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__NOTOC__
__NOTOC__
==COVID-19 associated multi-system inflammatory syndrome in children==
== Methods of Pacing ==
{{CMG}}; {{AE}} [..]<br>
Cardiac pacemakers consist of two parts: a '''pulse generator''' or simply generator which is the source of electric pulse, and a variable number of '''leads''' that convey the electric signal from the generator to the [[Myocardium|myocardium]]. Newer leadless pacemakers have been introduced reducing the risk of complications. There is no formal classification system for the pacemaker. Based upon their use they can be divided into '''temporary pacing''' or emergency use pacing and '''permanent pacing'''.
{{SK}} ; (MIS-C); (MIS-C) associated with COVID-19; (MIS-C) associated with SARS-CoV-2; Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19); Multisystem Inflammatory Syndrome in Children associated with COVID-19; Hyperinflammatory shock in children during COVID-19 pandemic. <br>


==[[COVID-19 associated multi-system inflammatory syndrome in children|Overview]]==
=== Temporary pacing ===
COVID-19 associated Multi-system Inflammatory Syndrome in Children is a new disease entity affecting children less than 21 years of age. The diagnostic criteria include fever and inflammation with multiorgan involvement AND no alternative diagnoses AND COVID-19 positive or history of exposure.
Temporary pacing is indicated if permanent pacing is not instantly available, not required, or contraindicated. Different types of temporary pacing techniques include transvenous pacing, transcutaneous pacing, epicardial pacing, transesophageal atrial pacing<ref name="pmid16943920">{{cite journal |vauthors=Verbeet T, Castro J, Decoodt P |title=Transesophageal pacing: a versatile diagnostic and therapeutic tool |journal=Indian Pacing Electrophysiol J |volume=3 |issue=4 |pages=202–9 |date=October 2003 |pmid=16943920 |pmc=1502053 |doi= |url=}}</ref>, transthoracic mechanical pacing, transthoracic pacing<ref name="pmid6383140">{{cite journal |vauthors=Hedges JR, Syverud SA, Dalsey WC |title=Developments in transcutaneous and transthoracic pacing during bradyasystolic arrest |journal=Ann Emerg Med |volume=13 |issue=9 Pt 2 |pages=822–7 |date=September 1984 |pmid=6383140 |doi=10.1016/s0196-0644(84)80450-3 |url=}}</ref> and transmediastinal pacing.


==[[COVID-19 associated multi-system inflammatory syndrome in children|Historical Perspective]]==
<br />
It was not long after the elderly and immunocompromised were considered high-risk for COVID-19, that Multi-system Inflammatory Syndrome in Children drew the clinicians' attention. An increasing number of severe inflammatory syndrome cases in the pediatric population was highlighted by the physicians in the United Kingdom on April 26th, 2020. The children although previously healthy were COVID-19 positive or had a history of close contact with COVID-19 patients.<ref name="urlHAN Archive - 00432 | Health Alert Network (HAN)">{{cite web |url=https://emergency.cdc.gov/han/2020/han00432.asp |title=HAN Archive - 00432 &#124; Health Alert Network (HAN) |format= |work= |accessdate=}}</ref> Since then the cases of COVID-19 associated Multi-system Inflammatory Syndrome in Children are on the rise, as are COVID-19 cases in adolescents.
{| class="wikitable"
! colspan=3 style="background: #4479BA; color: #FFFFFF; " align="center"|Types of temporary pacing
|-
!style="background: #4479BA; color: #FFFFFF; " align="center" |Type
!style="background: #4479BA; color: #FFFFFF; " align="center" |Description
!style="background: #4479BA; color: #FFFFFF; " align="center" |Indication
|-
|style="background: #DCDCDC; |Transvenous pacing {{main|Transvenous pacing}}
|Transvenous pacing, when used for temporary pacing, is an alternative to transcutaneous pacing. A pacemaker wire is placed into a vein, under sterile conditions, and then passed into either the right atrium or right ventricle.  The pacing wire is then connected to an external pacemaker outside the body.  Transvenous pacing is often used as a bridge to permanent pacemaker placement.  It can be kept in place until a permanent pacemaker is implanted or until there is no longer a need for a pacemaker and then it is removed.
|
|-
|style="background: #DCDCDC; |Transcutaneous pacing{{main|Transcutaneous pacing}}
|Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial stabilization of hemodynamically significant [[bradycardia]]s of all types. The procedure is performed by placing two pacing pads on the patient's chest, either in the anterior/lateral position or the anterior/posterior position. The rescuer selects the pacing rate, and gradually increases the pacing current (measured in mA) until electrical capture (characterized by a wide QRS complex with a tall, broad T wave on the [[electrocardiogram|ECG]]) is achieved, with a corresponding pulse. Pacing artifact on the [[electrocardiogram|ECG]] and severe muscle twitching may make this determination difficult. External pacing should not be relied upon for an extended period of time. It is an emergency procedure that acts as a bridge until transvenous pacing or other therapies can be applied.
|
|-
|style="background: #DCDCDC; |Epicardial Pacing{{Main|Epicardial}}
|Temporary epicardial pacing is used during open heart surgery should the surgical procedure create [[Atrioventricular block|atrioventricular block]]. The electrodes are placed in contact with the [[Epicardium|outer wall]] of the ventricle to maintain satisfactory cardiac output until a temporary transvenous electrode has been inserted.
|
|-
|style="background: #DCDCDC; |Transesophageal pacing
|
|
|-
|style="background: #DCDCDC; |Transthoracic pacing
|
|
|-
|style="background: #DCDCDC; |Transthoracic mechanical pacing
|Also known as percussive pacing, is the use of the closed fist, usually on the left lower edge of the sternum over the right ventricle, striking from a distance of 20 - 30 cm to induce a ventricular beat (the British Journal of Anesthesia suggests this must be done to raise the ventricular pressure 10 - 15mmhg to induce electrical activity). This is an old procedure used only as a life saving means until an electrical pacemaker is brought to the patient.<ref>(Cite_Journal)Percussion pacing in a three year-old girl with complete heart block during cardiac catheterization. C Eich, A Bleckmann and T. Paul, retrieved from http://bja.oxfordjournals.org/cgi/content/full/95/4/465</ref>
|
|-
|style="background: #DCDCDC; |Transmediastinal pacing
|
|
|}


