Background In-hospital cardiac arrest (IHCA) carries a high mortality and providing resuscitation to COVID-19 patients presents additional challenges for emergency physicians. Our objective was to describe outcomes of COVID-19 patients suffering IHCA at a rural hospital in Southern California. Methods Single-center retrospective observational study. A hospital registry of COVID-19 patients was queried for all patients who suffered IHCA and received cardiopulmonary resuscitation (CPR) between May 1st and July 31st, 2020. A manual chart review was performed to obtain patient demographics, oxygen requirement prior to cardiac arrest (CA), details of the resuscitation including presence of an emergency physician, and final disposition. Results Twenty-one patients were identified, most of whom were Hispanic, male, and aged 50–70. The most common medical comorbidities were diabetes and hypertension. Most patients suffered respiratory arrest, with an initial rhythm of pulseless electrical activity or asystole. Return of spontaneous circulation (ROSC) was achieved in 3/9 patients already receiving mechanical ventilation, but all 3 expired within the following 24 h. ROSC was achieved in 10/12 patients not already intubated, though most also expired within a few days. The only 2 patients who survived to discharge suffered respiratory arrest after their oxygen delivery device dislodged. Conclusion At a small rural hospital with limited resources and a predominantly Hispanic population, cardiac arrest in a COVID-19 patient portends an extremely poor prognosis. A better appreciation of these outcomes should help inform emergency providers and patients when discussing code status and attempts at resuscitation, particularly in resource limited settings.

Background Coronavirus Disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), most frequently presents with respiratory symptoms such as fever, dyspnea, shortness of breath, cough, or myalgias. There is now a growing body of evidence that demonstrates that severe SARS-CoV-2 infections can develop clinically significant coagulopathy, inflammation, and cardiomyopathy, which have been implicated in COVID-19 associated cerebrovascular accidents (CVAs). Case Report We report an uncommon presentation of a 32-year-old man who sustained a large vessel cerebellar stroke associated with a severe COVID-19 infection. He presented with a headache, worse than his usual migraine, dizziness, rotary nystagmus, and dysmetria on exam but had no respiratory symptoms initially. He was not a candidate for thrombolytic therapy or endovascular therapy and was managed with clopidogrel, aspirin, and atorvastatin. During hospital admission he developed COVID-19 related hypoxia and pneumonia, but ultimately he was discharged to home rehabilitation. Why Should an Emergency Physician Be Aware of This? We present this case to increase awareness among emergency physicians of the growing number of reports of neurological and vascular complications such as ischemic CVAs in otherwise healthy individuals who are diagnosed with SARS-CoV-2 infection. A brief review of the current literature will help elucidate possible mechanisms, risk factors, and current treatments for CVA associated with SARS-CoV-2.

Objective Few studies have examined the impact of coronavirus disease 2019 (COVID-19) on the primarily Latinx community along the U.S.-Mexico border. This study explores the socioeconomic impacts which contribute to strong predictors of severe COVID-19 complications such as intensive care unit (ICU) hospitalization in a primarily Latinx/Hispanic U.S.-Mexico border hospital. Methods A retrospective, observational study of 156 patients (≥ 18 years) Latinx/Hispanic patients who were admitted for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at a U.S.-Mexico border hospital from April 10, 2020, to May 30, 2020. Descriptive statistics of sex, age, body mass index (BMI), and comorbidities (coronary artery disease, hypertension, diabetes, cancer/lymphoma, current use of immunosuppressive drug therapy, chronic kidney disease/dialysis, or chronic respiratory disease). Multivariate regression models were produced from the most significant variables and factors for ICU admission. Results Of the 156 hospitalized Latinx patients, 63.5% were male, 84.6% had respiratory failure, and 45% were admitted to the ICU. The average age was 67.2 (± 12.2). Those with body mass index (BMI) ≥ 25 had a higher frequency of ICU admission. Males had a 4.4 (95% CI 1.58, 12.308) odds of ICU admission ( p = 0.0047). Those who developed acute kidney injury (AKI) and BMI 25–29.9 were strong predictors of ICU admission ( p < 0.001 and p = 0.0020, respectively). Those with at least one reported comorbidity had 1.98 increased odds (95% CI 1.313, 2.99) of an ICU admission. Conclusion Findings show that age, AKI, and male sex were the strongest predictors of COVID-19 ICU admissions in the primarily Latinx population at the U.S.-Mexico border. These predictors are also likely driven by socioeconomic inequalities which are most apparent in border hospitals. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-022-01478-1.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the coronavirus disease of 2019 (COVID-19) pandemic, has been associated with a variety of prothrombotic sequelae. The pathogenesis of this hypercoagulability has not yet been fully elucidated, but it is thought to be multifactorial with overactivation of the complement pathways playing a central role. There is emerging evidence that the resulting complications are not confined to the venous circulation, and even in patients without typical respiratory symptoms or traditional risk factors, there is a significant rate of arterial thromboembolic disease in patients with SARS-CoV-2 infection. Case Report: We describe a patient presenting with bilateral leg pain without any respiratory symptoms or fever who ultimately was found to be COVID-19 positive and had thromboembolism of the aorta and bilateral iliac occlusion. This report reviews available evidence on the prevalence of arterial thromboembolism in COVID-19 patients and some proposed mechanisms of the pathophysiology of COVID-19-associated coagulopathy. Conclusion: It is important that the emergency physician maintain a high degree of suspicion for arterial thromboembolic disease in patients who are infected with COVID-19 even in the absence of typical respiratory symptoms. Additionally, COVID-19 should be considered in patients with unexplained thromboembolic disease, as this may increase the detection of COVID-19. [Clin Pract

