OCH ED COVID-19 ASSOCIATED MULITSYSTEM INFLAMMATORY SYNDROME IN CHILDREN (CA-MIS-C) CARE PATH Updated 6/8/20

Arrival to ED with Usual ED care fever >24 hr i.e. Only fever/rash or fever/GI sx

No 1. Fever > 24 hrs. reported or documented >38 deg C 2. Laboratory evidence of inflammation 3. Illness requiring hospitalization Concern for Shock on Low No 4. Multisystem (>2) organ involvement * MIS-C? presentation? (i.e. Cardiac, Renal Resp. GI, Heme, Derm or Neuro) 5. No alternative diagnosis 6. COVID-19 positivity/exposure Yes  SARS-CoV-2 RT-PCR positive currently  Or Recently positive antibody testing High  Or COVID-19 exposure within 4 weeks prior to the onset of symptoms Screening labs Concern for Sepsis/SIRS No May include MIS-C? pathway CBC, MIS-C Set 1 Differential, Studies CRP, ESR CMP *** Yes

Admit * Multi system organ  MIS-C Set 1 & involvement Set 2  IV Fluid: Use judiciously (10cc/kg). Reassess for studies****  GI symptoms: Abd. pain, fluid overload after any bolus of fluids (rales,  ID Consult Vomiting, Diarrhea HSM, worsening clinical status), POCUS IVC  PICU Consult (80+%)  Ceftriaxone with additional antibiotics guided by  Consider  Rash, oral changes, ID Cardiology conjunctivitis (>50%)  Vasopressors guided by PICU (DA, Epi) Consult  LAN-unilateral cervical  STAT Echo for elevated troponin or BNP, >1.5 cm hemodynamic instability or abnormal EKG **See Emergency  Neuro: headache, Dept. Treatment lethargic, irritable  Extremity changes: erythema/edema  Cardiac dysfunction

Yes ****Per CHOP care path i.e. CRP or ESR>30 and Lymphopenia<1k Or Thrombocytopenia<150K Concerning labs? Or MIS-C Set 1 Studies MIS-C Set 2 Studies NA <135 SARS CoV2 PCR (if not Chest X-Ray Discharge post usual performed within 48 hrs) Echocardiogram ED care No SARS CoV IgG (unless Triglycerides known +) Antithrombin III MIS-C discharge Resp. viral panel ADAMTS13 instructions EKG Dx. needing No Procalcitonin Consider hospitalization? Arrange follow up ESR Blood type & screen with PMD Urine with micro/culture Additional blood cx Blood culture Rapid Strep Capture pt on Yes CBC/Diff Throat Culture MIS-C log CMP Antistreptolysin O (ASO) CRP Specific viral titers or Admit D-Dimer Collecting large volume Ferritin (5-10 mls) serum to store Capture pt on Troponin for future studies MIS-C log BNP Cytokine panel LDH Von Willebrand panel Floor team to VBG Immunoglobins including reassess MIS-C Lactate IgA (particularly if your possibility PT/PTT center uses IVIG known CK to have significant IgA contamination)