No abstract

Purpose The capability of lung ultrasound (LUS) to distinguish the different pulmonary patterns of COVID-19 and quantify the disease burden compared to chest CT is still unclear. Methods PCR-confirmed COVID-19 patients who underwent both LUS and chest CT at the Emergency Department were retrospectively analysed. In both modalities, twelve peripheral lung zones were identified and given a Severity Score basing on main lesion pattern. On CT scans the well-aerated lung volume (%WALV) was visually estimated. Per-patient and per-zone assessments of LUS classification performance taking CT findings as reference were performed, further revisioning the images in case of discordant results. Correlations between number of disease-positive lung zones, Severity Score and %WALV on both LUS and CT were assessed. The area under receiver operating characteristic curve (AUC) was calculated to determine LUS performance in detecting %WALV ≤ 70%. Results The study included 219 COVID-19 patients with abnormal chest CT. LUS correctly identified as positive 217 (99%) patients, but per-zone analysis showed sensitivity = 75% and specificity = 66%. The revision of the 121 (55%) cases with positive LUS and negative CT revealed COVID-compatible lesions in 42 (38%) CT scans. Number of disease-positive zones, Severity Score and %WALV between LUS and CT showed moderate correlations. The AUCs for LUS Severity Score and number of LUS-positive zones did not differ in detecting %WALV ≤ 70%. Conclusion LUS in COVID-19 is valuable for case identification but shows only moderate correlation with CT findings as for lesion patterns and severity quantification. The number of disease-positive lung zones in LUS alone was sufficient to discriminate relevant disease burden.

LUS patterns of COVID-19 pneumonia have been described and shown to be characteristic. The aim of the study was to predict the prognosis of patients with COVID-19 pneumonia, using a score based on LUS findings. Materials and Methods An observational, retrospective study was conducted on patients admitted to Niguarda hospital with a diagnosis of COVID-19 pneumonia during the period of a month, from March 2nd to April 3rd 2020. Demographics, clinical, laboratory, and radiological findings were collected. LUS was performed in all patients. The chest was divided into 12 areas. The LUS report was drafted using a score from 0 to 3 with 0 corresponding to A pattern, 1 corresponding to well separated vertical artifacts (B lines), 2 corresponding to white lung and small consolidations, 3 corresponding to wide consolidations. The total score results from the sum of the scores for each area. The primary outcome was endotracheal intubation, no active further management, or death. The secondary outcome was discharge from the emergency room (ER). Results 255 patients were enrolled. 93.7 % had a positive LUS. ETI was performed in 43 patients, and 24 received a DNI order. The general mortality rate was 15.7 %. Male sex (OR 3.04, p = 0.014), cardiovascular disease and hypertension (OR 2.75, p = 0.006), P/F (OR 0.99, p < 0.001) and an LUS score > 20 (OR 2.52, p = 0.046) were independent risk factors associated with the primary outcome. Receiver operating characteristic (ROC) curve analysis for an LUS score > 20 was performed with an AUC of 0.837. Independent risk factors associated with the secondary outcome were age (OR 0.96, p = 0.073), BMI (OR 0.87, p = 0,13), P/F (OR 1.03, p < 0.001), and LUS score < 10 (OR 20.9, p = 0.006). ROC curve analysis was performed using an LUS score < 10 with an AUC 0.967. Conclusion The extent of lung abnormalities evaluated by LUS score is a predictor of a worse outcome, ETI, or death. Moreover, the LUS score could be an additional tool for the safe discharge of patient from the ER.

No abstract

Objective: Definitive data on acute management of Blood Pressure (BP) in neurological Hypertensive Emergencies (HE) are still lacking. Aim of our study was to evaluate BP values and management as a determinant of in-hospital mortality and early complications in stroke patients. Design and method: We collected data of 267 patients, who presented with ischemic stroke and BP > 180/120 mmHg at the Emergency Department of Niguarda Hospital from 2015 to 2017. In-hospital mortality, hospitalization length and discharge disability (evaluated with modified Rankin score – mRs) were considered as outcomes. Results: Mean age was 75.7 ± 11.7 years with SBP values of 194.9 ± 14.9 mmHg at admission. 34.8% of the patients received anti-hypertensive treatment with those achieving a higher SBP reduction in comparison with the untreated one (dSBP 37.8 ± 26.8 mmHg vs 30.7 ± 20.8 mmHg p = 0.034). At the multivariate analysis in the overall population, no SBP values are related to all causes in-hospital mortality. Instead, higher admission SBP relates to high discharge disability and hospitalization length. Furthermore, SBP values at admission in Emergency Department appear as disability determinants in patients who did not receive systemic thrombolysis and in patients who did not receive antihypertensive drugs. In these two subgroups, higher SBP values at department entrance determine a higher in-hospital mortality. Conclusions: In overall population, no BP values are related to all causes in-hospital mortality while higher admission BP relates to high disability and hospitalization length.

