Most downloaded biology preprints, all time
in category emergency medicine
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1,171 downloads medRxiv emergency medicine
Antonio Gidaro, Federica Samartin, Anna Maria Brambilla, Chiara Cogliati, Stella Ingrassia, Francesco Banfi, Viola Cupiraggi, Cecilia Bonino, Marco Schiuma, Andrea Giacomelli, Stefano Rusconi, Jaqueline Curra, Antonio Luca Brucato, Emanuele Salvi
BackgroundAcute Hypoxemic Respiratory Failure (AHRF) is a common complication of Covid-19 related pneumonia, for which non-invasive ventilation (NIV) with Helmet Continuous Positive Airway Pressure (CPAP) is widely used. During past epidemics of SARS and MERS pneumomediastinum (PNM) and pneumothorax (PNX) were common complications (respectively 1.7-12% and 16,4%) either spontaneous or associated to ventilation. MethodsAim of our retrospective study was to investigate the incidence of PNX/PNM in COVID-19 pneumonia patients treated with CPAP. Moreover, we examined the correlation between PNX/PNM and Positive end-expiratory pressure (PEEP) values. We collected data from patients admitted to "Luigi Sacco" University Hospital of Milan from 21/02/2020 to 06/05/2020 with COVID-19 pneumonia requiring CPAP. ResultsOne-hundred-fifty-four patients were enrolled. During hospitalization 3 PNX and 2 PNM occurred (3.2%). Out of these five patients 2 needed invasive ventilation after PNX, two died. In the overall population, 42 patients (27%) were treated with High-PEEP (>10 cmH2O), and 112 with Low-PEEP ([≤]10 cmH2O). All the PNX/PNM occurred in the High-PEEP group (5/37 vs 0/112, p<0,001). ConclusionThe incidence of PNX appears to be lower in COVID-19 than SARS and MERS, but their occurrence is accompanied by high mortality and worsening of clinical conditions. Considering the association of PNX/PNM with high PEEP we suggest using the lower PEEP as possible to prevent these complications. "Key messages" boxO_ST_ABSSection 1: What is already known on this subjectC_ST_ABSO_LIElevated incidence of pneumomediastinum (PNM) and pneumothorax (PNX) occurring during SARS and MERS pneumonia (respectively 1.7-12%9,10 and 16,4%11), either spontaneous or associated to ventilation.Conversely, these complications have not been reported when NIV was used for the treatment of common pneumonia patients6,7. C_LIO_LISome cases of PNX and PNM have been recently reported in patients with COVID-19 pneumonia, most of them spontaneous12-14, in some cases related to NIV15,16 or endotracheal intubation (ETI)17,18. C_LI Section 2: What this study addsO_LIIncidence of PNX/PNM is lower in COVID19 pneumonia patients during CPAP (3,2%) than SARS and MERS. C_LIO_LIConsidering mortality rate and need of ETI, occurrence of PNX/PNM worsens prognosis. C_LIO_LIAll the PNX/PNM occurred in the High-PEEP (>10 cmH2O) group (5/37 vs 0/112, p<0,001). C_LIO_LIConsidering the association of high PEEP (>10 cmH2O) with PNX/PNM, the use of low PEEP values has to be taken into consideration. C_LI
994 downloads medRxiv emergency medicine
Jesper Eugen-Olsen, Izzet Altintas, Jens Tingleff, Marius Stauning, Hejdi Gamst-Jensen, Mette Bendz Lindstroem, Line Jee Hartmann Rasmussen, Klaus Tjelle Kristiansen, Christian Rasmussen, Jan Nehlin, Thomas Kallemose, Ove Andersen
OBJECTIVE To examine if baseline soluble urokinase plasminogen activator receptor (suPAR) can predict whether patients with COVID-19 symptoms will need mechanical ventilation during a 14-day follow-up. Furthermore, to examine differences in demographics, clinical signs, and biomarkers in patients tested either positive or negative for SARS-CoV-2. DESIGN Prospective cohort study including patients presenting with symptoms of COVID-19. SETTING Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark. PARTICIPANTS 407 patients presenting with symptoms of COVID-19 were included from the Emergency Department (ED). Patients were included from March 19 to April 3 and follow-up data was collected until April 17, 2020. MAIN OUTCOME MEASURES Primary outcomes were respiratory failure in patients presenting with symptoms of COVID-19 and in those with a positive SARS-CoV-2 RT-PCR test, respectively. Furthermore, we analysed differences between patients testing positive and negative for SARS-CoV-2, and disease severity outcomes in SARS-CoV-2 positive patients according to baseline suPAR. BACKGROUND Patients admitted to ED with clinical signs or symptoms of COVID-19 infection need a safe and quick triage, in order to determine if an in-hospital stay is necessary or if the patient can safely be isolated in their own home with relevant precautions. suPAR is a biomarker previously shown to be associated with adverse outcomes in acute medical patients. We aimed to examine if suPAR at baseline presentation is predictive of respiratory failure in patients presenting with symptoms of COVID-19. Furthermore, we examined demographic, clinical, and biochemical differences between SARS-CoV-2-positive and negative patients. RESULTS