Hypercoagulability in COVID-19: A rare case of DIC in SARS-CoV2 in the Emergency Department

Although SARS-CoV2 is increasingly being considered a systemic disease, there have been very few case reports documenting DIC as a rare but fatal consequence of the SARS-CoV2 syndrome. We present our patient scenario as an example of severe COVID sepsis in the ED and DIC. 67-year old nursing home resident with CAD, DM, HTN, and seizures presents to our ED resus room with altered mental status and hypoxia after a reported fall from bed. He was tachycardic to 110 and required a nonrebreather at 15L saturating at 96%. His physical exam revealed GCS 10, no focal neurologic deficits, dry mucous membranes, clear lung sounds, and soft abdomen. He was swabbed for COVID-19, and his 1-view CXR revealed multifocal hazy opacities. ECG showed new T-wave inversions in V2-V3 with prolonged QTc 512. He was empirically treated with vancomycin, ceftriaxone, and flagyl for MRSA/aspiration pneumonia. Prominent labs were as follows: Cr. 1.51 (baseline 0.4), CRP 14.0, ESR 20, WBC 13.9, hemoglobin 13.2, platelets 52, LDH 2005, Tbili 3.0, INR 2.68, PT 27.8, PTT 44, and hs-troponin 1649. Bedside ECHO demonstrated normal LV function but with slightly enlarged RV and mild septal bowing, no pericardial effusion. Although there was concern for pulmonary embolism, he had a severe contrast allergy and therefore could not undergo CTPE. CT head showed 2 small subacute R parietal and cerebellar infarcts, but his encephalopathy was deemed out of proportion to the stroke findings by the neurology team. He was not on any anticoagulants, and his encephalopathy, AKI, thrombocytopenia, and elevated hemolytic labs were concerning for TTP vs. DIC. His DIC panel later revealed D-dimer \u3e20.0 and fibrinogen \u3c60. His COVID-19 PCR swab also resulted as positive. Hematology determined that his elevated coagulation parameters and clear COVID sepsis precipitant were more indicative of DIC. He was given 2U cryoprecipitate and admitted to MICU.DIC is rarely seen in the ED and can be difficult to diagnose, but early detection is paramount to tailoring treatment strategies and as a valuable prognostic indicator at the time of admission. Our patient had presented with multi-organ dysfunction, and this included a pathologic hemostatic system in the form of DIC. Hypercoagulability has been associated with COVID-19, but the progression to DIC in critically ill COVID patients warrants further in-depth research and clinical attention.https://scholarlycommons.henryford.com/merf2020caserpt/1137/thumbnail.jp

Derivation and validation of the ED-SAS score for very early prediction of mortality and morbidity with acute pancreatitis: a retrospective observational study

BACKGROUND: Existing scoring systems to predict mortality in acute pancreatitis may not be directly applicable to the emergency department (ED). The objective of this study was to derive and validate the ED-SAS, a simple scoring score using variables readily available in the ED to predict mortality in patients with acute pancreatitis. METHODS: This retrospective observational study was performed based on patient data collected from electronic health records across 2 independent health systems; 1 was used for the derivation cohort and the other for the validation cohort. Adult patients who were eligible presented to the ED, required hospital admission, and had a confirmed diagnosis of acute pancreatitis. Patients with chronic or recurrent episodes of pancreatitis were excluded. The primary outcome was 30-day mortality. Analyses tested and derived candidate variables to establish a prediction score, which was subsequently applied to the validation cohort to assess odds ratios for the primary and secondary outcomes. RESULTS: The derivation cohort included 599 patients, and the validation cohort 2011 patients. Thirty-day mortality was 4.2 and 3.9%, respectively. From the derivation cohort, 3 variables were established for use in the predictive scoring score: ≥2 systemic inflammatory response syndrome (SIRS) criteria, age \u3e 60 years, and SpO2 \u3c 96%. Summing the presence or absence of each variable yielded an ED-SAS score ranging from 0 to 3. In the validation cohort, the odds of 30-day mortality increased with each subsequent ED-SAS point: 4.4 (95% CI 1.8-10.8) for 1 point, 12.0 (95% CI 4.9-29.4) for 2 points, and 41.7 (95% CI 15.8-110.1) for 3 points (c-statistic = 0.77). CONCLUSION: An ED-SAS score that incorporates SpO2, age, and SIRS measurements, all of which are available in the ED, provides a rapid method for predicting 30-day mortality in acute pancreatitis

