COVID-19 related MIS-C (Full Length Version)

Hi everyone, this is Dr. Peter Untevi. I wanted to film this special segment because we're seeing more children with multisystem inflammatory syndrome. And it's very important that this Covid related syndrome be given some thought to all of us in ems. Perhaps we should start with some protocols. And so I wanted to take the next 10 or 15 minutes to talk about mis C as it relates to us in EMS. We'll talk about some data, we'll talk about what the AAP just put out. And I really think we have to at least understand the illness, know how to treat it, and let's give those children the best chance they can to survive. So let's get started. Here's your case. This is the call you're going to get. It's 2 o' clock in the morning and you have a child who has a rash. It doesn't look well. You can see the blood pressure is low. You can see the child's tachycardic, tachypneic and overall does not look well. Right, so this is the pat. So you're noticing the rash, you're noticing red eyes, you're noticing the child has a fever. And immediately what may come to mind here is that this could be some type of infection. Now what is MIS C? Well, we've known this to be something else for many years in pediatrics, something called Kawasaki disease. Now you're looking at the screen here and you can see that with Kawasaki you have red eyes. But remember, those eyes do not have any discharge. Red cracked lips, a red tongue, swollen hands. But the foremost features are fever and a rash. Without a fever and a rash, we're not calling this Kawasaki disease. So first the definition of mis c. You have to be under 21 years of age, you have to have a fever. There has to be laboratory evidence of inflammation. These children are severely ill and they have to have multi system organ involvement. So they have cardiac issues, renal GI and so forth. And they have to have no alternative diagnosis, which is commonly what we found in Kawasaki. We looked for everything else and couldn't find it. And they have to have COVID positive, either by pcr, by serology, which is antibodies, or they had to have had an exposure to somebody with COVID within the last four weeks.

Now let's look at the common signs and symptoms of MIS C. We talked about Kawasaki, it looks like that, but it also has features of toxic shock where those children become hypotensive, they look severely ill, there's hyper inflammatory features, the inflammatory system just Goes haywire. You'll hear the word cytokine storm. They have altered cardiac function, oftentimes myocarditis, leading to hypotension and needing things like pressors. They have abnormal clotting where their entire clotting cascade goes haywire. And they oftentimes become thrombotic. And then oftentimes they'll have GI Symptoms. Now this is really important to actually learn this now because we're in the midst of COVID we're in the midst of MIS C cases, and in the next six to eight months, hopefully this will all be gone. But learn about what these kids will present with so that you don't miss it. Now, it's important to understand these children may have never had symptoms of. You can ask the family, they'll say, no, the child was never sick. That doesn't matter. These children could have been asymptomatic and still get Covid and get really sick. So if there's a history of the parent having Covid, you should know that. If there is a history of the child being exposed to somebody with COVID you should know that because that qualifies them now for being a candidate for MIS C. Another important thing is make sure we're assessing vital signs. Make sure you're making a full assessment head to toe on the child. Don't miss the skin, don't miss the eyes, don't miss the temperature, and more importantly, don't miss the tachycardia, the hypotension, and even do an end tidal. Right. If they're septic and their end tidal is now below 25, well, that just gave you a clue that this child has a lactic acidosis and they're just trying to breathe off that CO2 and therefore they're breathing faster. So there's a lot that we can do in the field. We can alert the hospital to a potential MIS C number one. But more importantly, these children need to go to a specialty hospital, a children's hospital that has all the subspecialists there, from the emergency physician who's pediatric trained to infectious disease to hematology to ICU gi, even renal, because again, this is a multi system issue. Oftentimes they will end up in an icu. So if you have the ability to get these kids to the right location the first time, I would do that. Here's a recommended treatment after the child gets to the hospital. Number one, ivig. This is IV immunoglobulin at a dose of one to two grams per kilo. We've been doing this for years with Kawasaki's with great benefit steroid therapy. So children are getting methylpredisolone at doses that range from 2 to 30 milligrams per kilogram. Anakinra is another steroid. And then these children often need a home taper of steroid for up to three weeks. In the hospital, the hematologist must be consulted as well as many other specialists. But this is particular because of the thrombotic events that are caused with this hyper inflammatory syndrome. And then lastly, these children ultimately end up on antibiotics, not because they have a bacterial disease, but just because of the prophylaxis and just being sure we're covering all of our bases. All right, so this is the paper that I want to highlight because it really gives us insight for those of us who are seeing these children at home when parents are calling us. And it really gives us a really good idea of what these kids will look like and then how to treat them. This paper looked at 99 children in New York State. Interestingly, when you look at the breakdown of the ages, you could see here that majority of the children were 6 to 12 years of age and lesser were 13 to 20. And then there were 31 children at 0 to 5 years of age, male and female. There was no difference between the two.