Among the 407 symptomatic patients, the median (interquartile range) age was 64 years (47-77), 58% were women, and median suPAR was 4.2 ng/ml (2.7-6.4). suPAR level below 4.75 ng/ml at admission ruled out respiratory failure during follow-up with an area under the curve (95% CI) of 0.89 (0.85-0.94) and a negative predictive value of 99.5%. Of the 407 symptomatic patients, 117 (28.8%) had a positive RT-PCR test for SARS-CoV-2 and presented with significant differences in vital signs, cell counts, and biomarkers compared to SARS-CoV-2 negative patients. In SARS-CoV-2 positive patients eligible for mechanical ventilation (N=87), 26 (30%) developed respiratory failure. Best baseline predictors of respiratory failure were suPAR with an area under the curve (95% CI) of 0.88 (0.80-0.95), EWS 0.84 (0.75-0.93), lactate dehydrogenase 0.82 (0.71-0.93), and C-reactive protein 0.80 (0.70-0.89). CONCLUSION SARS-CoV-2 affects several patient parameters underpinning the severe impact of the infection. A low suPAR level (<4.75 ng/ml) at baseline is a useful biomarker for aiding clinical decisions including discharge of patients presenting with symptoms of COVID-19.
987 downloads medRxiv emergency medicine
PurposeGlucocorticoids are widely used to treat acute respiratory distress syndrome (ARDS) despite its use is highly controversial based on randomized controlled trials and meta-analyses. As type I interferons (IFNs) are our first line of defense against severe viral respiratory infections, we explored whether glucocorticoids interfere with IFN signaling and whether their use associates to outcome of IFN beta treatment of ARDS. MethodsWe performed a propensity-matched post-hoc-analysis using data from the recent randomized INTEREST-trial comparing IFN beta-1a to placebo in ARDS patients. Based on the results of these analyses we utilized human lung tissue and human pulmonary endothelial cell cultures to investigate the effect of hydrocortisone on IFN nuclear signaling and the protein transcription of CD73, a molecule responsible for vascular integrity. ResultsWe found that hydrocortisone reduces the production, and prevents the nuclear translocation of IRF9, that is required for IFN beta-dependent signaling of multiple IFN-induced genes. In addition, hydrocortisone inhibits IFN beta-dependent upregulation of CD73 in human lung tissue. Additionally, we found that use of glucocorticoids with IFN beta-1a was independently associated with increased mortality (OR 5.4, 95% CI 2.1-13.9, P< 0.001) in the INTEREST-trial. ConclusionsGlucocorticoids inhibit type I IFN beta signaling and the upregulation of CD73 in human lung. This provides the mechanistic basis for the harmful association of glucocorticoids in IFN beta treated patients in the INTEREST-trial. Most importantly, it strongly speaks against the use of glucocorticoids in viral-induced ARDS such as in the currently expanding corona virus outbreak.
983 downloads medRxiv emergency medicine
OBJECTIVES: This study investigated the level of public awareness, knowledge and attitudes towards BLS among non-medical adult Omanis in Muscat City, Oman and explored the association between knowledge and attitude and the socio-demographic characteristics. DESIGN: Cross sectional design was used. Convenience sampling method in Muscat city from February to March 2020. Setting: The study setting was based in Muscat City, Oman. Participants: 426 Adults, non-medical Omanis, able to read and write Arabic Language, were included between February and March 2020. METHODS: Adopted, validated, online Arabic questionnaire was used, including four parts of 37 questions on socio-demographic information, awareness, knowledge and attitude. The results were presented in tables with descriptions. FINDINGS: Majority of participants were in age groups, 28-37 years (50.0%) and 18-27 years (35.7%); were female (57.0%); married (58.5%), single (39.9%); had secondary (31.5%), diploma (27.2%), bachelors(32.4%) education levels; and worked in government (28.6%), private sector (25.4%). Significantly, large proportion of them (62.0%) were aware about BLS. However, knowledge total scores were not normally distributed (0.917, P<0.001), with minimum, maximum, median and mean knowledge total score of 0 out of 15, 13 out of 15, 3 out of 15, 3.6 respectively. Also, attitude total scores were not normally distributed (0.976, P<0.001), with minimum, maximum, median and mean attitude total scores of 30 out of 65, 65 out of 65, 55 out of 65, 54.5 respectively. CONCLUSIONS: The awareness of non-medical adults toward Basic Life Support was substantial, whereas, knowledge level toward BLS was very low despite of its differences with respect to socio-demographic characteristics. In contrast, all participants had positive attitude toward BLS. Therefore, this study is advocating the need for mandatory training in Basic Life Support for all non-medics in the country as well as incorporating Basic Life Support teaching in school curriculum.
