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      Triage decision-making at the time of COVID-19 infection: the Piacenza strategy

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          Abstract

          Dear Editor, Since its detection in China in December 2019, coronavirus disease 2019 (COVID-19) rapidly spread throughout the world becoming a Public Health Emergency of International Concern. In January 2020, the WHO Emergency Committee decided to declare a global health emergency. On February 21, 2020, the first case of COVID-19 had been reported in Northern Italy (Codogno, Lombardy), becoming the beginning of the COVID-19 pandemic and humanitarian crises in Italy. The COVID-19 outbreak in Northern Italy has been the cause of the healthcare system crisis with a massive influx of patients to the Emergency Departments, particularly in Piacenza due to its proximity to Codogno. In few days, the COVID-19 epidemic paralysed our public health system and hospital organization, becoming a challenge for our Emergency Department. At the beginning of the Italian COVID-19 outbreak, we based the suspicion of COVID-19 infection upon the epidemiological risk: the exposure to confirmed COVID-19 case or prolonged contact with people in the geographical area with confirmed COVID-19 cases in the past 14 days. Unfortunately, with the global and severe spread of COVID-19 and the dramatically increased number of infected patients in Piacenza, despite being a relatively small city, our hospital became one of the epicentres of the Italian epidemic with 2276 cases and 447 deaths at this moment. The situation quickly turned critically with overcrowded Emergency Department and Intensive Care Unit, nearing collapse. As consequence, our own hospital became a quite totally dedicated COVID-19 hospital with 80% of beds reserved for ill COVID-19 patients. We felt deeply concerned both by the alarming levels of spread and severity, and by the number of critically ill patients who required an immediate hospitalization in the Intensive Care Unit. To avoid the complete collapse of our healthcare system because of the lack of expertise in epidemics and the presence of limited human resources, we needed to change our perspectives and develop a long-term plan against catastrophic consequences to warrant a “COVID-19-free way” in the Emergency Room and prevent COVID-19 spread in “COVID-19-free wards” in our hospital. From the literature, we have learned that fever and cough are the most common signs of COVID-19 infection, and the infection can progress to pneumonia with dyspnoea and chest symptoms in approximately 75% of patients. Based on these evidences, in the absence of flu-like symptoms, patients are considered “low-risk of COVID-19”. We partially agree with this consideration: some patients can complain symptoms as abdominal pain, vomiting, diarrhoea, fatigue, and general malaise even in the absence of fever and respiratory symptoms and even asymptomatic patients can have abnormalities on chest CT [1]. As reported in the literature, lung CT scan is the gold standard technique to diagnose COVID-19 pneumonia and nowadays, CT protocols are used to estimate the pulmonary damage. Unfortunately, in a mass influx situation, CT scan is not feasible for all the patients admitted to the Emergency Department, particularly in developing countries and small hospitals with limited resources. In this contest, point-of-care lung US can be an effective alternative, being a safe, low-cost, and easy technique commonly used by emergency physicians at the bedside for early diagnosis of pneumonia. Data reported in the literature confirmed that lung US gives results like chest CT scan and superior to chest X-ray in patients with pneumonia or adult respiratory distress syndrome (ARDS). Recently, three studies have confirmed the role of lung US in the diagnosis of COVID-19 pneumonia [2, 3]. Ultrasonographic features of COVID-19 pneumonia include thickened pleural line, B lines (focal in the early stage and in mild infection, multifocal and confluent in the progressive stage and in critically ill patients) and small subpleural consolidations with or without air bronchograms. According to the current appraisal of the WHO, we strongly believe that preventive measures and early diagnosis of COVID-19 are crucial to interrupt virus spread and avoid local outbreaks. Starting from this idea and to avoid misunderstanding COVID-19 diagnoses, we established a bold triage strategy based on an algorithm to investigate all the patients admitted to our Emergency Department with point-of-care lung US, even in the absence of clinical suspicious of COVID-19 infection (Fig. 1). For this reason, we created a “key area” in the triage room and a clear triage process based on the strictly collaboration between the triage nurse, who scheduled the patient, and the emergency clinician, who performed the point-of-care lung US to quickly identify ultrasound signs of interstitial syndrome. Patients, who did not complain