Danielle Graff, MD MSc
Beth Spurlin, MD PhD MBA
Co-Chairs, Pediatric EM Committee
PEM and the Community
Pediatric visits make up around 20% of all community ED visits and most of these patients will be treated and discharged. However, ~5% will require higher level of care or admission, requiring transportation to the local children’s hospital. There have been studies that show there is variability in the pediatric training that Emergency Medicine residents receive during their residency. Combined with the less frequently seen pediatric patient can lead to angst not only for the physician but also nursing and rest of the staff.
To help with such concerns, a Pediatric outreach education program has been implemented by the Just for Kids Transport team through Norton Children’s Hospital in connection with University of Louisville this past year. While the program had to be momentarily interrupted by Covid-19 pandemic, it is with hope that the program can be re-started as soon as the Spring of 2021. The program focuses on didactics and/or simulations in a multitude of scenarios including sepsis, anaphylaxis, respiratory disorders, cardiac diseases, and status epilepticus, among many others. Didactics can help re-familiarize the differences as well as current practices in pediatric management while the simulations concentrate on drug therapies and skill set. Simulations are held in YOUR ED in-order to have familiarity with your location/supplies as well as the ability to have multiple people, including physicians, nurses, respiratory therapists and technicians participate.
If interested please contact Beth Spurlin, MD, PHD, MBA or our clinical coordinator, Donna Callahan.
MIS-C: It’s the abbreviation for miscellaneous for a variety of reasons!
The COVID-19 virus has created many obstacles over the past year, including the evolving progression of severe illness in children. One such concern has been on a rare, but serious complication, multi-inflammatory syndrome in children (MIS-C). This can provide multiple clinical challenges for a provider in that it presents with symptoms similar to those seen in other childhood illnesses such as Kawasaki Disease and Toxic Shock Syndrome. To further complicate matters, definitions and diagnostic criteria vary for MIS-C and the myocardial dysfunction that may be seen insidiously is a major source of morbidity and mortality. It has been noted that that there has been an increase in the number of pediatric myocarditis cases seen over the past year in Kentucky.
While there have been cases of MIS-C throughout state, it is not abundantly common but should not be missed. Currently there has been at least 24 known cases in Kentucky of MIS-C meeting the definition. Nationally, the percent of MIS-C in COVID + pediatric patients is ~ 0.001-0.0018 or 1-2/1000 in COVID + pediatric patients. Per the CDC, as of January 2021, there have been 1,659 MIS-C cases meeting the definition with 26 related deaths across the nation.
Key Points from CDC:
- Most cases were in children and adolescents between the ages of 1 and 14 years, with an average age of 8 years.
- More than 70% of reported cases have occurred in children who are Hispanic or Latino or Black, Non-Hispanic.
- 99% of cases tested positive for SARS CoV-2. The remaining 1% were around someone with COVID-19.
- Most children developed MIS-C 2-4 weeks after infection with SARS-CoV-2.
- Slightly more than half (57%) of reported cases were male.
View Interactive Map MIS-C Cases by Jurisdiction on the CDC website.
Working Definition of MIS-C: (from the CDC and AAP)
• Individual aged <21 years presenting with fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
• Laboratory evidence of inflammation*
• Evidence of clinically severe illness requiring hospitalization, with multisystem (≥2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurological)
+
No alternative plausible diagnoses
+
Positive for current or recent SARS-CoV-2 (COVID-19) infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms
*Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin
In Emergency Departments:
Physicians, PAs and APPs are encouraged to consider other etiologies with a broad differential diagnosis as many non-SARS CoV2 etiologies cause similar signs and symptoms as well as laboratory changes. Premature closure of the diagnosis to MIS-C could result in delayed diagnosis and harm to the patient. One such example is of a patient that presented with a positive COVID exposure and labs similar to MIS-C but ultimately the diagnosis was a ruptured appendix.
Work-Up (per CDC and AAP guidelines):
Additional testing/management (strongly recommended if ferritin and/or troponin are abnormal):
**NEED to emphasize that the urgency of additional testing is dependent on disease severity
Take-Home Points:
- While there have been cases of MIS-C throughout out state and specifically at the children’s hospitals, it is not abundantly common but should not be missed.
- If any suspicion, get the initial labs and contact your local children’s hospital to discuss further; children with abnormal ferritin and/or troponin should be admitted for further evaluation and work-up.
- One of the trends pediatric hospitals in Kentucky have noticed is an increase in myocarditis since the beginning of the pandemic and specifically over the past few months.
- Most cases were in children and adolescents with an average age of 8 years.
- More than 70% of reported cases are Hispanic, Latino or Black.
- Most children developed MIS-C 2-4 weeks after infection with SARS-CoV-2.