972 downloads medRxiv emergency medicine
Steve Goodacre, Ben Thomas, Ellen Lee, Laura Sutton, Amanda Loban, Simon Waterhouse, Richard Simmonds, Katie Biggs, Carl Marincowitz, Jose Schutter, Sarah Connelly, Elena Sheldon, Jamie Hall, Emma Young, Andrew Bentley, Kirsty Challen, Chris Fitzsimmons, Tim Harris, Fiona Lecky, Andrew Lee, Ian Maconochie, Darren Walter
Background Hospital emergency departments play a crucial role in the initial management of suspected COVID-19 infection. We aimed to characterise patients attending emergency departments with suspected COVID-19, including subgroups based on sex, ethnicity and COVID-19 test results. Methods We undertook a mixed prospective and retrospective observational cohort study in 70 emergency departments across the United Kingdom (UK). We collected presenting data from 22446 people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020. Outcomes were admission to hospital, COVID-19 result, organ support (respiratory, cardiovascular or renal), and death, by record review at 30 days. Results Adults were acutely unwell (median NEWS2 score 4) and had high rates of admission (67.1%), COVID-19 positivity (31.2%), organ support (9.8%) and death (15.9%). Children had much lower rates of admission (27.4%), COVID-19 positivity (1.2%), organ support (1.4%) and death (0.3%). Adult men and women presented in similar numbers (10210 versus 10506), but men were more likely to be admitted (72.9% v 61.4%), require organ support (12.2% v 7.7%) and die (18.7% v 13.3%). Black or Asian adults tended to be younger than White adults (median age 54, 50 and 67 years), were less likely to be admitted (60.8%, 57.3%, 69.6%) or die (11.9%, 11.2%, 16.8%), but were more likely to require organ support (15.9%, 14.3%, 8.9%) or have a positive COVID-19 test (40.8%, 42.1%, 30.0%). Adults admitted with confirmed COVID-19 had similar age and comorbidities (except chronic lung disease) to those who did not have COVID-19 confirmed, but were much more likely to need organ support (22.2% v 8.9%) or die (32.7% v 15.9%). Conclusions Important differences exist between patient groups presenting to the emergency department with suspected COVID-19. People with confirmed COVID-19 have a poor prognosis, compared with similar emergency admissions without confirmed COVID-19.
945 downloads medRxiv emergency medicine
Marcela P Vizcaychipi, Claire L Shovlin, Michelle Hayes, Suveer Singh, Linsey Christie, Alice Sisson, Roger Davies, Christopher Lockie, Alice Howard, Alexander Brown, Alex McCarthy, Monica Popescu, Amandeep Gupta, James Armstrong, Hisham Said, Timothy Peters, Richard T Keays, ChelWest COVID-19 Consortium
BACKGROUND: COVID-19 is a global health emergency. Recent data indicate a 50% mortality rate across UK intensive care units. METHODS: A single institution, two-centre retrospective analysis following implementation of a Decision Support tool and real-time data dashboard for early detection of patients requiring personalised enhanced care, focussing particularly on respiratory rate, diastolic blood pressure, oxygenation indices, C-reactive protein, D-dimer and ferritin. Protocols differing from conventional practice included high-dose prophylactic anticoagulation for all COVID-19 positive patients and antioxidant prescription. RESULTS: By 22nd April 2020, 923 patients tested COVID-19 positive. 569 patients (61.7%) were male. The majority presented with advanced disease: interquartile ranges were C-reactive protein 44.9-179mg/L, D-dimer 1070-3802ng/L, and ferritin 261-1208g/L. Completed case fatality rates were 25.1% [95% CI 20.0, 30.0] in females, 40.5% [95% CI 35.9, 45.0] in males. 139 patients were admitted to intensive care where current death rates are 16.2% [95% CI 3.8, 28.7] in females, 38.2% [95% CI 28.6, 47.8] in males with no trends for differences based on ethnicity. A real-time traffic lights dashboard enabled rapid assessment of patients using critical parameters to accelerate adjustments to management protocols. In total 513 (55.6%) of patients were flagged as high risk for thromboembolic disease, exceeding the numbers flagged for respiratory deteriorations (N=391, 42.4%), or cytokine storm (N=68, 7.4%). There was minimal evidence that age was associated with disease severity, but males had higher levels of all dashboard indices, particularly C-reactive protein and ferritin (p<0.0001) which displayed no relationship with age. CONCLUSIONS: Survival rates are encouraging. Protocols employed (traffic light-driven personalised care, protocolised early therapeutic anticoagulation based on D-dimer >1,000ng/L and/or CRP>200 mg/L, personalised ventilatory strategies and antioxidants) are recommended to other units. Males are at greater risk of severe disease, most likely as the obligate SARS-CoV-2 receptor is on the X-chromosome, and require especially close, and early attention.
