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.