SARS-CoV-2, which causes the disease COVID-19, generally has a mild disease course in children. However, a severe post-infectious inflammatory process known as multisystem inflammatory syndrome in children has been observed in association with COVID-19. This inflammatory process is a result of an abnormal immune response with similar clinical features to Kawasaki disease. It is well established that multisystem inflammatory syndrome in children is associated with myocardial dysfunction, coronary artery dilation or aneurysms, and occasionally arrhythmias. The most common electrocardiographic abnormalities seen include premature atrial or ventricular ectopy, variable degrees of atrioventricular block, and QTc prolongation, and rarely, haemodynamically significant arrhythmias necessitating extracorporeal membrane oxygenation support. However, presentation with fever, hypotension, and relative bradycardia with a left axis idioventricular rhythm has not been previously reported. We present a case of a young adolescent with multisystem inflammatory syndrome in children with myocarditis and a profoundly inappropriate sinus node response to shock with complete resolution following intravenous immunoglobulin.

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Introduction: Family-centered rounding (FCR) allows the medical team to partner with patients in medical decision-making, improving communication, and enhancing safety. However, FCR may compromise aspects of the resident education experience. In a survey of pediatric residents at our children's hospital, only 20% felt FCR provided the best educational experience. We designed this project to increase the percentage of residents with a positive perception of the educational experience on FCR from 20% to 80% in 6 months. Methods: This project utilized The Model for Improvement and sequential plan-do-study-act cycles. A needs assessment identified educational activities negatively impacted by FCR. We then designed a hybrid FCR process with formal presentations outside patient rooms followed by traditional bedside FCR. Our primary measure was the percentage of residents positively perceiving the FCR educational experience. Our balancing measures included rounding duration and family satisfaction and comprehension. Results: Residents who perceive FCR to be the best educational experience improved from a baseline of 21% to 76%, with a calculated response rate of 79%. Patients receiving FCR remained above 80%. All surveyed families understood their care plans and remained satisfied with the information provided, although 21% were concerned about the number of people present on rounds during the COVID-19 pandemic. Forty-three percent of hospitalist rounds exceeded the allotted time. Conclusions: The hybridization of FCR to include formal presentations may improve the resident learning experience while preserving family satisfaction and comprehension.

Results Following PDSA 1, there were reductions in mean time from referral to PET (40.5 to 27.3 days), to CT/MRI Brain (35.8 to 18.8 days), and to diagnosis (41.4 to 30.1 days), all significant by special cause variation. Following PDSA 2, the percentage of LC clinic patients with a CT chest recommending clinic referral increased (25.2% to 37.0%, p=0.041), with increased recommendations from regional hospitals (4.2% to 16.5%, p=0.022). When a radiologist recommended LC clinic referral, time to referral and assessment were faster (7.3 vs. 15.5 days, p=0.0001; 20.3 vs. 26.2 days, p=0.001, respectively). Conclusions Standardization of radiologist reporting and LC clinic triage led to significant improvement in timeliness of specialist access, diagnosis and staging investigations.

A 2-month-old previously healthy, full-term female presented with fever, nonbloody emesis, and melena. On presentation, she was febrile, in status epilepticus requiring antiepileptic medications, and hypotensive requiring fluid resuscitation, inotropic support, and rapid sequence intubation. Initial physical exam was notable for pulmonary rales, abdominal distention, and signs of severe dehydration but no dysmorphic features or palpable lymphadenopathy.Laboratory investigation revealed leukocytosis (23 × 10 3 µ/L) with left shift, thrombocytosis (798 × 10 3 / µL), elevated c-reactive protein (CRP) (8.2 mg/dL), elevated procalcitonin (31.76 ng/mL), elevated erythrocyte sedimentation rate (ESR) (66 mm/h), normocytic anemia (Hgb 8.7 g/dL), hypoalbuminemia (2 g/dL), hypocalcemia (5.1mg/dL), hyperphosphatemia (13.8 mg/dL), coagulopathy (PT 16.1 seconds, INR 1.3, PTT 39 seconds), elevated parathyroid hormone (PTH) (357 pg/mL), 25-OH Vitamin D deficiency (<4 ng/mL), and acute kidney injury (BUN 50 mg/dL, Cr 1.5 mg/dL). Electrolytes were significant for a hypochloremic metabolic acidosis (CO2 13). Blood, urine, and cerebrospinal fluid (CSF) cultures were negative. CSF cell count revealed 2 WBC, 465 RBC, 34% neutrophils, 22% lymphocytes, 42% macrophages, 2% eosinophils. SARS-CoV-2, RSV, and Influenza nasopharyngeal swabs and HSV 1/2 serum PCRs were negative. Virginia newborn metabolic screen was normal.Radiographic investigation showed dilated loops of bowel on the computed tomography (CT) of the abdomen and pelvis and unremarkable head CT. Extensive bilateral pulmonary opacities were seen on X-ray. Splenic evaluation