Pediatric emergency medicine trisk 1749 1749
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PR interval or sinus tachycardia. Higher grade heart block is usually transient
may be an indication for pacing.
The treatment of choice is penicillin (either oral penicillin V or injectable
benzathine penicillin). Patients presenting to the ED with a history of ARF are at
risk for recurrence of ARF, endocarditis, or heart failure.
TABLE 86.11
MODIFIED JONES CRITERIA FOR ACUTE RHEUMATIC FEVER.
Must also have evidence of strep infection (see text)
Major criteria
Minor criteria
Carditis—clinical or subclinical
Fever
Polyarthritis
Chorea
Arthralgia
Elevated ESR or CRP
Subcutaneous nodules
Erythema marginatum
KAWASAKI DISEASE
KD is the most common generalized systemic vasculitis and the most common
form of acquired heart disease in children in the United States. The heart can be
affected in both the acute and chronic phase. KD typically affects infants and
young children less than 5 years old. It is rare under the age of 4 months or in
adults. These patients often present to the ED with fever, rash, and irritability.
They have a hyperdynamic precordium, sinus tachycardia, rub, gallop, or
murmur. They may exhibit signs of depressed myocardial function, myocarditis,
or pericarditis during the acute phase. Coronary artery aneurysms (CAA) or
ectasia occur in 25% of untreated children with KD. Children with incomplete
features of KD are at increased risk of developing CAA due to delays in making
the diagnosis resulting in delays in therapy. CAA typically develop in the second
to third weeks of illness with coronary stenosis developing later. Although
myocardial infarction is rare, affecting <3% of patients within 1 year of onset;
myocardial infarction, sudden death, and ischemic heart disease may occur. KD
should be considered in any child with 5 days of fever. Workup includes CBC, Creactive protein level, ESR, LFTs, and urinalysis and urine culture. These tests
will provide supporting evidence for the diagnosis as well as prognostic
indicators. Thrombocytopenia is a risk factor for development of CAA. EKG
typically has sinus tachycardia and nonspecific ST and T changes. An