891 downloads medRxiv emergency medicine
Background: There is a shortage of chemical reagents for severe acute respiratory syndrome - coronavirus 2 (SARS-CoV-2) diagnosis and a surge of SARS-CoV-2 cases, especially in limited-resource settings. Therefore, the combination of an optimal assay kit is necessary. Methods: We compared the ability to screen SARS-CoV-2 among three primer-probe sets in two different master mixes, Invitrogen SuperScript III One-Step RT-PCR and LightCycler Multiplex RNA Virus Master. Results: The assay with TIB-Molbiol, IDT, and Phu Sa sets for LightCycler Multiplex RNA Virus Master or Invitrogen SuperScript III One-Step RT-PCR showed positive results from a single reaction of triplicate in the three days of 4.8 copies per reaction. R-squared and amplification efficiency were 0.97 and ranged from 107 to 108%, respectively. Conclusions: Our findings indicated that TIB-Molbiol, IDT, and Phu Sa primer-probe sets could be beneficial for the laboratory screening of SARS-CoV-2 by RT-qPCR assay of E gene. There is a need to consider the combination of these reagent sets as a new strategy to increase the testing capacity of screening programs for COVID-19.
878 downloads medRxiv emergency medicine
Background Covid-19 virus activity appears to have affected some parts of the United Kingdom more than others. Dumfries and Galloway (D&G) has seen fewer hospitalised cases than predicted. We wondered whether this might be related at least in part to population density. Methods We compared Covid-19 hospitalisation rates/100,000 population in D&G with those of the other 10 mainland Scottish health boards. We chose two time points: 19th April which was the peak of the pandemic in Scotland and 15th May, seven and a half weeks after lockdown. We used chi square and odds ratios with 95% confidence intervals to test for differences in hospitalisation rates and Pearson correlation coefficient to examine the relation between hospitalisation rates and population density. Population density for each health board was provided by National Records of Scotland. Results Hospitalisation in D&G was 13.4/100,000 on 19th April, falling to 1.3/100,000 by 15th May. Corresponding hospitalisation rates in Greater Glasgow & Clyde (GGC) were 50.1/100,000 and 38.9/100,000. Compared to GGC, hospitalisation rates in D&G were 3 times lower at peak (OR 0.27, 95% CI 0.17, 0.42) and 30 times lower by 15th May (OR 0.03, 95% CI 0.01, 0.14). Hospitalisation rates for the other health boards lay in between values recorded for D&G and GGC and fell in 10 of the 11 boards between these two dates. There was a positive association between hospitalisation rate and population density (r=0.756, p=0.007 on 19th April and r=0.840, p<0.001 for 15th May). Conclusion We have confirmed there are large differences in Covid-19 hospitalisation rates across the 11 mainland Scottish health boards, that are in part related to population density. These data support a regional rather than one nation approach to easing Covid-19 restrictions.
818 downloads medRxiv emergency medicine
Clinical prediction scores support the assessment of patients in the emergency setting to determine the need for further diagnostic and therapeutic steps. During the current COVID-19 pandemic, physicians in emergency rooms (ER) of many hospitals have a considerably higher patient load and need to decide within a short time frame whom to hospitalize. Based on our clinical experiences in dealing with COVID-19 patients at the University Hospital Zurich, we created a triage score with the acronym AIFELL consisting of clinical, radiological and laboratory findings. The score was then evaluated in a retrospective analysis of 122 consecutive patients with suspected COVID-19 from March until mid-April 2020. Descriptive statistics, Student's t-test, ANOVA and Scheffe's post hoc analysis confirmed the diagnostic power of the score. The results suggest that the AIFELL score has potential as a triage tool in the ER setting intended to select probable COVID-19 cases for hospitalization in spontaneously presenting or referred patients with acute respiratory symptoms.
808 downloads medRxiv emergency medicine
Objective: As a consequence of the health crisis arising from the SARS-CoV-2 coronavirus pandemic, ozone treatments are being applied as disinfectant in emergency vehicles, without objective evidence on its efficacy. Here we evaluate the efficacy of ozone treatment over bacterial strains and virus-like particles. Method: A preparation of a lentiviral vector (lentivector) and dried cultures of two bacterial strains (gram + Staphylococcus aureus and gram - Salmonella enterica ser. Enteritidis) were placed inside an ambulance at two different locations. The interior of the vehicle was subjected to 10 min and 20 min treatments (3 and 6 times the recommended time by the manufacturer). Following the treatments, lentivector preparations were titrated, and viable bacteria (colony forming units, CFUs) counted and compared to pre-treatment titers and infectious CFUs of the same lysates and cultures. Results: None of the treatments significantly reduced either lentivector titer or the number of viable bacteria. Conclusions: At least in the analyzed conditions and for the microorganisms used in this study, it can be concluded that ozone treatment is not advisable for the disinfection of emergency vehicles.