==[[COVID-19 associated multi-system inflammatory syndrome in children|Pathophysiology]]==


==[[COVID-19 associated multi-system inflammatory syndrome in children|Causes]]==
=== Permanent Pacing ===
According to {CDC} no specific cause of COVID-19 associated multi-system inflammatory syndrome in children has been identified. However, the concomitant exposure or infection with COVID-19 has been observed. <ref name="urlFor Parents: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 | CDC">{{cite web |url=https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/mis-c.html |title=For Parents: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 &#124; CDC |format= |work= |accessdate=}}</ref>
[[Image:Fluoroscopy pacemaker leads right atrium ventricle.png|thumb|left|Right atrial and right ventricular leads as visualized under X-ray during a pacemaker implant procedure. The atrial lead is the curved one making a U shape in the upper left part of the figure.]]
Permanent pacing with an implantable pacemaker involves the transvenous placement of one or more pacing electrodes within a chamber, or chambers, of the heart. The procedure is performed by the incision of a suitable vein into which the electrode lead is inserted and passed along the vein, through the valve of the heart, until positioned in the chamber. The procedure is facilitated by [[fluoroscopy]] which enables the physician or cardiologist to view the passage of the electrode lead. After satisfactory lodgment of the electrode is confirmed the opposite end of the electrode lead is connected to the pacemaker generator.


==[[COVID-19 associated multi-system inflammatory syndrome in children|Differentiating COVID-19 associated multi-system inflammatory syndrome in children from other diseases]]==
The pacemaker generator is a hermetically sealed device containing a power source, usually a lithium battery, a sensing amplifier which processes the electrical manifestation of naturally occurring heartbeats as sensed by the heart electrodes, the computer logic for the pacemaker and the output circuitry which delivers the pacing impulse to the electrodes.
:COVID-19 associated multi-system inflammatory syndrome in children must be differentiated from other diseases that cause [[rash]] such as [[Kawasaki disease]] and [[toxic shock syndrome]].
*[[Kawasaki disease]] A patient with fever for 5 or more days and at least 4 clinical signs ([[rash]], bilateral conjunctival injection, more than 1.5 cm of cervical [[lymphadenopathy]], oral mucosal changes and extremity changes) is known to have Kawasaki disease. Typically a patient is less than 5 years of age. <ref name="urlCase Definition | Kawasaki Disease | CDC">{{cite web |url=https://www.cdc.gov/kawasaki/case-definition.html |title=Case Definition &#124; Kawasaki Disease &#124; CDC |format= |work= |accessdate=}}</ref>


*[[Toxic Shock Syndrome]]
Most commonly, the generator is placed below the subcutaneous fat of the chest wall, above the muscles and bones of the chest. However, the placement may vary on a case by case basis.


