BRONCHIOLITIS　
　Acute, small airway obstruction in young infant, <2y/o
　Etiology: RSV, parainfluenza viruses
　Coryza, cough, dyspnea, prominent wheezing, crackles and retraction
　Chest AP view: hyperinflation of the lungs
　ABG or pulse oximeter prn
　Tx: humidified O2, hydration, ventilation prn
　Aerosolized ribavirin is indicated for those with respiratory failure, immunosuppression or severe coexisting disease

HERPANGINA, HAND-FOOT-MOUTH DISEASE
　Sudden onset of fever, <4mm vesilces and ulcers over anterior tonsillar pillars and soft palate, uvula, tonsils,
　phayrngeal wall, rash or vesicles over palms and soles
　Etiology: coxasackievirus A, coxasackievirus B, entervorius 71
　Tx: supportive
　　If EV71 induces HFMD or herpangina, treat patients according to stage-based management.
　　Indication for IVIG usage: combined with encephalitis, polio-like syndrome, sepsis-like syndrome, myocarditis,
　　cardiopulmonary failure

Table Clinical staging and management for EV71 infection

GINGIVOSTOMATITIS
　Buccal mucosa, and lips ulcers, injected gum, fetid odor
　Etiology: herpes simplex virus-1
　Tx: supportive tx, acyclovir 50mg/kg/day for 5-7days in early stage (started within the first 4 days of disease onset)

CHICKEN POX (varicella)
　Incubation period: 10-21 days ( about 2 weeks)
　Contagious from 1-2 days before the rash appears and while uncrusted vesicles are present, which is usual 3-7 days
　Itching lesion appear first on the scalp, face or trunkRvesicles, simultaneous presence of lesions in various stages of
　evolution
　Etiology: varicella-zoster virus
　Tx: (1) acyclovir 20mg/kg/dose po qid for 7days, started within 24 hours of onset of varicella for selected
　　　immunocompetent cases ,
　　(2) for immunocompromized patients or patients with complications such as encephalitis, or hepatitis, or
　　　hemorrhagic chickenpox, intravenous acyclovir 500mg/m2 or 10mg/kg/g8h

CELLULITIS
　Warm, erythematous, tender and indurated skin and soft tisscue
　Etiology: Sta. aureus, GAS; H.influenzae type b in<5y/o, anaerobes when from sinusitis
　Periorbital (preseptal) cellulitis; orbital cellulitis (ptosis, chemosis, ophthalmoplegia, decreased vision)R admission,
　and ophthalmologist's consultation
　B/C, pus/C
　Tx:
　　PCNase-resistant PCN ( oxacillin) or 1st cephalosporin (keflin) for 7-10 days, vancomycin if severe status plus
　　possible ORSA infection
　　Use cefuroxime if Hib was considered, and augmentin if combined with sinusitis

ACUTE OTITIS MEDIA (AOM)
　Bulging, opacified, discolored eardrum, poorly visualized landmarks & decreased mobility of the drum
　Etiology: pneumococcus, H. influenzae (nontypable), M. catarrhalis & GAS
　Tx: analgestics
　1st amoxcillin, or augmentin for 10 days
　OM with effusion: effusion persisted >4 wks after AOM, ventilation tube insertion if effusion persists for more then
　3 months

PHARYNGITIS, TONSILLITIS
　Sore throat , injected pharynx and tonsils & fever
　Etiology: b-hemolytic GAS, adenovius or other viral infection
　Dx: positive throat culture ( vigorous swabbing of both tonsillar areas and the post. pharynx, which, if done properly,
　usually induces a gag reflex), rapid Ag detection, ASLO ( >500 todd unit or rise 3-6 weeks after GAS pharyngitis)
　Tx: PCN, or clindamycin p.o. for entire 10 days if proven GAS infection
　to prevent rheumatic fever

DEEP NECK INFECTION
　Subamndibular, parapharyngeal (ant.& post.R carotid sheath), peritonsillar retropharyngeal abscess
　Mass/abscess, fever, <3y/o, dysphagia, dyspnea
　Etiology: GAS, Sta. aureus, oral anaerobes
　Neck lat. view, CT
　Tx: surgical drainage, oxacillin + Aq- PCN, or augmentin

ADENITIS
　LN enlarged (>3cm), tender, erythema
　Etiology: Sta. aureus, GAS or Kawasake disesase; TB,
　Oxacillin or keflin for 10-14 days

PNEUMONIA (PN)
　Viral PN, atypical PN, bacterial PN
　CXR, S/S
　Neonate: GBS, occasionally Sta.aureus, G(-) enteric bacilli
　◎1m/o-5y/o: respiratory virus, Chlamydia trachomatis ( <4m/o, afebrile, Hx of conjunctivitis, eosinophilia, rare
　　wheezing), H. influenzae type b, pneumococcus, Sta. aureus
　　Tx: AM (oxacillin) + GM, 2^nd or 3^rd cephalosporin, augmentin
　◎>5y/o: pneumococcus, Mycoplasma pneumoniae
　　Tx: amoxicillin, erythromycin (nontoxic), 2nd/3rd cephalosporin, augmentin
　◎aspiration PN: oral anaerobes
　◎TB : patient responds slowly or not at all to antibiotics therapy
　　Tx duration:
　◎Mycoplasma: erythromycin/clarithromycin 10 days or azithromycin for 3 to 5 days
　◎Pneumococcus: 7 days~10days, longer duration (2 to 4 weeks) if empyema
　◎Hib, other streptococcus: 1-2 weeks
　◎Sta. aureus: IV 3wks + po 1-3 wks
　Indications for hospitalization: significant respiratory distress or toxicity, cyanosis, age <6m/o, empyema or pleural
　effusion, possible staphylococcal PN, and inadequate home care
　Tx: postural drainage & physiotherapy, symptomatic care, chest tapping and chest tube insertion if empyema or
　massive effusion,
　CXR resolution may lag behind clinical improvement.