802 downloads medRxiv emergency medicine
BO_SCPLOWACKGROUNDC_SCPLOWRapid triaging, as in the current COVID-19 pandemic, focuses on age and pre-existing medical conditions. In contrast, preoperative assessments use cardiopulmonary exercise testing (CPET) to categorise patients to higher and lower risk independent of diagnostic labels. Since CPET is not feasible in population-based settings, our aims included evaluation of a triage/screening tool for cardiorespiratory risk. MO_SCPLOWETHODSC_SCPLOWCPET-derived anaerobic thresholds were evaluated retrospectively in 26 patients with pulmonary arteriovenous malformations (AVMs) who represent a challenging group to risk-categorise. Pulmonary AVM-induced hypoxaemia secondary to intrapulmonary right-to-left shunts, anaemia from underlying hereditary haemorrhagic telangiectasia and metabolic equivalents derived from the 13-point Veterans Specific Activity Questionnaire (VSAQ) were evaluated as part of routine clinical care. Pre-planned analyses evaluated associations and modelling of the anaerobic threshold and patient-specific variables. RO_SCPLOWESULTSC_SCPLOWIn the 26 patients (aged 21-77, median 57 years), anaerobic threshold ranged from 7.6-24.5 (median 12.35) ml.min-1kg-1 and placed more than half of the patients (15, 57.7%) in the >11 ml.min- 1kg-1 category suggested as "lower-risk" for intra-abdominal surgeries. Neither age nor baseline SpO2 predicted anaerobic threshold, or lower/higher risk categories, either alone or in multivariate analyses, despite baseline oxygen saturation (SpO2) ranging from 79 to 99 (median 92)%, haemoglobin from 108 to 183 (median 156)g.L-1. However, lower haemoglobin, and particularly, arterial oxygen content and oxygen pulse, were associated with increased cardiorespiratory risk: Modelling a haemoglobin increase of 25g.L-1 placed a further 7/26 (26.9%) patients in a lower risk category. For patients completing the VSAQ, derived metabolic equivalents were strongly associated with anaerobic threshold, enabling risk evaluations through a simple questionnaire. CO_SCPLOWONCLUSIONSC_SCPLOWBaseline exercise tolerance may override age and diagnostic labels in triage settings. These data support approaches to risk reduction by aerobic conditioning and attention to anaemia. The VSAQ is suggested as a rapid screening tool for cardiorespiratory risk assessment to implement during triage/screening. Key MessagesO_ST_ABSWhat is already knownC_ST_ABSO_LIAlongside age, pre-existing medical conditions are perceived negatively during triage assessments, particularly if rare, and/or theoretically expected to influence cardiorespiratory risk; C_LIO_LIAnaesthetists use cardiopulmonary exercise testing to categorise patients to higher and lower risk independently to diagnostic labels, but this is not feasible in acute settings; C_LIO_LIPulmonary arteriovenous malformations are an exemplar of a condition where, due to expected or measured abnormalities (hypoxaemia-low PaO2 SpO2), poor physiological capacity might be predicted. C_LI What this study addsO_LINeither age nor baseline SpO2 predicted lower/higher risk categories by anaerobic threshold, but haemoglobin-dependent indices of oxygen delivery to the tissues were associated with higher risk, offering opportunities for improvement by attention to anaemia and aerobic conditioning; C_LIO_LIBaseline exercise tolerance may override age and diagnostic labels in triage settings: the 13-point VSAQ Veterans Specific Activity Questionnaire (VSAQ) is suggested as a rapid screening tool for cardiorespiratory risk assessment. C_LI
779 downloads medRxiv emergency medicine
David van Klaveren, Alexandros Rekkas, Jelmer Alsma, Rob JCG Verdonschot, Dick TJJ Koning, Marlijn JA Kamps, Tom Dormans, Robert Stassen, Sebastiaan Weijer, Klaas-Sierk Arnold, Benjamin Tomlow, David M Kent, Stephanie CE Schuit, Hester Lingsma
Background and aimThe COVID-19 pandemic is putting extraordinary pressure on emergency departments (EDs). To support decision making about hospital admission, we aimed to develop a simple and valid model for predicting mortality and need for admission to an intensive care unit (ICU) in suspected-COVID-19 patients presenting at the ED. MethodsFor model development, we included patients that presented at the ED and were admitted to 4 large Dutch hospitals with suspected COVID-19 between March and August 2020, the first wave of the pandemic in the Netherlands. Based on prior literature we included patient characteristics, vital parameters and blood test values, all measured at ED admission, as potential predictors. Logistic regression analyses with post-hoc uniform shrinkage was used to obtain predicted probabilities of in-hospital death and of being admitted to the ICU, both within 28 days after admission. Model performance (AUC; calibration plots, intercepts and slopes) was assessed with temporal validation in patients who presented between September and December 2020 (second wave). We used multiple imputation to account for missing predictor values. ResultsThe development data included 5,831 patients who presented at the ED and were hospitalized, of whom 629 (10.8%) died and 5,070 (86.9%) were discharged within 28 days after admission. A simple model - named COVID Outcome Prediction in the Emergency Department (COPE) - with linear age and logarithmic transforms of respiratory rate, CRP, LDH, albumin and urea captured most of the ability to predict death within 28 days. Patients who were admitted in the first month of the pandemic had substantially increased risk of death (odds ratio 1.99; 95% CI 1.61-2.47). COPE was well-calibrated and showed good discrimination for predicting death in 3,252 patients of the second wave (AUC in 4 hospitals: 0.82; 0.82; 0.79; 0.83). COPE was also able to identify patients at high risk of needing IC in second wave patients below the age of 70 (AUC 0.84; 0.81), but overestimated ICU admission for low-risk patients. The models are implemented as a web-based application. ConclusionCOPE is a simple tool that is well able to predict mortality and ICU admission for patients who present to the ED with suspected COVID-19 and may help to inform patients and doctors when deciding on hospital admission.