This graphic is very important because what it demonstrates is that the wave of MIS C doesn't happen during the actual wave of COVID It happens about three weeks later. So these children are not actively having Covid for the most part, but their body is now reacting and having this hyper inflammatory syndrome, this cytokine storm, weeks down the road. And that's an important thing because if you're having an outbreak in your community today, then you'll find that the wave of MIS C will come about a month later. And what about race? Whites and blacks get it at an equal portion. However, the Asian population has a decreased ratio, at least in this study. Out of New York State, coexisting conditions are important. You can see here that 36% of children had a coexisting condition, 29% of which was obesity. That's important to understand if you're treating a child who has a rash, who's tachycardic and hypotensive, and they're obese. That's one of the risk factors. Now let's talk about the clinical findings. What are you going to find when you arrive at the house of these children? First and foremost, they all have fever or chills. Remember this Fever is due to the inflammatory response, it's not due to the actual infection. Number two, 80% of them have GI symptoms. Nausea, diarrhea, vomiting. That's important to understand and we've seen that in the adult population as well. Dermatologic. So the rash, Kawasaki's, we always would look for the rash here. It's the same thing. 62% of those children had a detectable rash on physical exam.

Now let's move downward to conjunctivitis. Remember, this is red eyes without discharge. That's a very important distinction.

Moving on down to headache, only 29% of children and then musculoskeletal at 20%.

Now, what about upper respiratory? Well, it turns out that a lot of these children didn't have a respiratory illness. Again, why is because they're weeks past the COVID Now, they may have respiratory issues related to the sepsis, hypotension, therefore the tachypneic. But you'll see in another slide coming up that these children were mainly not requiring oxygen. And that suggests again that it's not a primary lung issue. This may be the most important slide because it's a heat map of the age ranges and which kids were sicker with MIS C. You could see that if you scroll down here to myocarditis and you look to the right. The 6 to 12 year olds at 50% had myocarditis. The 13 to 20 year olds, 73.1% had myocarditis. This is very, very important and shows that the older children got sicker with MIS C whereas the younger children you could see on the graphic, they had the dermatologic or mucocutaneous. At 87.1%, they had more GI symptoms. But it's important. We're going to see older children with MIS C who get sicker. Now, most importantly, in pediatrics, we have to do a great vital sign evaluation with our assessment. Take a look at what these vital signs show. They're all tachycardic, many of them are tachypneic, but again, that's from a lactic acidosis, not from a primary lung disease. Now, when you look at hypotension, again, scroll to the right and you can see that 46% of the 13 to 20 year olds were hypotensive. Again, older children got sicker, they became hypotensive and they needed increased care in the icu. And then go all the way to the bottom and you'll notice that very few, only 4% of the children had an O2 sat less than 92%. That's critical because we know Covid causes hypoxia. But in these children it didn't. Again, because this is the inflammatory aspect of the syndrome rather than the primary disease. Now, you're probably wondering, when are we going to see these children? When are they going to present to us in EMS or to the hospital? Well, it turns out this data shows it's on day number four. These children presented then, and you can see that 80% of them required ICU admission. That's a lot. These children are much sicker than the Kawasaki disease children who almost never saw the icu. If we go down further, you can see that from a respiratory therapy issue. BIPAP or CPAP or high flow nasal cannula, mechanical ventilation. Very few of those children needed it and even ecmo. However, the vasopressor support was critical, as was the systemic glucocorticoids, methylpredisolone and so forth, and ivig. So we're treating these kids like Kawasaki Disease, and they do need pressure support. So now we know, in conclusion, that MIS C is here and it's due to Covid. It's a sequelae of COVID It happens weeks later. And now many really great people have put together algorithms on how to look for Covid, how to evaluate it, how to treat it. And the Children's Hospital of Philadelphia I have here up on the screen has a very nice ED ICU and inpatient clinical pathway for the evaluation of MIS C. We're gonna post this in the show notes, and we're gonna really advise everyone, whether you're an EMS professional, an emergency department clinician, or up in the ICU to really have an algorithm, have a protocol. More importantly, be on the lookout for this because it's easily missed if you're just looking at another child who has a fever. So that's been an overview of MIS C. We'll be living with this for the next six to eight months, more than likely. So please train on it. Send this video out to others who you think may find it useful. And again, thank you for your attention. This has been Dr. Peter Antevi for another edition of the Hantevi Minute.