classical symptoms of COVID-19 infection but with positive lung US, have been considered as probable cases and needed further investigation before admission to “COVID-19-free wards”. Fig.1 Flowchart for COVID-19 triage. Positive and negative are referred to the presence or absence of typical ultrasonographic signs of COVID-19 pneumonia, respectively. ED Emergency Department, SpO2 peripheral capillary oxygen saturation The primary goal was to increase as better as possible measures to prevent COVID-19 infection and avoid COVID-19 spread among hospitalized patients in “COVID-19-free ward” of our own hospital. Here we report our experience and preliminary results in the first month of Italian epidemic. From February 23, 2020, to March 24, 2020, ten patients (six males, four females) presented to our Emergency Department complaining of syncope, proctorrhagia, rectorrhagia, abdominal pain, vomiting, right foot and leg pain, and neurological symptoms. Patients’ characteristics are reported in Table 1. None of them referred flu-like symptoms or dyspnoea, even though four out of ten (40%) had severe hypoxemia with pulse oxygen level (SpO2) below 95%. Fever (body temperature above 37.5 °C) was present in four patients, three of them with hypoxemia. Even in the absence of respiratory symptoms, the patients were immediately investigated with lung US, which showed in all the cases ultrasonographic findings of COVID-19 interstitial pneumonia. The diagnosis of COVID19 pneumonia has been confirmed by chest CT scan in all the patients. Interestingly, nasopharyngeal (NP) swabs for 2019-nCoV by real-time PCR confirmed the diagnosis of COVID-19 pneumonia only in five out of nine (55%) patients; in four patients (45%) it was negative. Unfortunately, in one case (pt 3, Table 1), the result was unavailable due to a technical problem. We collected a second NP swab from this patient after 48–72 h, which resulted positive. Our data confirm that despite high specificity, the reported sensitivity of rRT-PCR testing is as low as 60–70% [4]. Table 1 Patients’ characteristics at admission in the Emergency Department Pt 1 Pt 2 Pt 3 Pt 4 Pt 5 Pt 6 Pt 7 Pt 8 Pt 9 Pt 10 Age (yo) 67 86 78 61 81 83 53 76 77 54 Sex F F M M M F F M M F Symptoms at admission Vasovagal syncope Proctorrhagia Right foot and leg pain Abdominal pain Abdominal pain and rectorrhagia in OACs Dysarthria, confusion, left hemiplegia Vomiting Abdominal pain and fatigue Confusion after cranial trauma in OACs Abdominal pain and vomiting SpO2 (%) 98 97 96 90 96 97 86 84 85 98 Body temperature (°C) 36.0 36.0 36.6 38.2 37.3 37.0 36.0 37.5 37.6 39.0 Lung US Diffuse basal B lines Diffuse B lines + bilateral basal subpleural Cs Diffuse B lines in the left lobe, and focal B lines in the right lobe Diffuse bilateral basal B lines and subpleural Cs Focal basal bilateral B lines Diffuse bilateral basal B lines Diffuse bilateral basal B lines B lines and subpleural Cs in the right lower lobe Diffuse bilateral basal B lines Diffuse bilateral basal B lines and fine subpleural Cs Chest CT scan GGO + crazy-paving pattern ND GGO + Cs with air bronchograms GGO + crazy-paving pattern and basal Cs GGO + basal Cs GGO GGO + basal Cs GGO + Cs with air bronchograms GGO GGO Chest X-ray ND Diffuse interstitial pneumonia Basal bilateral Cs ND ND Left basal interstitial markings ND ND ND Normal Nasopharyngeal swab Negative Positive NA Positive Negative Negative Negative Positive Positive Positive Final diagnosis Syncope in COVID-19 pneumonia Proctorrhagia in COVID-19 pneumonia Critical limb ischemia in COVID-19 pneumonia Intestinal perforation in COVID-19 pneumonia Rectorrhagia in COVID-19 pneumonia Cerebral ischemia in COVID-19 pneumonia COVID-19 pneumonia Intestinal perforation in COVID-19 pneumonia Traumatic brain injury in COVID-19 pneumonia Gastrointestinal symptoms in COVID19 pneumonia Abnormal values are in bold Pt patient, YO years old, M male, F female, OAC oral anticoagulants, SpO2 peripheral capillary oxygen saturation, GGO ground glass opacity, Cs consolidations, ND not done, NA not available Our experience demonstrates that in the epidemic phase of COVID-19, diagnosis of COVID-19 pneumonia is a real challenge for emergency physicians and point-of-care lung US can help us to early detect pulmonary and pleural findings in patients without respiratory symptoms and/or fever. For this reason, we strongly recommend US lung to assess COVID-19 pneumonia in all the patients referred to Emergency Department even in the absence of suspicious symptoms of COVID-19, especially if pulse oxygen levels are lower than normal values. Our results highlight the role of point-of-care US lung in the triage decision-making at the time of worldwide COVID-19 infection and global healthcare system crisis. We hope that our experience will be helpful for other Emergency Departments to solve quickly these pandemic and humanitarian crises, particularly in developing countries with limited resources and Emergency Departments where CT scan is not available.