__NOTOC__
The outer casing of pacemakers is so designed that it will rarely be rejected by the body's [[immune system]]. It is usually made of [[titanium]], which is inert in the body.
==[[COVID-19 associated multi-system inflammatory syndrome in children epidemiology and demographics|Epidemiology and Demographics]]==
The nature of COVID-19 associated multi-system inflammatory syndrome in children makes the data requiring an update all the time.  No causal relationship to any demographic factor has been established. 
 
===Age===
The diagnostic criteria including children age less than 21 years helps highlight the age group that can be affected. The limited data of eight patients showed the affected children's age between 4- 14 years. <ref>{{cite journal|doi=10.1016/ S0140-6736(20)31094-1}}</ref>
 
===Mortality===
*The limited data available shows low [[mortality rate]] due to COVID-19 associated multi-system inflammatory syndrome in children.
 
===Geographic Distribution===
* Most of the cases have been reported in North America and Europe but the evolving nature of itself COVID-19 and COVID-19 associated multi-system inflammatory syndrome in children requires more effort to keep the world updated.
 
==[[COVID-19 associated multi-system inflammatory syndrome in childrenrisk factors|Risk Factors]]==
 
==[[COVID-19 associated multi-system inflammatory syndrome in children screening|Screening]]==
 
==[[COVID-19 associated multi-system inflammatory syndrome in children natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 
==Diagnosis==
==WHO preliminary case definition==
A preliminary case is a patient 0-19 years of age having a fever for more than three days and at least two of the following findings<ref>[https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19| WHO reports multisystem-inflammatory-syndrome in children with COVID-19]</ref>:                                               
 
*#Rash or bilateral non-purulent conjunctivitis or mucocutaneous inflammation signs (oral, hands or feet).
*#Hypotension or shock.
*#Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP),
*#Evidence of coagulopathy (by PT, PTT, elevated d-Dimers).
*#Acute gastrointestinal problems (diarrhea, vomiting, or abdominal pain).
AND
*Elevated markers of inflammation such as [[ESR]], [[C-reactive protein]], or [[procalcitonin]].
AND
*No other obvious microbial cause of inflammation, including bacterial [[sepsis]], staphylococcal or streptococcal shock syndromes.
AND
*Evidence of COVID-19 (RT-PCR, antigen test or [[serology]] positive), or likely contact with patients with COVID-19.
[[COVID-19 associated multi-system inflammatory syndrome in children history and symptoms|History and Symptoms]] | [[COVID-19 associated multi-system inflammatory syndrome in children physical examination|Physical Examination]] | [[COVID-19 associated multi-system inflammatory syndrome in children laboratory findings|Laboratory Findings]] | [[COVID-19 associated multi-system inflammatory syndrome in children electrocardiogram|Electrocardiogram]] |[[COVID-19 associated multi-system inflammatory syndrome in children here chest x ray|Chest X Ray]] | [[COVID-19 associated multi-system inflammatory syndrome in children CT|CT]] | [[COVID-19 associated multi-system inflammatory syndrome in children MRI|MRI]] | [[COVID-19 associated multi-system inflammatory syndrome in children echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[COVID-19 associated multi-system inflammatory syndrome in children other imaging findings|Other Imaging Findings]] | [[COVID-19 associated multi-system inflammatory syndrome in children other diagnostic studies|Other Diagnostic Studies]]
 
==Treatment==
[[COVID-19 associated multi-system inflammatory syndrome in children medical therapy|Medical Therapy]] | [[COVID-19 associated multi-system inflammatory syndrome in children surgery|Surgery]] | [[COVID-19 associated multi-system inflammatory syndrome in children primary prevention|Primary Prevention]] | [[COVID-19 associated multi-system inflammatory syndrome in children secondary prevention|Secondary Prevention]] | [[COVID-19 associated multi-system inflammatory syndrome in children cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[COVID-19 associated multi-system inflammatory syndrome in children future or investigational therapies|Future or Investigational Therapies]]

Revision as of 13:03, 6 June 2020

Methods of Pacing

Cardiac pacemakers consist of two parts: a pulse generator or simply generator which is the source of electric pulse, and a variable number of leads that convey the electric signal from the generator to the myocardium. Newer leadless pacemakers have been introduced reducing the risk of complications. There is no formal classification system for the pacemaker. Based upon their use they can be divided into temporary pacing or emergency use pacing and permanent pacing.