A Rare Case of Tolosa-Hunt Syndrome

A 27-year old female with no past medical history presented to the ED multiple times with intractable headaches and blurry vision. Her symptoms involved a right-sided throbbing pain for 6 weeks with recent onset of progressively worsening blurry vision with increasing right eye pressure. She had multiple ER visits, PCP appointments, as well as ophthalmology and neurology evaluations. Her CT and MRI images did not reveal any abnormalities initially, and she was repeatedly symptomatically treated with migraine cocktails, magnesium, as well as solumedrol during her ED visits. However, after 6 weeks of ongoing symptoms, an MRV demonstrated soft tissue thickening of the right cavernous sinus and anterior Meckel\u27s Cave, with extension into the foramen rotundum, right proptosis with increased edema and enhancement of the right superior and lateral rectus muscles with edema of the right lacrimal gland. Lumbar puncture revealed 39 WBCs, 95% lymphocytes, normal protein and glucose. HCV, VZV, CMV, EBV, bacterial and fungal CSF cultures were negative. ANA, DNA, ENA, ANCA, Sjogren\u27s antibodies,serum and CSF ACE, lyme antibodies, CSF cytology and flow cytometry, serum and CSF IgG subclasses were negative. Her symptoms were controlled with IV methylprednisolone 250mg Q6 while inpatient. Ophthalmology performed a right anterior orbitotomy with lacrimal gland biopsy, which demonstrated a possible vasculitic process with lymphocytic perivascular inflammation. She achieved good symptom control with prednisone. Based on her clinical presentation, imaging, and biopsy results, she was diagnosed with Tolosa-Hunt syndrome. This case report emphasizes the recognition of a common chief complaint due to a rare, inflammatory disorder. In the ED setting, steroids may provide the best diagnostic clue for a patient with multiple previous visits for intractable headaches as well as presence of concurrent periorbital inflammation.https://scholarlycommons.henryford.com/merf2019caserpt/1024/thumbnail.jp

HEART Score and Stress Test Emergency Department Bayesian Decision Scheme: Results from the Acute Care Diagnostic Collaboration.

BACKGROUND: Accurate identification of patients at risk of major adverse cardiac events (MACE) places a substantial burden on emergency physicians (EPs). Bayesian nomogram for risk stratification in low- to intermediate-risk cardiovascular patients has not been investigated previously. OBJECTIVE: The objective of this study was to develop a comparative diagnostic model using Bayesian statistics for exercise treadmill test (ETT) and stress echocardiogram (ECHO) to calculate post-test diagnostic risk of MACE using HEART (history, electrocardiogram, age, risk factors, and troponin) risk score as predictor of pretest probability. METHODS: Stratification was made by applying HEART scores for the prediction of MACE. Likelihood ratios (LR) were calculated using pooled sensitivity and specificity of ETT and ECHO from the American College of Cardiology Foundation/American Heart Association systematic review. Post-test probabilities were obtained after inserting HEART score and LR into Bayesian nomogram. Analysis of variance was used to assess statistical association. RESULTS: Positive LR (LR+) for ETT was 4.56 and negative LR (LR-) was 0.27; for ECHO, LR+ 5.65 and LR- 0.15. Bayesian statistical modeling post-test probabilities for LR+ and low HEART risk yielded a post-test probability for ETT of 7.75% and 9.09% for ECHO; intermediate risk gave 47.62% and 52.63%, respectively. For LR-, low HEART risk post-test probability for ETT was 0.46% and for ECHO 0.26%; intermediate risk probabilities were 4.48% and 2.49%, respectively. LR- was statistically significant in ruling out MACE with ECHO (p \u3c 0.001), but no significant differences were seen for LR+ (p = 0.64). CONCLUSIONS: This Bayesian analysis demonstrated slight superiority of stress ECHO over ETT in low- and intermediate-risk patients in ruling out MACE