770 downloads medRxiv emergency medicine
Background CoVid-19 can be a life-threatening lung disease or a trivial upper respiratory infection depending on whether the alveoli are involved. Emergency department (ED) screening in symptomatic patients with normal vital signs is frequently limited to oro-nasopharyngeal swabs. We tested the null hypothesis that patients being screened for CoVid-19 in the ED with normal vital signs and without hypoxia would have a point-of-care lung ultrasound (LUS) consistent with CoVid-19 less than 2% of the time. Methods Subjects Subjects were identified from ED ultrasound logs. Inclusion criteria Age 14 years or older with symptoms prompting ED screening for CoVid-19. Exclusion criteria Known congestive heart failure or other chronic lung condition likely to cause excessive B lines on LUS. Intervention Structured blinded ultrasound review and chart review Analysis We used an exact hypothesis tests for binomial random variables. We also measured LUS diagnostic performance using computed tomography as the gold standard. Results We reviewed 77 charts; 62 met inclusion criteria. Vital signs were normal in 31 patients; 10 (32%) of these patients had LUS consistent with CoVid-19. We rejected the null hypothesis (p-value for bitest <0.001). The treating physicians' interpretation of their own point of care lung ultrasounds had a sensitivity of 100% (95% CI 75%, 100%) and specificity of 80% (95% CI 68%, 89%). Conclusion LUS has a meaningful detection rate for CoVid-19 in symptomatic emergency department patients with normal vital signs. We recommend at least LUS be used in addition to PCR testing when screening symptomatic ED patients for CoVid-19.
743 downloads medRxiv emergency medicine
Study objective: We aimed to describe the preparedness and response to the COVID-19 pandemic in referral EDs caring for children across Europe. Methods: We did a cross-sectional point prevalence survey, which was developed and disseminated through the pediatric emergency medicine research networks for Europe (REPEM) and the United Kingdom and Ireland (PERUKI). We included a pre-determined number of centers based on each country population: five to ten EDs for countries with > 20 million inhabitants and one to five EDs for the other countries. ED directors or named delegates completed the survey between March 20th and 21st to report practice in use one month after the outbreak in Northern Italy. We used descriptive statistics to analyse data. Results: Overall 102 centers from 18 countries completed the survey: 34% did not have an ED contingency plan for pandemics and 36% had never had simulations for such events. Wide variation on PPE items was shown for recommended PPE use at pre-triage and for patient assessment, with 62% of centers experiencing shortage in one or more PPE items. COVID-19 positive ED staff was reported in 25% of centers. Only 17% of EDs had negative pressure isolation rooms. Conclusion: We identified variability and gaps in preparedness and response to the COVID-19 epidemic across European referral EDs for children. Early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and appropriate isolation facilities emerged as key factors that should be optimized to improve preparedness and inform responses to future pandemics.
