Emergency Department, ICU and Inpatient Clinical Pathway for
Evaluation of Possible Multisystem Inflammatory Syndrome (MIS-C)
- Talking Points for Families
Related Pathways
- COVID-19 Screening, Outpatient Specialty and Primary Care
- COVID-19 Screening, ED
- COVID-19 Screening, Inpatient
- COVID-19, Acute, All Settings
- Fever, Emergency
- Kawasaki Disease, Incomplete Kawasaki Disease, Emergency and Inpatient
- Sepsis, ED, Inpatient, PICU
- Sepsis, N/IICU
- Sepsis, CICU/CCU
- VTE Prevention Pathway, Inpatient
Clinical/Historical Features to Guide Need for Evaluation:
- Rash (more common)
- Polymorphic, maculopapular, petechial, NOT vesicular
- GI Symptoms (more common)
- Diarrhea, abdominal pain, vomiting
- Extremity changes
- Erythema and edema of the hands and feet in acute phase
- Oral Mucosal Changes
- Erythema and cracking of lips, strawberry tongue, and/or erythema of oral and pharyngeal mucosa
- Conjunctivitis (more common)
- May be bulbar or limbic-involving, without exudate
- Lymphadenopathy (less common)
- Cervical > 1.5 cm, unilateral (infrequently observed)
- Neurologic Symptoms
- Headache, irritability, lethargy, altered mental status, neck stiffness, cranial nerve palsies
- Epidemiologic Link to COVID
- Patient with history of COVID disease or close contact with known Positive COVID case in past 4-6 weeks, or person placed in quarantine
- FLOC/RN Team Assessment
- History & Physical Exam
- COVID Exposure, diagnosis
- Assess for Evidence of Inflammation
- Consider Differential Diagnosis for MIS-C
- Assess for Evidence of Shock
- ED Sepsis Triage
- Sepsis Huddle as clinically indicated
- Common Features of Shock in Children
Evaluation for Possible MIS-C in a stable patient
Suspected MIS-C with Shock
Fever/history of fever ≥ 38.0°C for ≥ 3 days
+
≥ 2 Clinical /Historical Features OR strong clinical suspicion with shorter fever duration
Review Kawasaki Pathway
+
≥ 2 Clinical /Historical Features OR strong clinical suspicion with shorter fever duration
Review Kawasaki Pathway
Fever/history of fever ≥ 38.0°C for ≥ 1 day
+
Evidence of myocardial dysfunction or
Hypotension/vasopressor requirement
+
≥ 2 Clinical/Historical Features
+
Evidence of myocardial dysfunction or
Hypotension/vasopressor requirement
+
≥ 2 Clinical/Historical Features
Initial Laboratory Testing
- CBC, CMP, CRP, ESR
- Other testing as clinically indicated to identify cause of fever, based on clinical features
- Sepsis Pathway — Use ED Sepsis Order Set
- Additional Diagnostic Laboratory Studies
- Add COVID PCR, RRP, Troponin, BNP, D-dimer, Ferritin, Save Our Specimen, ECG
- Fluid Resuscitation, Vasopressors
- Antibiotics
- Echo as clinically indicated
Labs and Physical
Exam Reassuring
Exam Reassuring
Labs or exam concerning but inconsistent with MIS-C
- CRP ≥ 3 mg/dL and/or
- ESR ≥ 40 mm/hr
- AND
- Lymphopenia < 1k or
- Thrombocytopenia < 150k or
- Na < 135 or
- Abnormal creatinine for age
Admit to Inpatient
Consider Further Evaluation
- Review Kawasaki Pathway
- Consider Differential Diagnosis for MIS-C
- Additional ancillary labs:
- Troponin, BNP, EKG
- Save our specimen
- ECG, COVID-PCR
- Cardiology Consultation if:
- For review of abnormal ECG
- Abnormal BNP, troponin
- Concerns on PE
- Consider culture, antibiotics
Note:
Patients likely to have MIS-C can deteriorate rapidly despite fluid resuscitation, consider PICU admit for pts requiring >40-60 mL/kg to achieve VS stability
Discharge
- Tolerates PO
- Reassuring PE
- PCP follow-up 24-48 hrs
- Isolation
- Consult ID and Rheum BEFORE treatment; DIRT and cardiology as indicated
- Review Kawasaki disease pathway
Consider Differential diagnosis for MIS-C - Patients likely to have MIS-C can deteriorate rapidly despite fluid resuscitation
- Reassessment is cornerstone
- Monitor MS, VS, perfusion
- VS Parameters
- Evaluate for Common Features of Shock in Children
- Consider CAT
- If assessments suggest deterioration
- Diagnosis of MIS-C Confirmed or Likely
- Discuss w/ Subspecialists to expedite initiation of MIS-C directed therapy
- Consider treatment after multidisciplinary evaluation
- Monitoring Clinical, Lab, Imaging Response
- Discharge criteria and Follow-up Plan
- Isolation
- Care to be provided by inpatient team, consultants as indicated
- Additional Laboratory Studies/Imaging for PICU Patients with MISC
- ED, Inpatient and PICU Sepsis Pathway
- Consider vasopressors, milrinone
- Consider bedside cardiac US
- Consult ID and Rheum BEFORE treatment; DIRT and cardiology as indicated
- Consider Differential diagnosis for MIS-C
- Consider treatment AFTER multidisciplinary evaluation:
- Monitoring Clinical, Lab, Imaging Response
- Discharge and Follow-up Plan
Note:
Guidance is based on expert consensus. As this guidance will evolve, consider ID, Rheumatology, Dysregulated Immune Response Team and Critical Care Medicine consultation for individualized recommendations for suspected cases.
Posted: May 2020
Revised: July 2021
Authors: K. Chiotos, MD; D. Corwin, MD; L. Sartori, MD; M. Congdon, MD; J. Lavelle, MD; S. Swami, MD; J. Burnham, MD; H. Bassiri, MD; A. John, MD; F. Balamuth, MD; K. Cohn, MD; M. Blackstone, MD; J. Callahan, MD; V. Kampalath, MD; R. Rempell, MD; M. Elias, MD; T. Giglia, MD; C. Witmer, MD; D. Davis, MD; C. Kerman, MD; D. Whitney, MD; E. Behrens, MD; D. Teachey, MD; C. Jacobstein, MD
Revised: July 2021
Authors: K. Chiotos, MD; D. Corwin, MD; L. Sartori, MD; M. Congdon, MD; J. Lavelle, MD; S. Swami, MD; J. Burnham, MD; H. Bassiri, MD; A. John, MD; F. Balamuth, MD; K. Cohn, MD; M. Blackstone, MD; J. Callahan, MD; V. Kampalath, MD; R. Rempell, MD; M. Elias, MD; T. Giglia, MD; C. Witmer, MD; D. Davis, MD; C. Kerman, MD; D. Whitney, MD; E. Behrens, MD; D. Teachey, MD; C. Jacobstein, MD