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          Most cited references 4

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          Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases

          Background Chest CT is used for diagnosis of 2019 novel coronavirus disease (COVID-19), as an important complement to the reverse-transcription polymerase chain reaction (RT-PCR) tests. Purpose To investigate the diagnostic value and consistency of chest CT as compared with comparison to RT-PCR assay in COVID-19. Methods From January 6 to February 6, 2020, 1014 patients in Wuhan, China who underwent both chest CT and RT-PCR tests were included. With RT-PCR as reference standard, the performance of chest CT in diagnosing COVID-19 was assessed. Besides, for patients with multiple RT-PCR assays, the dynamic conversion of RT-PCR results (negative to positive, positive to negative, respectively) was analyzed as compared with serial chest CT scans for those with time-interval of 4 days or more. Results Of 1014 patients, 59% (601/1014) had positive RT-PCR results, and 88% (888/1014) had positive chest CT scans. The sensitivity of chest CT in suggesting COVID-19 was 97% (95%CI, 95-98%, 580/601 patients) based on positive RT-PCR results. In patients with negative RT-PCR results, 75% (308/413) had positive chest CT findings; of 308, 48% were considered as highly likely cases, with 33% as probable cases. By analysis of serial RT-PCR assays and CT scans, the mean interval time between the initial negative to positive RT-PCR results was 5.1 ± 1.5 days; the initial positive to subsequent negative RT-PCR result was 6.9 ± 2.3 days). 60% to 93% of cases had initial positive CT consistent with COVID-19 prior (or parallel) to the initial positive RT-PCR results. 42% (24/57) cases showed improvement in follow-up chest CT scans before the RT-PCR results turning negative. Conclusion Chest CT has a high sensitivity for diagnosis of COVID-19. Chest CT may be considered as a primary tool for the current COVID-19 detection in epidemic areas. A translation of this abstract in Farsi is available in the supplement. - ترجمه چکیده این مقاله به فارسی، در ضمیمه موجود است.
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            Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic

            Dear Editor, Up to 24 February 2020, there have been 77,269 officially reported confirmed cases of 2019 novel corona virus (SARS-CoV-2) infection in China. As lung abnormalities may develop before clinical manifestations and nucleic acid detection, experts have recommended early chest computerized tomography (CT) for screening suspected patients [1]. The high contagiousness of SARS-CoV-2 and the risk of transporting unstable patients with hypoxemia and hemodynamic failure make chest CT a limited option for the patient with suspected or established COVID-19. Lung ultrasonography gives the results that are similar to chest CT and superior to standard chest radiography for evaluation of pneumonia and/or adult respiratory distress syndrome (ARDS) with the added advantage of ease of use at point of care, repeatability, absence of radiation exposure, and low cost [2]. In this report, we summarize our early experience with lung ultrasonography for evaluation of SARS-CoV-2 infection in China with the intent of alerting frontline intensivists to the utility of lung ultrasonography for management of COVID-19. Ultrasonographic features of nCoV pneumonia We performed lung ultrasonography on 20 patients with COVID-19 using a 12-zone method [3]. Characteristic findings included the following: Thickening of the pleural line with pleural line irregularity; B lines in a variety of patterns including focal, multifocal, and confluent; Consolidations in a variety of patterns including multifocal small, non-translobar, and translobar with occasional mobile air bronchograms; Appearance of A lines during recovery phase; Pleural effusions are uncommon. The observed patterns occurred across a continuum from mild alveolar interstitial pattern, to severe bilateral interstitial pattern, to lung consolidation. Table 1 summarizes typical lung ultrasonography finds in patients with COVID-19 respiratory disease in comparison with chest CT findings. Typical lung ultrasonography images are shown in the supplementary material (Supplementary Fig. 1.) Table 1 CT and ultrasonographic features of COVID-19 pneumonia Lung CT Lung ultrasound Thickened pleura Thickened pleural line Ground glass shadow and effusion B lines (multifocal, discrete, or confluent) Pulmonary infiltrating shadow Confluent B lines Subpleural consolidation Small (centomeric) consolidations) Translobar consolidation Both non-translobar and translobar consolidation Pleural effusion is rare. Pleural effusion is rare More than two lobes affected Multilobar distribution of abnormalities Negative or atypical in lung CT images in the super-early stage, then diffuse scattered or ground glass shadow with the progress of the disease, further lung consolidation Focal B lines is the main feature in the early stage and in mild infection; alveolar interstitial syndrome is the main feature in the progressive stage and in critically ill patients; A lines can be found in the convalescence; pleural line thickening with uneven B lines can be seen in patients with pulmonary fibrosis The findings of lung ultrasonography features of SARS-CoV-2 pneumonia/ARDS are related to the stage of disease, the severity of lung injury, and comorbidities. The predominant pattern is of varying degrees of interstitial syndrome and alveolar consolidation, the degree of which is correlated with the severity of the lung injury. A recognized limitation of lung ultrasonography is that it cannot detect lesions that are deep within the lung, as aerated lung blocks transmission of ultrasonography, i.e., the abnormality must extend to the pleural surface to be visible with on ultrasonography examination. Chest CT is required to detect pneumonia that does not extend to the pleural surface. Based upon our experience, we consider that lung ultrasonography has major utility for management of COVID-19 with respiratory involvement due to its safety, repeatability, absence of radiation, low cost and point of care use; chest CT may be reserved for cases where lung ultrasonography is not sufficient to answer the clinical question. We find there is utility of lung ultrasonography for rapid assessment of the severity of SARS-CoV-2 pneumonia/ARDS at presentation, to track the evolution of disease, to monitor lung recruitment maneuvers, to guide response to prone position, the management of extracorporeal membrane therapy, and for making decisions related to weaning the patient form ventilatory support. Electronic supplementary material Supplementary Figure 1: Typical lung ultrasonography images of nCoV pneumonia. B lines; B. confluent B lines; C. small consolidations; D. translobar consolidation. Supplementary Figure 1 Typical lung ultrasonography images of nCoV pneumonia. A. B lines; B. confluent B lines; C. small consolidations; D. translobar consolidation. (TIFF 34299 kb)
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              Can Lung US Help Critical Care Clinicians in the Early Diagnosis of Novel Coronavirus (COVID-19) Pneumonia?