702 downloads medRxiv emergency medicine
Ben Thomas, Steve Goodacre, Ellen Lee, Laura Sutton, Amanda Loban, Simon Waterhouse, Richard Simmonds, Katie Biggs, Carl Marincowitz, Jose Schutter, Sarah Connelly, Elena Sheldon, Jamie Hall, Emma Young, Andrew Bentley, Kirsty Challen, Chris Fitzsimmons, Tim Harris, Fiona Lecky, Andrew Lee, Ian Maconochie, Darren Walter
Objectives: The World Health Organisation (WHO) and National Institute for Health and Care Excellence (NICE) recommend various triage tools to assist decision-making for patients with suspected COVID-19. We aimed to estimate the accuracy of triage tools for predicting severe illness in adults presenting to the emergency department (ED) with suspected COVID-19 infection. Methods: We undertook a mixed prospective and retrospective observational cohort study in 70 EDs across the United Kingdom (UK). We collected data from people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020, and used presenting data to determine the results of assessment with the following triage tools: the WHO algorithm, NEWS2, CURB-65, CRB-65, PMEWS and the swine flu adult hospital pathway (SFAHP). We used 30-day outcome data (death or receipt of respiratory, cardiovascular or renal support) to determine prognostic accuracy for adverse outcome. Results: We analysed data from 20892 adults, of whom 4672 (22.4%) died or received organ support (primary outcome), with 2058 (9.9%) receiving organ support and 2614 (12.5%) dying without organ support (secondary outcomes). C-statistics for the primary outcome were: CURB-65 0.75; CRB-65 0.70; PMEWS 0.77; NEWS2 (score) 0.77; NEWS2 (rule) 0.69; SFAHP (6-point) 0.70; SFAHP (7-point) 0.68; WHO algorithm 0.61. All triage tools showed worse prediction for receipt of organ support and better prediction for death without organ support. At the recommended threshold, PMEWS and the WHO criteria showed good sensitivity (0.96 and 0.95 respectively), at the expense of specificity (0.31 and 0.27 respectively). NEWS2 showed similar sensitivity (0.96) and specificity (0.28) when a lower threshold than recommended was used. Conclusion: CURB-65, PMEWS and NEWS2 provide good but not excellent prediction for adverse outcome in suspected COVID-19, and predicted death without organ support better than receipt of organ support. PMEWS, the WHO criteria and NEWS2 (using a lower threshold than usually recommended) provide good sensitivity at the expense of specificity.
701 downloads medRxiv emergency medicine
A new type of Coronavirus (SARS CoV2) was identified on January 7th, 2020, and the disease was named COVID 19 caused by this virus. The first confirmed COVID 19 (+) case in Antalya was detected on March 14th, 2020 and transferred by an Antalya 112 emergency ambulance to hospital. Using of Personal Protective Equipment (PPE) in ambulance work standards against COVID 19, was recommended by global health authorities. The aim of this descriptive, retrospective and cross-sectional study which is conducted between 14 March and 31 May 2020, is to evaluate the level of PPE usage, the risk analysis results of Antalya 112 ambulance teams during outbreak. There were 5344 possible and 787 confirmed COVID 19 (+) positive ambulance cases between the dates of study conducted. The majority of these cases were male (62%) and over the age of 65 (47%). The majority of cases were result in transferred to healthcare facilities (75.48%). The total 2361 ambulance team workers were taken to risk analysis measurements in terms of COVID 19. The majority of ambulance team members were assessed with no risk available. The ambulance team members who are assessed with no risk available, has preferred to use Level 4 PPE (N95/FPP/Goggle/face protection, Gloves, Apron/coverall) mostly (84.50%) during ambulance transfers. Using mask on patient and the level of PPE usage showed negative correlation with risk level of Healthcare Workers (HCWs). There have been detected only 2 HCWs diagnosed with COVID 19 with Computed Tomography. The follow-up procedures of two HCWs has been finalized, and both of them cured. The studies about easy to use, hightech PPE with maximum protection, are recommended for further studies.
684 downloads medRxiv emergency medicine
Introduction: Recent localized surges in COVID-19 cases have resulted in the hospitals serving those areas being overwhelmed. In such cases, the ability to rapidly and objectively determine a patient's acuity and predict near-term care needs is a major challenge. At issue is the clinician's ability to correctly identify patients at risk for subsequent rapid clinical deterioration. Data-driven tools that can support such determinations in real-time may be a valuable adjunct to clinician judgement during COVID-19 surges. Objective: To assess the effectiveness of the Rothman Index (RI) predictive model in distinguishing the risk of subsequent deterioration or elevated care needs among hospitalized COVID-19 patients at the time of hospital admission. Methods: We evaluated the initial RI score on admission to predict COVID-19 patient risk for 216 COVID-19 patients discharged from March 21st to June 7th, 2020 at Sinai LifeBridge Hospital and 1,453 COVID-19 patients discharged from any of Yale New Haven Health System's Yale New Haven, Bridgeport, and Greenwich hospitals from April 1st to April 28th, 2020. In-hospital mortality as a function of age and RI on admission for COVID-19 and non-COVID-19 patients were compared. AUC values using each COVID-19 patient's initial RI on admission to predict in-hospital mortality, mechanical ventilation, and ICU utilization were computed, as were precision and recall for mortality prediction at specific RI thresholds. Results: The RI computed at the time of admission provides a high degree of objective discrimination to differentiate the COVID-19 population into high and low risk populations at the outset of hospitalization. The high risk segment based on initial RI constitutes 20-30% of the COVID-19 positive population with mortality rates from 40-50%. The low risk segment based on initial RI constitutes 40%-55% of the population with mortality rates ranging from 1%-8%. Of note is that COVID-19 patients who present with heightened but generally unremarkable acuity can be identified early as having considerably elevated risk for subsequent physiological deterioration. Conclusion: COVID-19 patients exhibit elevated mortality rates compared to non-COVID-19 medical service patients and may be subject to rapid deterioration following hospital admission. A lack of predictive indicators for identifying patients at high risk of subsequent deterioration or death can pose a challenge to clinicians. The RI has excellent performance characteristics when stratifying risk among COVID-19 patients at the time of admission. The RI can assist clinicians in real-time with a high degree of objective discrimination by segmenting the COVID-19 population into high and low risk populations. This supports rapid and optimal patient bed assignment and resource allocation.
