromycin OR Clindamycin + Quinnine
Tularemia
Franscisella tularensis
Vectors -Dermacentor and amblyomma spp.
Fevers, malaise, body aches.
Leukocytosis, thrombocytopenia, hyponatremia, transaminitis, sterile pyuria
Wound and glandular lymphadenopathy, conjunctivitis, oropharyngeal form. Pneumonic form, typhoidal form.
Confirmation by isolation of Tularensis (culture) or seroconversion (IgG/IgM) in paired sera
Treatment is streptomycin
Tick Bite prophylaxis
- Was it an ixodes tick? If no, no ppx
- Is it engorged or attached >36hr> if no, no ppx
- Has it been 72 hours since removal. If yes, no ppx
- Can they take doxy? If no, no ppx
- Is lyme endemic? If no, no ppx
Peds Pharm: PALS Drugs by Dr. Lucking
Bradycardia- atropine (min 0.1, max 0.5mg) epinephrine, treat as PEA if <60
Tachycardia-
- Sinus tach -treat underlying condition
- SVT- vagal maneuver, (ice to face), adenosine (proximal and fast) 0.1mg/kg
- Vtach- cardiovert, amio or procainamide
- Vfib- rare. Same as adults. Amio 5mg/kg
Epi spritzer
Used for brady/hypotension in a patient with a pulse to prevent cardiac arrest
Peri-intubation
0.001mg/kg (1/10 of a code dose)
RSI
If age <1 consider atropine as pre-medication
Historically, lidocaine was given for ICP, however this has fallen out of favor
Fentanyl 1mcg/kg max dose 100mct. Immediate onset, 30-60min duration
Midazolam 0.1mg/kg max 5mg. onset 3-5 mins. Duration <2 hours
Ketamine 2mg/kg. onset 30 seconds. Duration 5-10mins. Contraindicated in <3mo age
Etomidate 0.3mg/kg. does not provide analgesia. Can reduce sz threshold.
Propofol 1-2mg/kg.
Rocuronium 1mg/kg. duration 26-46 minutes
Succinylcholine 1-2mg/kg, hyperkalemia, malignant hypothermia