Background Coronavirus disease 2019 (COVID‐19) is characterized by severe lung involvement and hemodynamic alterations. Critical care ultrasonography is vital because it provides real time information for diagnosis and treatment. Suggested protocols for image acquisition and measurements have not yet been evaluated. Methods This cross‐sectional study was conducted at two centers from 1 April 2020 to 30 May 2020 in adult patients with confirmed COVID‐19 infection admitted to the critical care unit. Cardiac and pulmonary evaluations were performed using the ORACLE protocol, specifically designed for this study, to ensure a structured process of image acquisition and limit staff exposure to the infection. Results Eighty‐two consecutively admitted patients were evaluated. Most of the patients were males, with a median age of 56 years, and the most frequent comorbidities were hypertension and type 2 diabetes, and 25% of the patients had severe acute respiratory distress syndrome. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), E/e’ ratio > 14 (29.3%), and right ventricular dilatation (28%) and dysfunction (26.8%). A high rate of fluid responsiveness (82.9%) was observed. The median score (19 points) on pulmonary ultrasound did not reveal any variation between the groups. Elevated pulmonary artery systolic pressure was associated with higher in‐hospital mortality. Conclusion The ORACLE protocol was a feasible, rapid, and safe bedside tool for hemodynamic and respiratory evaluation of patients with COVID‐19. Further studies should be performed on the alteration in pulmonary hemodynamics and right ventricular function and its relationship with outcomes.

Highlights Clinical signs are not useful for detecting DVT in critically ill COVID-19 patients DVT occurs despite full dose anticoagulation in critically ill COVID-19 patients Severe COVID-19 patients present a high prevalence of bilateral DVT

. We present the case of a patient with myocardial infarction and COVID-19 infection who developed hemorrhagic pericardial effusion and cardiac tamponade. The differential diagnosis included postinfarction pericarditis and mechanical complications, thrombolysis, Dressler´s syndrome and viral pericarditis. The histopathological examination of the pericardial tissue sample and electron microscopy established the diagnosis.

Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Background: Coronavirus disease 2019 (COVID-19) frequently involves cardiovascular manifestations such as right ventricular (RV) dysfunction and alterations in pulmonary hemodynamics. We evaluated the application of the critical care ultrasonography ORACLE protocol to identify the most frequent alterations and their influence on adverse outcomes, especially those involving the RV (dilatation and dysfunction). Methods:This cross-sectional study included 204 adult patients with confirmed COVID-19 admitted at three centers. Echocardiography and lung ultrasound images were acquired on admission using the ORACLE ultrasonography algorithm.Results: Two-hundred and four consecutive patients were evaluated: 22 (11.9%) demonstrated a fractional shortening of < 35%; 33 (17.1%) a tricuspid annular plane systolic excursion (TAPSE) of < 17 mm; 26 (13.5%) a tricuspid peak systolic S wave tissue Doppler velocity of < 9.5 cm/sec; 69 (37.5%) a RV basal diameter of > 41 mm; 119 (58.3%) a pulmonary artery systolic pressure (PASP) of > 35 mm Hg; and 14 (11%) a TAPSE/PASP ratio of < .31. The in-hospital mortality rate was 37.6% (n = 71). Multiple logistic regression modeling showed that PASP > 35 mm Hg, RV FS of < 35%, TAPSE < 17 mm, RV S wave < 9.5, and TAPSE/PASP ratio < .31 mm/mm Hg were associated with this outcome. PASP and the TAPSE/PASP ratio had the lowest feasibility of being obtained among the investigators (62.2%). Conclusion:The presence of RV dysfunction, pulmonary hypertension, and alteration of the RV-arterial coupling conveys an increased risk of in-hospital mortality in patients presenting with COVID-19 upon admission; therefore, searching for these alterations should be routine. These parameters can be obtained quickly and safely with the ORACLE protocol.

. The differential diagnosis of giant inverted T waves in the ECG includes, among others, Takotsubo syndrome (TTS). In a critically ill patient with acute hemodynamic or respiratory deterioration, a stress-related cardiomyopathy syndrome needs to be ruled out. In COVID-19 infection the main physiopathological mechanisms include systemic inflammatory response syndrome and thrombosis, which can condition cardiovascular complications. We present the case of a patient with COVID-19 infection who developed acute hemodynamic and respiratory collapse associated with giant inverted T waves in the ECG and regional wall motion abnormalities in the transthoracic echocardiogram. The resolution of these alterations after medical management supports the diagnosis of TTS caused by COVID-19 infection; to date, few cases of this association have been reported.

Background B-lines have been associated with adverse clinical outcomes in patients with heart failure (HF) when found at hospital discharge or during outpatient visits. Whether lung unltrasound (LUS) assessed B-lines may predict in-hospital mortality in patients with acute HF is still undetermined. Aim To evaluate the association between B-lines on admission and in-hospital mortality among patients admitted with acute HF. Methods Hand-held LUS was used to examine patients with acute HF. LUS was performed in 8 chest zones with a pocket ultrasound device and analyzed offline. The association between B-lines and in-hospital mortality was assessed using Cox regression models. Results We included 62 patients with median age 56 years, 69.4% men, and median left ventricle ejection fraction 25%. The sum of B-lines ranged from 0 to 53 (median 6.5). An optimal ROC-determined cut-off of ≥ 19 B-lines demonstrated a sensitivity of 57% and a specificity of 86% (AUC 0.788) for in-hospital mortality. The incremental prognostic value of LUS when compared with lung crackles or peripheral edema by integrated discrimination improvement was 12.96% (95% CI: 7.0, 18.8, p = 0.02). Patients with ≥19 B-lines had a four-fold higher risk of in-hospital mortality (HR 4.38; 95% CI: 1.37, 13.95, p &lt; 0.01). Conclusion In patients admitted with acute HF, point-of-care LUS measurements of pulmonary congestion (B-lines) are associated with in-hospital mortality.

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