SUPPLEMENTAL TABLE 1
User name:__________________________________
User email:__________________________________
User city:__________________________________
User country:__________________________________
User specialty (Check one):
Primary Care General Pediatrician Pediatric Infectious Disease Pediatric Intensive Care Pediatric Cardiology Pediatric Rheumatology Nursing
Epidemiologist
Laboratory professional Other Pediatric Specialty
Patient Age: __________________________________
Patient Weight:_______________________________
Close contact exposure to SARS COV2 (parent, caregiver): Yes/No
Respiratory symptoms (check all that apply):
Accessory respiratory muscle use Cough
Inspiratory stridor Shortness of breath Expiratory wheezing
Superinfected by non-SARS COV2 organism Cardiovascular symptoms (check all that apply):
Abnormal Echocardiography(If yes then inset) Dilated left ventricle
LVEF < 50%
Valvar regurgitation (moderate or severe) Coronary aneurysm Z score over 2.5 Pericardial effusion
Arrhythmia
Myocarditis diagnosis Peripheral edema Pulmonary embolism Other embolism
Coronary artery dilation or aneurysm 1
Neurological symptoms (check all that apply):
Headache
Hemorrhagic stroke Ischemic stroke Loss of smell or taste Meningitis
Peripheral neuropathy
Gastrointestinal symptoms (check all that apply):
Abdominal pain Diarrhea
Loss of appetite/Anorexia Nausea
Vomiting
Laboratory results (check all that apply):
Troponin I elevated NT-proBNP elevated BNP elevated
Creatinine eG FR < 50% of predicted ALT elevated
Elevated aPTT D dimer elevated
Procalcitonin elevated White blood cell count < 5K White blood cell count > 10K Platelet < 150K
Platelet > 600K
C reactive protein elevated Arterial blood gas pH < 7.35 Arterial lactate > 2mmol/L Imaging (check all that apply):
Chest Xray Pneumonitis/pneumonia Chest Xray pulmonary edema Chest CT scan abnormal
COVID-19 (SARS COV2) testing (Check all that apply):
SARS COV2 PCR test positive SARS COV2 antigen test positive SARS COV2 IgM positive
SARS COV2 IgG positive
2
Skin Symptoms (Check all that apply):
Conjunctival injection Erythematous rash
Lymph node swelling or tenderness Peeling skin
Pernio
Pruritus without visible rash Strawberry tongue
Therapies (Check all that apply):
Antiarrhythmics (beta blockers, calcium channel blockers, digoxin, amiodarone, sotalol, lidocaine, etc).
cPAP / biPAP
Direct thrombin inhibitor Diuretic therapy
ECMO
Endotracheal ventilation
Heparin infusion / Low molecular weight heparin Inhaled heliox
Inhaled nitric oxide
Inotropic infusion (Dopamine, Epinephrine, Milrinone, etc.) Intravenous immunoglobulin
Macrolide antibiotic
Oral anti factor Xa inhibitor (NOAC) Oral pulmonary vasodilators Protease inhibitor
t-PA / streptokinase / other thrombolytic Supplemental oxygen by cannula
Systemic afterload reducers
Vasoconstrictor infusion (Norepinephrine, Vasopressin, etc.) Warfarin
Other antibiotic Other antiviral
This patient had past history of (check all that apply):
None of these Abnormal cholesterol
Anti TNF a / IL-1 / IL-6 therapy Arrhythmia
Asthma/reactive airways Chemotherapy use Cholesterol medicine
Complex congenital heart disease Cystic fibrosis
3
Disease modifying anti-inflammatory medicine Diuretic therapy
Hematologic cancer Hematology disorder Hypertension
Hypertension medicine
Immunosuppressed / immunocompromised Inborn disorder of metabolism
Inflammatory condition (Rheumatoid arthritis, systemic lupus, etc)
Mechanical ventilator Neuromuscular disorder Non-insulin diabetes medicine Polycystic ovarian syndrome Pregnancy
Prematurity 24-32 weeks Prematurity 32-36 weeks Restrictive lung disease Sex hormone use (any) Solid organ transplant Solid tumor cancer
Tracheostomy
Type 1 diabetes mellitus Type 2 diabetes mellitus Other
4