Five Key Points for Pediatric Multisystem Inflammatory Syndrome

COVID-19 proved a relentless enemy. Its mortality and morbidity are high in elderly patients with comorbidities. Many young and healthy individuals succumb to the disease, and some older patients have multiple comorbidities that have survived unexpectedly.

The variable during this pandemic was the child. Most children who develop COVID-19 have mild symptoms or are asymptomatic.A small percentage develops an inflammatory syndrome called Pediatric multisystem inflammatory syndrome, Or MIS-C.

Not Kawasaki

First identified as Kawasaki disease (KD) when first seen in New York City / North Jersey, MIS-C presented a large number of nonstandard patients and had doctors press the pause button. It was. They started testing these patients and found that they were all COVID positive. Since then, MIS-C has been identified throughout the United States wherever COVID is found in pediatric patients.

Kawasaki disease is an acute febrile illness of unknown etiology that mainly affects children under the age of four. Clinical symptoms include fever, rash, swelling of the limbs, inflammation and redness of the white of the eyes, swelling of the lymph nodes in the neck, inflammation and inflammation of the mouth, lips, and throat. It is one of the leading causes of acquired heart disease in the United States with serious complications such as coronary aneurysms, reduced myocardial contractility and heart failure, myocardial infarction, arrhythmias, coronary dilatation, and peripheral arterial occlusion. It is one. Children with KD may exhibit severe shock or cardiac arrest.

MIS-C appears in the same way as KD, but MIS-C is found in patients up to the teens. Some of these children improve without treatment, while others require intensive care.

Signs and symptoms

The signs and symptoms of MIS-C are slightly different from COVID, and it may not happen to parents that their child is infected with either. Children with the following signs / symptoms are considered infected with COVID.

• heat
• stomach ache
• vomiting
• diarrhea
• Neck pain
• rash
• Bloody eyes
• Feel extra tired

The unpredictability of COVID is the most painful thing for EMS. Healthy people, including children, went to the ICU and died. Symptom assessment and management is essential in the pre-hospital environment for a small number of children who develop severe or life-threatening acute respiratory symptoms. In children, severe illness presents with the following signs and symptoms:

• Dyspnea
• Persistent chest pain and pressure
• New mess
• Difficult to get up or difficult to get up
• Light, gray, or blue skin, lips, or nail bed, depending on skin color
• Severe abdominal pain

On-site treatment

If the patient’s symptoms are mild, monitor vital signs and pay particular attention to pulse oximetry. Supply oxygen as needed and transport in a comfortable location. Remember that children have a very efficient decompensation mechanism, but when they become decompensated, it’s like dropping a rock from a tall building.

As with all COVID patients, treat symptoms and symptoms: poor ventilation, inadequate oxygenation, and hypotension / poor circulation. (These components are VIP Mnemonic, Ventilation / oxygenation, injection, And Presser.).

As with all pediatric ventilation, airway maintenance and oxygenation are our mainstays.Everything is COVID, any number of SpOs₂ Less than 92% is a precursor to rapid deoxidation. Waiting for the patient to complain of shortness of breath can be too late and you will be surprised that the pulse oximetry readings are less than 84%. Ventilation and oxygenation with high flow oxygen is essential.

Before proceeding to vasopressors, it is important to inject large doses using a conservative approach to body fluids. Use crystalline fluid, but do not bolus the patient too quickly. If you inject too much or too fast fluid, the alveoli will leak more heavily.

If you need to move to a vasopressor, epinephrine or norepinephrine is the best vasopressor for pediatric patients. The Society of Emergency Medicine strongly recommends the use of dopamine. Infusion with a push dose presser or IV pump is best.

Pediatric patients with signs and symptoms of MIS-C should be transferred to a children’s hospital for evaluation and treatment. If not available, a hospital with pediatric ED is recommended. Make sure that patients land in the appropriate facility, as clinical progression can be heterogeneous at best and pediatric patients may require more advanced resources in rapidly advancing disease. Is important.

MIS-C in my community

You will definitely see this. This is one of the reasons why clinical trials involving pediatric patients and the COVID vaccine have begun. The number of cases of pediatric COVID and MIS-C is increasing as schools are reopened and restrictions are lifted. The CDC reports that the group of patients with the highest number of cases during this current surge is 10 to 20 years old.

Long-term complications

We’re still learning about MIS-C and how it affects children, so we don’t know why some children get sick with it and others don’t. We also do not know if children with certain health conditions are more likely to have MIS-C.

When we talk about “long-haul carriers,” it’s a misnomer. The recovery is not well understood. What does recovery from COVID-19 mean? It infects 36 million people, many of whom develop neurological abnormalities such as cardiomyopathy, pulmonary fibrosis, glacial opacity of the lungs, end organ damage due to coagulation disorders, and stroke. Some patients who are currently recovering require a heart or lung transplant. The question we are struggling with is whether these cases are outliers or part of the long-term trajectory of COVID.

Currently, the long-term effects of COVID-19 are unknown as far as children with multisystem inflammatory syndrome are concerned. We have seen children develop a severely damaged heart due to COVID. The effects of COVID-19 on pediatric patients may not be known or understood for years to come.

Overview

You can see MIS-C in our community. It is similar to Kawasaki disease, with the only difference being found in children up to teens. Identify and manage life-threatening warning signs such as cyanosis, chest pain, abdominal pain, confusion, and decreased consciousness. Use the VIP approach to prioritize airways, breathing, and circulation. If possible, transport your MIS-C child to a children’s hospital or facility with a pediatric ED.

resource

Abrams JY, Godfred-Cato SE, Oster ME, Other Severe Acute Respiratory Syndrome Pediatric multisystem inflammatory syndrome associated with coronavirus 2: Systematic review. J Pediatrics, 2020; 226: 45–54 [epub ahead of print]..

American Medical College Association. Coronavirus (COVID-19) Resource Hub, www.aamc.org/ coronavirus-covid-19-resource-hub.

Pediatric multisystem inflammatory syndrome (MIS-C) with Ebina-Shibuya R, Namkoong H, Shibuya Y, Horita N. COVID-19: Insights from concomitant cases of familial Kawasaki disease. Int J Infect Dis, August 2020; 97: 371–3.

Pediatric multisystem inflammatory syndrome associated with Esposito S, Principle N.SARS-CoV-2. Paediatr drag, March 2021; 23 (2): 119–29.

Feldstein LR, Tenforde MW, Friedman KG and more. Overcoming COVID-19 investigators. Characteristics and outcomes of US children and adolescents with pediatric multisystem inflammatory syndrome (MIS-C) compared to severe acute COVID-19. JAMA, March 16, 2021; 325 (11): 1,074–87.

National Emerging Special Pathogen Training and Education Center. New coronavirus (COVID-19), https: //repository.netecweb.org/.

National Institute of Health. Care for critically ill adult patients with COVID-19, www.covid19treatmentguidelines.nih.gov / critical-care /.

An assistant secretary office for preparation and response, technical resources, support centers, and information exchange. COVID-19 resource, https: //asprtracie.hhs.gov/COVID-19.

Pan American Health Organization. COVID-19 Recommendations: Prehospital Emergency Medical Services (EMS), www.paho.org / en / documents / covid-19-recommendations-prehospital-emergency-medical-services-ems.

World Health Organization. COVID-19 Clinical Management: Lifestyle Guidance, www.who.int / publications / i / item / WHO-2019-nCoV-clinical-2021-1.

Daniel R. Gerard, MS, RN, NRP are EMS Coordinators in Alameda, California. He is recognized as an expert in providing and designing EMS systems, integrating EMS / medical services, and providing out-of-hospital care service delivery models.