Objective The treatment of outpatient COVID‐19 patients at high risk of disease progression has been challenging, as both the virus and available therapeutics change. Here, we sought to evaluate the effect of vaccination status on the use of sotrovimab during the early phase of the Omicron surge. Methods This was a retrospective observational study performed at El Centro Regional Medical Center, a rural hospital on the southern Californian border. The electronic medical record was queried for all emergency department (ED) patients who received an infusion of sotrovimab between January 6 and February 6, 2022. We obtained patient demographics, COVID‐19 vaccination status, medical comorbidities, and whether patients returned to the ED within 30 days. We stratified our cohort according to vaccination status and performed a multivariable logistic regression model to evaluate the relationship between these factors. Results One hundred seventy patients received an infusion of sotrovimab in the ED. The patient cohort had a median age of 65 years, 78.2% were Hispanic, and obesity (63.5%) was the most common comorbidity. A total of 73.5% of patients were vaccinated against COVID‐19. A total of 12/125 (9.6%) of vaccinated patients returned to the ED within 30 days, versus 10/45 (22.2%) in the unvaccinated cohort, which was statically significant (P = 0.03). The presence of medical comorbidities was not associated with the primary outcome. Conclusion Of patients who received sotrovimab, those who were vaccinated were less likely to return to the ED within 30 days compared to those who were unvaccinated. Given the effectiveness of the COVID‐19 vaccination campaign, and with the emergence of new variants, it is unclear what role monoclonal antibody therapy should play in the treatment of outpatient COVID‐19 patients.

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nucleocapsid (N) proteins of the SARS-CoV-2 virus are of particular interest as easily measurable potential indirect markers of both previous infection and resistance to reinfection. Previous studies in hospitalized patients have found that anti-N IgG levels decline over time. We undertook this study to characterize the kinetics of anti-N IgG in a longitudinal cohort of health care workers in an acute hospital setting.Methods: All HCWs who were either employed or part of the medical staff at six acute-care hospitals in Phoenix, AZ in June 2019 were invited to participate in a longterm study of the impact of the COVID-19 pandemic on HCWs. A cohort of 1358 HCWs provided informed consent, filled out a questionnaire regarding their health care role and potential COVID-19 symptoms, and had blood drawn between June 15 th and August 15 th, 2020 (Draw 1). The questionnaire and blood draws were repeated in October 2020 (Draw 2), January 2021 (Draw 3), and April 2021. SARS-CoV-2 anti-N IgG was measured using the Abbott Architect platform, using a signal to cutoff ratio (S/Co) greater than 1.4 as a positive result. A participant's first positive result was treated as Time 0. Anti-N IgG S/Co values at each time point were summarized as mean, median, and inter-quartile range, and differences over time were tested using the Friedman's test.Results: 290 participants (21.4%) had at least one positive IgG, with a median S/ Co of 4.96, IQR 2.37-6.67. The Month 3 median S/Co was 2.32, IQR 1.34-4.22, Month 6 median was 0.96, IQR 0.51-2.05, and Month 9 median was 0.60, IQR 0.26-1.29 (See Figure). Freidman's test for differences was significant at p<0.0001 at all time points. No participant was hospitalized for their acute COVID-19 illness. 68/244 participants (27.4%) were seronegative at 3 months, 81/126 (64.3%) at six months, and 65/84 (77.4%) at nine months.Conclusion: In a cohort of health care workers with mild to moderate COVID-19, anti-N IgG levels steadily decreased over 9 months from the initial positive IgG. The high rates of conversion to seronegative over a relatively short time frame illustrate why antibody-based testing must be interpreted cautiously when used as a definitive marker of prior COVID infection.

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