683 downloads medRxiv emergency medicine
Background: In recent studies, up to half of immunocompromised (IC) subject populations fail to develop antibodies after COVID-19 vaccination. Purpose and Methods: Here, we explore whether T-cells which respond to the spike (S) antigenic sequence and its less conserved S1, and the conserved S2 component are present in serial samples before and after each dose of mRNA1273 or BNT162b2 vaccines in 20 healthy immunocompetent subjects. Single samples from 7 vaccinated IC subjects were also tested. Simultaneously, we measured IgG antibodies to the receptor binding domain (RBD) of S1, and anti-S IgG, and frequencies of monocytic CD14+HLA-DR- (M-MDSC) and polymorphonuclear CD14-CD15+CD11b+ (PMN-MDSC) myeloid-derived suppressor cells. Results: In healthy subjects, S1-, S2-, and S-reactive CD4 and CD8 T-cell frequencies showed a numeric but not statistically significant decrease after the first vaccine dose and were accompanied by increased MDSC frequencies (p<0.05). After the second dose, S2- and S-reactive CD4 and CD8 cells and MDSC approached pre-vaccination levels. In healthy subjects, a) S1-reactive CD8 frequencies were significantly higher after the second dose compared with pre-vaccination levels (p=0.015), b) anti-RBD and anti-S IgG were present in all after the second dose. Among seven IC subjects, anti-RBD and anti-S IgG were absent in 4 and 3 subjects, respectively. S1-reactive CD8 cells were identified in 2 of 4 anti-RBD negative subjects. S-reactive CD4 or CD8 cells were identified in all three anti-S negative subjects. Conclusions: In healthy immunocompetent subjects, mRNA vaccines induce antibodies to the spike antigenic sequences and augment CD8 cells reactive to the S1 spike sequence, which is more specific for the SARS-CoV-2 virus. In this exploratory cohort of vaccinated immunocompromised subjects, S1-reactive CD8 cells can be detected in some who are negative for RBD antibody, and S-reactive T-cells are present in all who are negative for spike antibody.
678 downloads medRxiv emergency medicine
Objective: To evaluate leg-heel chest compression without previous training as an alternative for medical professionals and its effects on distance to potential aerosol spread during chest compression. Methods: 20 medical professionals performed standard manual chest compression followed by leg-heel chest compression after a brief instruction on a manikin. We compared percentage of correct chest compression position, percentage of full chest recoil, percentage of correct compression depth, average compression depth, percentage of correct compression rate and average compression rate between both methods. In a second approach, potential aerosol spread during chest compression was visualized. Results: There was no significant difference between manual and leg-heel compression. The distance to potential aerosol spread could have been increased by leg-heel method. Conclusion: Under special circumstances like COVID-19-pandemic, leg-heel chest compression may be an effective alternative without previous training compared to manual chest compression while markedly increasing the distance to the patient.
659 downloads medRxiv emergency medicine
Background: Although the number of intensive care unit (ICU) beds is crucial during the COVID-19 epidemic caring for the most critically ill infected patients, there is no recognized early indicator to anticipate ICU bed requirements. Methods: In the Ile-de-France region, from February 20 to May 5, 2020, emergency medical service (EMS) calls and the response provided (ambulances) together the percentage of positive reverse transcriptase polymerase chain reaction (RT-PCR) tests, general practitioner (GP) and emergency department (ED) visits, and hospital admissions of COVID-19 patients were recorded daily and compared to the number of COVID-19 ICU patients. Correlation curve analysis was performed to determine the best correlation coefficient (R), depending on the number of days the indicator has been shifted. A delay [≥]7 days was considered as an early alert, and a delay [≥]14 days a very early alert. Findings: EMS calls, percentage of positive RT-PCR tests, ambulances used, ED and GP visits of COVID-19 patients were strongly associated with COVID-19 ICU patients with an anticipation delay of 23, 15, 14, 13, and 12 days respectively. Hospitalization did not anticipate ICU bed requirement. Interpretation: The daily number of COVID19-related telephone calls received by the EMS and corresponding dispatch ambulances, and the proportion of positive RT-PCR tests were the earliest indicators of the number of COVID19 patients requiring ICU care during the epidemic crisis in the Ile-de-France region, rapidly followed by ED and GP visits. This information may help health authorities to anticipate a future epidemic, including a second wave of COVID19 or decide additional social measures. Funding: Only institutional funding was provided.
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