ACUTE GASTROENTERITIS (AGE)
　Food poisoning, viral ( rotavirus), bacterial ( salmonella, campylobacter, shigella)
　S/A (WBC, blood, mucus), S/C
　Tx: supportive
　◎Salmonella (intracellular): ampicillin, or 3rd cephalosporin (Rocephin, or cefotaxime)
　　Indications for treatment: <3m/o, immunocompromized , severe toxicity, hemoglobinopathy (sickle cell anemia),
　　chronic inflammatory bowel disease, extra-GI tract infection ( bacteremia, menigitis, osteomyelitis)
　◎Shigella: baktar for 5 days, 3rd cephalosproin (po或iv), or fluoroguinolone
　◎Campylobacter: erythromycin for 5-7 days if severe symptoms

URINARY TRACT INFECTION (UTI)
　Fever, pyuria
　NB: male, thereafter female 多
　U/A( WBC>5/HPF, WBC>30uL nitrite(+)), U/C( bag urine, middle stream urine, suprapubic aspirate, sterile cath
　urine collection), renal ehco, VCUG
　Etiology: E. coli, Proteus, Klebsiella
　Tx: adequate hydration & AM+GM for 10-14 days ( clinical improvement within 2-3days)

OSTEROMYELITIS & SEPTIC ARTHRITIS
　Joint swelling, warmth, reddish, limping gait pseudoparalysis
　Consult ortho for synovial fluid aspiration or emergent drainage for hip and shoulder joints
　B/C, Pus/C and Gram stain, SBT
　Etiology: Sta. aureus (MSSA & MRSA), pneumococcus (check MIC), Hib for <5y/o
　Tx: Oxacillin, Vancomycin for MRSA for 4-6 weeks or high resistant pneumococcus, Rocephin for intermittent
　　resistant Pneumococcus

SARS probable cases without respiratory distress

1. Diagnosis: suspected cases再加上已有Pneumonia
2. Vital signs：1). BT, RR q8h
　　　　　　2). On oximeter if 病人SOB, 視情形每1至 4小時記錄SaO2
3. IVF D0.225S (1000cc) keep maintainance (po+IV) (請儘量打上，不勉強)
4. on 一般 diet
5. Lab同suspect cases; 若有respiratory distress視情形抽ABG
6. Respiratory care: 絕對不可使用nebulizer, 因會造成更多aerosol, 更可能nosocomial infection, 避免chest care,
　suction, 吸藥等, 若一定要則必需有三級防護, 可用O2 cannula,（其次mask）
7. Medication 同 suspected cases
　1). Symptomatic treatmentR視情況給予
　2). Oral ribavirin 40mg/kg/day bid (total 5-7 days) with questionable effect
　3). 使用Antibiotics (Azithromycin 10mg/Kg QD for 5 days and/or cefuroxime)
　4). Randomized (依照亂數表來randomization) 使用IVIG 1g/kg QD 1 至 2 days
8. 若開始有respiratory distress, 或發燒flare up (如退燒1 or 2天後又再發燒, 或越燒越高,越頻繁), 則需至少
　chest X-ray QD追蹤及追蹤ABG, CBC, CRP, LDH, GOT等

SARS probable cases with respiratory distress
1. Definition: requirement of O2 supply (cannula or mask, never nebulizer) 或Multifocal pneumonia patches
2. IVF D0.225S (1000cc) keep maintainance 80% (po+IV)
3. Respiratory care : 絕對不可使用nebulizer, 因會造成更多aerosol,更可能nosocomial infection, 避免chest care,
　suction, 吸藥等, 若一定要則必需有三級防護, 可用O2 cannula , （其次mask）
4. Advanced treatment in addition to probable cases without respiratory distress
　1). 使用IVIG 1g/kg OD×2 days (與Stage II合起來使用次數不超過兩次)with questional effect
　2). Ribavirin(total 5-7 days)with questional effect及Antibiotics (可選擇more broad spectrum)
　3). Methylprednisolone: 若Clinical or radiological rapid progress考慮使用methylprednisolone pulse therapy 10 to
　　20 mg/Kg QD for 3 days
　是否繼續用maintainance 的 steroid 由主治醫師決定。
　**但最好從fever onset算起超過7天才使用, 以免virus shedding 過長或relapse
5. Close monitor of oxygenation (on oximeter), ABG prn, F/U CXR prn
6. If PaO2/FiO2＜300 or SaO2<90% with O2 supply, 則照會 chest 或 infection and Dr.夏紹軒，看是否需
　elective intubation, 及是否使用 methylprednisolone pulse therapy
7. On ETT criteria
　1). O2 cannula or mask (4 to 6 L/Min) is unable to keep SaO2＞90﹪,
　2). Relative indication 150<PaO2/FiO2＜300
　　Absolute indication: PaO2/FiO2＜150
8. 若病人情況惡化(PaO2/FiO2＜150)，須放endo時，
　1). 盡量白天， elective intubation, 需安全防護裝備--Call OR (TEL：2396)外科準備室，找麻醉科來on
　　endo。他們有特殊裝備。
　2). Call主治醫師。