Temporary pacing

Temporary pacing is indicated if permanent pacing is not instantly available, not required, or contraindicated. Different types of temporary pacing techniques include transvenous pacing, transcutaneous pacing, epicardial pacing, transesophageal atrial pacing[1], transthoracic mechanical pacing, transthoracic pacing[2] and transmediastinal pacing.


Types of temporary pacing
Type Description Indication
Transvenous pacing
Main article: Transvenous pacing
 Transvenous pacing, when used for temporary pacing, is an alternative to transcutaneous pacing. A pacemaker wire is placed into a vein, under sterile conditions, and then passed into either the right atrium or right ventricle. The pacing wire is then connected to an external pacemaker outside the body. Transvenous pacing is often used as a bridge to permanent pacemaker placement. It can be kept in place until a permanent pacemaker is implanted or until there is no longer a need for a pacemaker and then it is removed.
Transcutaneous pacing
Main article: Transcutaneous pacing
 Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial stabilization of hemodynamically significant bradycardias of all types. The procedure is performed by placing two pacing pads on the patient's chest, either in the anterior/lateral position or the anterior/posterior position. The rescuer selects the pacing rate, and gradually increases the pacing current (measured in mA) until electrical capture (characterized by a wide QRS complex with a tall, broad T wave on the ECG) is achieved, with a corresponding pulse. Pacing artifact on the ECG and severe muscle twitching may make this determination difficult. External pacing should not be relied upon for an extended period of time. It is an emergency procedure that acts as a bridge until transvenous pacing or other therapies can be applied.
Epicardial Pacing
Main article: Epicardial
 Temporary epicardial pacing is used during open heart surgery should the surgical procedure create atrioventricular block. The electrodes are placed in contact with the outer wall of the ventricle to maintain satisfactory cardiac output until a temporary transvenous electrode has been inserted.
Transesophageal pacing
Transthoracic pacing
Transthoracic mechanical pacing Also known as percussive pacing, is the use of the closed fist, usually on the left lower edge of the sternum over the right ventricle, striking from a distance of 20 - 30 cm to induce a ventricular beat (the British Journal of Anesthesia suggests this must be done to raise the ventricular pressure 10 - 15mmhg to induce electrical activity). This is an old procedure used only as a life saving means until an electrical pacemaker is brought to the patient.[3]
Transmediastinal pacing


Permanent Pacing

Right atrial and right ventricular leads as visualized under X-ray during a pacemaker implant procedure. The atrial lead is the curved one making a U shape in the upper left part of the figure.

Permanent pacing with an implantable pacemaker involves the transvenous placement of one or more pacing electrodes within a chamber, or chambers, of the heart. The procedure is performed by the incision of a suitable vein into which the electrode lead is inserted and passed along the vein, through the valve of the heart, until positioned in the chamber. The procedure is facilitated by fluoroscopy which enables the physician or cardiologist to view the passage of the electrode lead. After satisfactory lodgment of the electrode is confirmed the opposite end of the electrode lead is connected to the pacemaker generator.

The pacemaker generator is a hermetically sealed device containing a power source, usually a lithium battery, a sensing amplifier which processes the electrical manifestation of naturally occurring heartbeats as sensed by the heart electrodes, the computer logic for the pacemaker and the output circuitry which delivers the pacing impulse to the electrodes.

Most commonly, the generator is placed below the subcutaneous fat of the chest wall, above the muscles and bones of the chest. However, the placement may vary on a case by case basis.

The outer casing of pacemakers is so designed that it will rarely be rejected by the body's immune system. It is usually made of titanium, which is inert in the body.

  1. ↑ Verbeet T, Castro J, Decoodt P (October 2003). "Transesophageal pacing: a versatile diagnostic and therapeutic tool". Indian Pacing Electrophysiol J. 3 (4): 202–9. PMC 1502053. PMID 16943920.
  2. ↑ Hedges JR, Syverud SA, Dalsey WC (September 1984). "Developments in transcutaneous and transthoracic pacing during bradyasystolic arrest". Ann Emerg Med. 13 (9 Pt 2): 822–7. doi:10.1016/s0196-0644(84)80450-3. PMID 6383140.
  3. ↑ (Cite_Journal)Percussion pacing in a three year-old girl with complete heart block during cardiac catheterization. C Eich, A Bleckmann and T. Paul, retrieved from http://bja.oxfordjournals.org/cgi/content/full/95/4/465
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