Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Kawasaki Disease or Incomplete Kawasaki Disease
Consider KD for:
Patients with ≥ 3 days of fever and any principal clinical features of KD
or
Infants ≤ 6 mos with ≥ 7 days of unexplained fever
Patients with ≥ 3 days of fever and any principal clinical features of KD
or
Infants ≤ 6 mos with ≥ 7 days of unexplained fever
Adapted from 2017 AHA KD Guidelines
Clinical decision-making should be individualized to specific patient circumstances
Clinical decision-making should be individualized to specific patient circumstances
Team Assessment
- History and Physical, Clinical Criteria
- Assess for presence of clinical criteria at any time during current febrile illness
- Laboratory Testing
- Lab testing if H&P consistent with complete or incomplete KD
- Consider lab testing if 3 days of fever and strong clinical suspicion for KD
Complete Kawasaki Disease
- Fever ≥ 5 days and ≥ 4 principal clinical features
- or
- Fever ≥ 4 days and 5 principal clinical features
- Use Incomplete Kawasaki Disease Algorithm to determine need for further evaluation and treatment
- CHOP Expedited ID Outpatient Follow-Up Pilot
- Evaluate as clinically indicated
- Consider pitfalls in KD diagnosis
- Admit/discharge as clinically indicated
Admit and Treat
- Admit
- Evaluation as indicated
- Consider treatment
Review Pathway for possible MIS-C Consultation as needed to determine if further labs, imaging
Discharge
Follow up in 24 hrs
Follow up in 24 hrs
Initial treatment for KD includes IVIG, ASA (high or low dose), +/- Steroids
Send save our specimen
testing prior to treatment with IVIG
testing prior to treatment with IVIG
Age ≤ 6 mos
Age > 6 mos
- Intravenous Immunoglobulin
- Antiplatelet Therapy
- Low dose
- Steroids
- Echo within 24 hrs
- Consult Cardiology and Rheumatology
- Intravenous Immunoglobulin
- Antiplatelet Therapy
- High dose x 24 hrs
- Low dose after 1st 24 hrs
- Echo within 24 hrs
- Consult Cardiology
Monitor Response to Treatment
- Review echo results with Cardiology
- Further management based on echo results and initial treatment response
- Z-scores of coronary arteries all < 2.5
- Steroids
- Infliximab Therapy
- Discuss all abnormal echocardiogram results with Cardiology (Z-score of ≥ 2.5)
- Infliximab Therapy
- Principal Clinical Features of KD
- May not all be present at the same time
- Oral changes
- Erythema and cracking of lips, strawberry tongue, and/or erythema of oral and pharyngeal mucosa
- Conjunctivitis
- Bilateral bulbar conjunctival injection without exudate
- Rash
- Maculopapular, diffuse erythroderma, or erythema multiforme-like
- Extremity changes
- Erythema and edema of the hands and feet in acute phase and/or periungual desquamation in subacute phase
- Lymphadenopathy
- Cervical lymphadenopathy (≥ 1.5 cm diameter), usually unilateral
See AHA Guidelines page e935, Figure 2. Clinical features of classic Kawasaki disease
- Pitfalls in KD Diagnosis
- Consider KD for:
- Infants < 6 mos w/ prolonged fever
and irritability - Infants with prolonged fever and unexplained aseptic meningitis
- Infants/children with prolonged fever and any of the following:
- Unexplained or culture negative shock
- Cervical lymphadenitis unresponsive to antibiotic therapy
- Retropharyngeal or parapharyngeal phlegmon unresponsive to
antibiotic therapy
- Infants < 6 mos w/ prolonged fever
- Documented viral or bacterial (e.g., strep) may co-exist in patients with KD
- KD with Shock or
KD with Macrophage Activation Syndrome - Consult Rheumatology and Cardiology
- Timely management with IVIG and
additional treatments - Consider ICU consult and/or management