Hemodynamic monitoring of unstable patients is an everyday issue for Emergency Physicians (EP). Considering the difficulty, in Emergency Department (ED) settings, to assess invasively Stroke Volume (SV), Cardiac Output (CO) and Peripheral Vascular Resistance (PVR), EP should be familiar with non-invasive, easy and reproducible methods that can estimate these parameters. The use of Left Ventricular Outflow Tract aortic Velocity Time Integral (LVOT-VTI) with echocardiography, as estimate of SV, integrated with inferior vena cava collapse index and clinical examination could give the opportunity to non-invasively understand at which point of an ideal cardiac output/central venous pressure relation (according to the Frank Starling law) the patient is situated. In this case report we describe a septic patient accessing the ED with both respiratory and cardiac failure, and we show that the use of aortic LVOT-VTI is an easy and reproducible approach to understand cardiac hemodynamic in scenarios involving multiple pathologic mechanisms.

BackgroundDuring COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure (ARF), a large use of non-invasive positive pressure ventilation (NIPPV) was done in the Emergency Departments (EDs) and medical wards despite the lack of recommendations. We aimed to assess the use of continuous positive airway pressure (CPAP) in the ED. The primary endpoint was the rate of CPAP failure and the need of endotracheal intubation (ETI). Secondary endpoints were in-hospital mortality and intensive care unit (ICU) and in-hospital length of stay. Study design and MethodsA retrospective observational study enrolling adult patients admitted to the ED of Niguarda Hospital, Milan, Italy, with ARF due to COVID-19 pneumonia from March 18th to April 18th 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. ResultsA total of 52 patients were included in this study. 38 patients (73%) were judged eligible for ETI. 18 (34.6%) were intubated. 16 (30.8%) patients died: 7 (38.9%) and 9 (26.5%) in the ETI and non-ETI group respectively. The median hospital length of stay was different in ETI and non-ETI patients: 26 days [IQR 16-37] vs 15 days [IQR 9-17] (p=0.005). The median invasive mechanical ventilation time was 11 days [IQR 7-21] with an ICU length of stay of 14.5 days [IQR 10-28]. During the CPAP trial, variations between ETI and non-ETI patients over time were found for positive end-expiratory pressure (PEEP) (p=0.003) and respiratory rate (RR) (p=0.059).ConclusionsA short closed monitored CPAP trial could be considered for ARF due to COVID-19 pneumonia before considering ETI. A progressive PEEP titration should target patient’s SpO2 improvement and RR reduction. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and NIPPV in patients with ARF due to COVID-19 pneumonia.

Background During COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure (ARF), a large use of non-invasive positive pressure ventilation (NIPPV) was done in the Emergency Departments (EDs) and medical wards despite the lack of recommendations. We aimed to assess the use of continuous positive airway pressure (CPAP) in the ED. The primary endpoint was the rate of CPAP failure and the need of endotracheal intubation (ETI). Secondary endpoints were in-hospital mortality and intensive care unit (ICU) and in-hospital length of stay. Methods A retrospective observational study enrolling adult patients admitted to the ED of Niguarda Hospital, Milan, Italy, with ARF due to COVID-19 pneumonia from March 18th to April 18th 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. Results A total of 52 patients were included in this study. 38 patients (73%) were judged eligible for ETI. 18 (34.6%) were intubated. 16 (30.8%) patients died: 7 (38.9%) and 9 (26.5%) in the ETI and non-ETI group respectively. The median hospital length of stay was different in ETI and non-ETI patients: 26 days [IQR 16–37] vs 15 days [IQR 9–17] (p = 0.005). The median invasive mechanical ventilation time was 11 days [IQR 7–21] with an ICU length of stay of 14.5 days [IQR 10–28]. During the CPAP trial, variations between ETI and non-ETI patients over time were found for positive end-expiratory pressure (PEEP) (p = 0.003) and respiratory rate (RR) (p = 0.059). Conclusionss A short closed monitored CPAP trial could be considered for ARF due to COVID-19 pneumonia before considering ETI. A progressive PEEP titration should target patient’s RR reduction. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and NIPPV in patients with ARF due to COVID-19 pneumonia.