              Dear Editor: As reported by Feng et al, chest CT has a pivotal role for the diagnosis and assessment of lung involvement in COVID-19 pneumonia (1). Nowadays CT protocols are used to estimate the pulmonary damage (1,2,3). Unfortunately, CT scanning is not available in all emergency departments. Lung US is a surface imaging technique greatly developed in the last decades and strongly recommended for acute respiratory failure (4). It is commonly used in the emergency department at the bedside for early diagnosis of pneumonia. It is a highly sensitive and specific technique considered as an alternative to chest radiography or CT scanning (5,6). We evaluated the role of lung US in patients who presented to our emergency department with COVID-19 pneumonia. Twelve patients (9 male and 3 female, mean age 63±13 years) with flu-like symptoms in the last 4–10 days and COVID-19 infection underwent bedside lung US and CT. Two patients had emphysema but without need of oxygen therapy at home. None of the patients had severe respiratory distress (PaO2/FiO2 257–376 mmHg). In all the patients, we found a diffuse B-pattern with spared areas. Only three patients had posterior subpleural consolidations. Chest CT scan was performed in all 12 patients and showed a strong correlation with US: bilateral lung involvement with ground-glass opacity; five of 12 patients had a crazy-paving pattern. Organizing pneumonia was confirmed in four patients as well as detected with lung US. We are aware that our data are preliminary and further studies are necessary to confirm the role of lung US in the diagnosis and management of COVID-19 pneumonia, but we strongly recommend the use of bedside US for the early diagnosis of COVID-19 pneumonia in all the patients who presented to the emergency department with flu-like symptoms in novel COVID-19 era.
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                Author and article information

                Contributors
                poggiali.erika@gmail.com , E.Poggiali@ausl.pc.it
                Journal
                Intern Emerg Med
                Intern Emerg Med
                Internal and Emergency Medicine
                Springer International Publishing (Cham )
                1828-0447
                1970-9366
                9 May 2020
                : 1-4
                Affiliations
                GRID grid.413861.9, Emergency Department, , Guglielmo da Saliceto Hospital, ; Via Taverna 49, Piacenza, Italy
                Article
                2350
                10.1007/s11739-020-02350-y
                7210104
                32385627
                © Società Italiana di Medicina Interna (SIMI) 2020

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                Categories
                Ce - Letter to the Editor

                Emergency medicine & Trauma

                covid-19, triage decision-making, triage strategy, lung ultrasound

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