Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region

OBJECTIVES

Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock.

METHODS

We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors.

RESULTS

Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]).

CONCLUSIONS

Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods

Objective

New York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year.

Methods

Retrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019–December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20–6/7/20) and late (6/8/20–12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events.

Results

There was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)].

Conclusions

NYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.

Multisystem Inflammatory Syndrome in Children

Background

Multisystem inflammatory syndrome in children (MIS-C) is a newly recognized condition affecting children with recent infection or exposure to coronavirus disease 2019 (COVID-19). MIS-C has symptoms that affect multiple organs systems, with some clinical features resembling Kawasaki disease (KD) and toxic shock syndrome (TSS).

Objective of the Review

Our goal was to review the current literature and describe the evaluation and treatment algorithms for children suspected of having MIS-C who present to the emergency department.

Discussion

MIS-C has a wide clinical spectrum and diagnosis is based on a combination of both clinical and laboratory findings. The exact mechanism of immune dysregulation of MIS-C is not well understood. Physical findings may evolve and do not necessarily appear at the same time. Gastrointestinal, cardiac, inflammatory, and coagulopathy manifestations and dysfunction are seen frequently in MIS-C.

Conclusions

The diagnosis of MIS-C is based on clinical presentation and specific laboratory findings. In the emergency setting, a high level of suspicion for MIS-C is required in patients exposed to COVID-19. Early diagnosis and prompt initiation of therapy offer the best chance for optimal outcomes.

Rupture of the Corpus Cavernosum in a Pediatric Patient

ABSTRACT

Pediatric penile pain is an uncommon complaint and is associated with a wide differential diagnosis including infectious, inflammatory, traumatic, and idiopathic conditions. Penile fractures, anatomically known as rupture of the corpus cavernosum, are almost exclusively reported in sexually mature patients and usually involve forceful manipulation during sexual activity. Rupture of the corpus cavernosum is a true urologic emergency. Failure to recognize and treat rupture of the corpus cavernosum has been associated with residual penile angulation, persistent hematoma, abscess, erectile dysfunction, and fibrosis. We present the case of a previously healthy 7-year-old boy who presented to our emergency department with complaints of penile pain with movement after falling and colliding with staircase railing. Examination showed ecchymosis and swelling of the penile shaft; both testicles were palpable and nontender, with no perineal or scrotal bruising. Ultrasound noted discontinuity along the right corpus cavernosum consistent with a rupture of the right corpus cavernosum. Testicles were noted to be in the scrotum with normal Doppler flow. Flexible cystoscopy revealed an uninjured urethra and bladder. Our patient was urgently taken to the operating room for repair of his injury. Thanks to the timely surgical correction, there were no postsurgical complications, and he was discharged home on postoperative day 1. This case demonstrates that although most reports of corpus cavernosum injuries are associated with sexual intercourse, other modes are possible and should be considered for acute-onset penile pain in pediatric patients.