Role of heparin during endovascular therapy for acute ischemic stroke

•Patients who received heparin had significantly lower rates of hemorrhage.•Heparin-treated patients had nonsignificantly higher reperfusion rates.•Heparin use during endovascular therapy for AIS patients was found to be safe. Systemic heparinization has become the mainstay anticoagulant in neurointerventional procedures to prevent thromboembolic complications. Its benefit during endovascular therapy for acute stroke however has not been established. The purpose of this study is to retrospectively evaluate the impact of heparin during endovascular therapy for acute ischemic stroke (AIS). We performed a retrospective review of our interventional stroke database from February 2009 to September 2012 for patients with anterior circulation AIS with ICA-T or MCA M1 occlusions. 76 patients were categorized into 2 groups: intraprocedural vs. no intraprocedural heparin use. Outcomes measured included reperfusion (modified TICI scale), cerebral hemorrhages (ECASS criteria), and 90-day outcomes (modified Rankin scale). Baseline characteristics were similar between heparin and non-heparin treated patients, except for presence of CAD (6% vs. 30%, p=0.01), Coumadin (0% vs. 11%, p=0.04), and NIHSS (15.6±5.0 vs. 18.1±4.6, p=0.03). There was a nonsignificantly higher reperfusion rate achieved in heparin-treated patients compared to non heparin-treated patients (63% vs. 50%, p=0.35). Patients who received heparin had significantly lower rates of hemorrhage (p=0.02). Multivariate logistic regression for good outcome revealed only age (OR 0.86; 95% CI 0.78–0.95; p<0.01), ASPECTS (OR 2.14; 95% CI 1.01–4.50; p=0.04), and successful reperfusion (OR 19.25; 95% CI 2.37-155.95; p<0.01) independently associated with mRS 0–2 at 90 days. The use of intraprocedural heparin in patients with AIS from MCA M1 or ICA-T occlusion was found safe. The impact of heparinization is unclear and warrants further evaluation

Derivation and validation of the ED-SAS score for early prediction of mortality in acute pancreatitis

Background and Objectives: Existing scoring systems to predict mortality in acute pancreatitis largely account for variables present within the first 24 or more hours of hospital admission. The objective of this study was to derive and validate a simple predictive score using variables readily available in the emergency department (ED) to predict mortality in acute pancreatitis. Methods: We performed a retrospective observational study across 2 independent health systems, one used for the derivation cohort and one for the validation cohort. The health systems encompassed 10 community and academic EDs. Adult patients were eligible who presented to the ED, required hospital admission, and were confirmed to have a final diagnosis of acute pancreatitis. We excluded patients with chronic pancreatitis or hepatic failure and those with a recurrent episode of pancreatitis. We standardized and validated data collection instruments across sites. The analysis consisted of multivariable logistic regression, and candidate variables in the derivation cohort of a prediction score were selected a priori based on reliable availability in the ED and the existing literature. We applied the score to the validation cohort and report odds ratios associated with the primary outcome of 30-day mortality. Results: The derivation cohort included 599 patients (mean age 53 years, 47% female), and the validation cohort 2,011 patients (mean age 56 years, 51% female). Thirty-day mortality in the derivation cohort was 4.2% and 3.9% in the validation cohort. From the derivation cohort, 3 variables were retained in a prediction score: ≥2 SIRS criteria, age \u3e60 years, and SpO2 \u3c96%. Summing the presence (1 point) or absence (0 points) of each variable yielded an ED-SAS score (SIRS, age, SpO2), ranging from 0 to 3. In the derivation cohort, mortality based on scores from 0 to 3 was 0%, 1.3%, 10.4%, and 15.4% respectively. Applied to the validation cohort, the OR for death increased substantially for each additional ED-SAS point: 4.4 (95% CI 1.8 - 10.8) for 1 point, 12.0 (95% CI 4.9 - 29.4) for 2 points, and 41.7 (95% CI 15.8 - 110.0) for 3 points. Model discrimination in the derivation and validation cohort for predicting mortality was good (C-statistic 0.80 and 0.77 respectively). Conclusion: An ED-SAS score that incorporates age, SIRS, and ED SpO2 measurement provides a rapid method for predicting mortality in acute pancreatitis earlier than existing score systems

Minor respiratory compromise and emergency department predictors of mortality in acute pancreatitis

Background: Data looking at the first 48-hours of hospitalization for acute pancreatitis shows that lung injury predicts mortality. The objective of this study was to test if early respiratory compromise in the ED predicts mortality in acute pancreatitis. We secondarily assessed the addition of the quick sequential organ failure assessment (qSOFA) in predicting mortality. Methods: We performed a retrospective observational study across 8 EDs and 5 hospitals that was inclusive of consecutive adult patients hospitalized for acute pancreatitis. We excluded patients with lipase levels \u3c 3-times the upper limit of the normal laboratory range. The primary outcome was inpatient mortality. We performed univariate and multivariate logistic regression to determine clinical predictors of these outcomes, in which the main variable of interest was respiratory compromise defined by an initial ED SPO2 ≤ 92%. We further combined key ED variables to derive an area under the curve (AUC) for predicting mortality. Results: The study included 2,090 patients, of whom 51.5% were female and the mean age was 55.5 (SD 17.5) years. The median presenting lipase was 976 u/ L (IQR 281 - 2500). Death was uncommon (n=34, 1.6%). In univariate analysis, highly significant predictors of mortality were SPO2 ≤ 92%, qSOFA score, and low albumin. Patients with a presenting SPO2 ≤ 92% had 9.2% vs. 1.3% mortality (OR 7.5, 95% CI 3.1 - 17.7). Those with a qSOFA score ≥ 2 had 9.8% vs. 1.3% mortality (OR 8.6, 95% CI 3.9 - 18.9). Adjusting for age, gender, race, leukocytosis, hematocrit, and major comorbidities, qSOFA ≥ 2 remained a significant predictor of mortality (OR 2.6, 95%CI 1.7 - 4.1, p\u3c0.001). Low albumin (OR 2.7, 95% CI 1.2 - 6.2, p=0.02) and SPO2 ≤ 92% (OR 2.6, 95% CI 1.0-7.1, p=0.05) also remained significant predictors. By combining qSOFA with the presence of low albumin or SPO2 ≤ 92% into a novel ED acute pancreatitis score (EDAPS), the EDAPS score had good accuracy for predicting mortality (AUC 0.80, 95% CI 0.72-0.89). Conclusion: Across a large cohort of patients admitted for acute pancreatitis, mortality is markedly lower than previous data has shown. Independent predictors of mortality present in the ED include low albumin, SPO2 ≤ 92%, and a qSOFA score ≥ 2

Minor respiratory compromise and emergency department predictors of mortality in acute pancreatitis

Background: Data looking at the first 48-hours of hospitalization for acute pancreatitis shows that lung injury predicts mortality. The objective of this study was to test if early respiratory compromise in the ED predicts mortality in acute pancreatitis. We secondarily assessed the addition of the quick sequential organ failure assessment (qSOFA) in predicting mortality. Methods: We performed a retrospective observational study across 8 EDs and 5 hospitals that was inclusive of consecutive adult patients hospitalized for acute pancreatitis. We excluded patients with lipase levels \u3c 3-times the upper limit of the normal laboratory range. The primary outcome was inpatient mortality. We performed univariate and multivariate logistic regression to determine clinical predictors of these outcomes, in which the main variable of interest was respiratory compromise defined by an initial ED SPO2 ≤ 92%. We further combined key ED variables to derive an area under the curve (AUC) for predicting mortality. Results: The study included 2,090 patients, of whom 51.5% were female and the mean age was 55.5 (SD 17.5) years. The median presenting lipase was 976 u/ L (IQR 281 - 2500). Death was uncommon (n=34, 1.6%). In univariate analysis, highly significant predictors of mortality were SPO2 ≤ 92%, qSOFA score, and low albumin. Patients with a presenting SPO2 ≤ 92% had 9.2% vs. 1.3% mortality (OR 7.5, 95% CI 3.1 - 17.7). Those with a qSOFA score ≥ 2 had 9.8% vs. 1.3% mortality (OR 8.6, 95% CI 3.9 - 18.9). Adjusting for age, gender, race, leukocytosis, hematocrit, and major comorbidities, qSOFA ≥ 2 remained a significant predictor of mortality (OR 2.6, 95%CI 1.7 - 4.1, p\u3c0.001). Low albumin (OR 2.7, 95% CI 1.2 - 6.2, p=0.02) and SPO2 ≤ 92% (OR 2.6, 95% CI 1.0-7.1, p=0.05) also remained significant predictors. By combining qSOFA with the presence of low albumin or SPO2 ≤ 92% into a novel ED acute pancreatitis score (EDAPS), the EDAPS score had good accuracy for predicting mortality (AUC 0.80, 95% CI 0.72-0.89). Conclusion: Across a large cohort of patients admitted for acute pancreatitis, mortality is markedly lower than previous data has shown. Independent predictors of mortality present in the ED include low albumin, SPO2 ≤ 92%, and a qSOFA score ≥ 2

Simple Predictors of Mortality in Acute Pancreatitis

Background: Various historical studies have found that hypoxia portends a poor prognosis in patients hospitalized with acute pancreatitis. The objective of this study is to test early respiratory compromise on hospital presentation as a mortality predictor in acute pancreatitis. Secondary aims of the study were assessing prognostication abilities of the quick sequential organ failure assessment (qSOFA) and hypoalbuminemia in acute pancreatitis. Methods: This is a retrospective observational study based on adult patients hospitalized for acute pancreatitis. The data were collected from eight standalone emergency departments and five hospitals within Henry Ford Health System of Southeast Michigan. Patients with lipase levels less than three times the upper limit of the normal laboratory range were excluded. The primary outcome was inpatient mortality. Univariate and multivariate logistic regression was performed to determine predictors of adverse outcomes. The main variable of interest was respiratory compromise, defined as an initial SpO2 of 92% on presentation. We combined other key variables on presentation to derive an area under the curve (AUC) for predicting mortality. Results: The study included 2,090 patients, mean age 55.5 years (SD 17.5) and 51.5% female. The median presenting lipase was 976 U/L (IQR 281-2500). Death was uncommon (n=34, 1.6%). Via univariate analysis, highly significant predictors of mortality were SpO2 92%, qSOFA score 2, and low albumin. Patients with a presenting SpO2 92% had 9.2% mortality, in contrast to a 1.3% mortality rate among those with an SpO2 above 92% on presentation (OR 7.5, 95% CI 3.1-17.7). Those with a qSOFA score 2 suffered 9.8% mortality, compared to an average 1.3% mortality rate among those with a qSOFA of 0 or 1 (OR 8.6, 95% CI 3.9-18.9). Adjusting for age, gender, race, leukocytosis, hematocrit, and major comorbidities, qSOFA 2 remained a significant predictor of mortality (OR 2.6, 95% CI 1.7-4.1, p \u3c 0.001). Low albumin (OR 2.7, 95% CI 1.2-6.2, p 0.02) and SpO2 92% (OR 2.6, 95% CI 1.0-7.1, p 0.05) also remained significant predictors. By combining qSOFA with the presence of low albumin and SpO2 92% into a novel early acute pancreatitis score (EAPS), the EAPS score had good accuracy for predicting mortality (AUC 0.80, 95% CI 0.72-0.89). Conclusions: Independent predictors of mortality on initial presentation include low albumin, SpO2 92%, and a qSOFA score 2. Perhaps these simple prognosticators can guide clinical practice by more precisely identifying those with acute pancreatitis who are more critically ill and could benefit from closer monitoring