ICU admission Risk Factors of Latinx/Hispanic COVID-19 patients at a US Mexico Border Hospital

Objectives: To describe the association of demographics of sex, comorbidities, age with the risk of severe (Coronavirus Disease 2019) COVID-19 requiring intensive care unit level of care, and death in a primarily Latinx/Hispanic U.S.-Mexico border hospital operating at surge capacity.Background: According to the CDC, the Latinx/Hispanic population in the U.S. have been particularly affected by severe COVID-19 complications and high mortality rates. Border hospitals and their emergency departments (ED) are particularly vulnerable to widespread communicable respiratory infections and severe COVID-19 complications and poor outcomes such as surges of hospitalizations and death. Multiple factors such as inadequate healthcare infrastructure in border areas, access to preventative healthcare and subsequently higher prevalence of comorbidities that increase the risk for severe COVID-19 in the Latinx/Hispanic patient population overall. At the U.S.-Mexico border region, there is a paucity of research and data regarding how COVID-19 affects this predominantly Latinx/Hispanic community. Our study seeks to identify demographic, and clinical risk factors that make this specific community vulnerable to severe COVID-19 complications such as intensive care unit (ICU) utilization and death.Methods: This is was a retrospective, observational chart review of 156 hospitalized COVID-19 patients during a surge at a border hospital. Adult patients (> 18 years) diagnosed with SARS-CoV-2 and met admission criteria from April 10, 2020 to May 30, 2020 were included. Excluded were pediatric patients (< 18 years of age), patients who did not consent for treatment, pregnant women, patients who did not meet the above inclusion criteria. Descriptive statistics of sex, age categories of 18-49, 50-64, and > 65 years or older, BMI, presence of at least one comorbidity (coronary artery disease, hypertension, diabetes, cancer/lymphoma, current use of immunosuppressive drug therapy, chronic kidney disease/dialysis, or chronic respiratory disease), along with complications were done. Multivariate regression models were produced from the most significant variables and factors for ICU admission. The final, reduced regression model, a p-value <0.05 was considered statistically significant and confidence intervals were reported at a level 95%.Results: Of the 156 hospitalized patients, 63.5% (99) were male, 132 (84.6%) admitted for respiratory failure, average age was 67.2 (+/-12.2). There were 71 (45.5%) patients who required intensive care. Those > 65 years old had a higher frequency of ICU admission. Seventy-nine percent (49) of the ICU patients had a BMI over 25. Most common comorbidities were diabetes, hypertension, and coronary artery disease/hyperlipidemia. The regression model showed that males had a 4.4 (95% CI 1.576, 12.308) odds of ICU admission (p=0.0047). Those who developed acute kidney injury (AKI) and BMI 25-29.9 were strong predictors of ICU admission (p<0.001 and p=0.0020, respectively). No single comorbidity was associated with ICU admission. However, those with at least one comorbidity, there was 1.984 increased odds (95% CI 1.313, 2.998) of an ICU admission. Of those admitted in the ICU, 72% (16) died.Conclusion: The Latinx/Hispanic border populations have a high prevalence of comorbidities and potential complications that increase their risk for COVID-19 complications that lead to ICU admissions and death

Case Report of Thrombosis of the Distal Aorta with Occlusion of Iliac Arteries in COVID-19 Infection

Introduction: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the coronavirus disease of 2019 (COVID-19) pandemic, has been associated with a variety of prothrombotic sequelae. The pathogenesis of this hypercoagulability has not yet been fully elucidated, but it is thought to be multifactorial with overactivation of the complement pathways playing a central role. There is emerging evidence that the resulting complications are not confined to the venous circulation, and even in patients without typical respiratory symptoms or traditional risk factors, there is a significant rate of arterial thromboembolic disease in patients with SARS-CoV-2 infection.Case Report: We describe a patient presenting with bilateral leg pain without any respiratory symptoms or fever who ultimately was found to be COVID-19 positive and had thromboembolism of the aorta and bilateral iliac occlusion. This report reviews available evidence on the prevalence of arterial thromboembolism in COVID-19 patients and some proposed mechanisms of the pathophysiology of COVID-19-associated coagulopathy.Conclusion: It is important that the emergency physician maintain a high degree of suspicion for arterial thromboembolic disease in patients who are infected with COVID-19 even in the absence of typical respiratory symptoms. Additionally, COVID-19 should be considered in patients with unexplained thromboembolic disease, as this may increase the detection of COVID-19

Case Report of Thrombosis of the Distal Aorta with Occlusion of Iliac Arteries in COVID-19 Infection

Introduction: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for the coronavirus disease of 2019 (COVID-19) pandemic, has been associated with a variety of prothrombotic sequelae. The pathogenesis of this hypercoagulability has not yet been fully elucidated, but it is thought to be multifactorial with overactivation of the complement pathways playing a central role. There is emerging evidence that the resulting complications are not confined to the venous circulation, and even in patients without typical respiratory symptoms or traditional risk factors, there is a significant rate of arterial thromboembolic disease in patients with SARS-CoV-2 infection.Case Report: We describe a patient presenting with bilateral leg pain without any respiratory symptoms or fever who ultimately was found to be COVID-19 positive and had thromboembolism of the aorta and bilateral iliac occlusion. This report reviews available evidence on the prevalence of arterial thromboembolism in COVID-19 patients and some proposed mechanisms of the pathophysiology of COVID-19-associated coagulopathy.Conclusion: It is important that the emergency physician maintain a high degree of suspicion for arterial thromboembolic disease in patients who are infected with COVID-19 even in the absence of typical respiratory symptoms. Additionally, COVID-19 should be considered in patients with unexplained thromboembolic disease, as this may increase the detection of COVID-19

Outcomes for in-hospital cardiac arrest for COVID-19 patients at a rural hospital in Southern California.

BackgroundIn-hospital cardiac arrest (IHCA) carries a high mortality and providing resuscitation to COVID-19 patients presents additional challenges for emergency physicians. Our objective was to describe outcomes of COVID-19 patients suffering IHCA at a rural hospital in Southern California.MethodsSingle-center retrospective observational study. A hospital registry of COVID-19 patients was queried for all patients who suffered IHCA and received cardiopulmonary resuscitation (CPR) between May 1st and July 31st, 2020. A manual chart review was performed to obtain patient demographics, oxygen requirement prior to cardiac arrest (CA), details of the resuscitation including presence of an emergency physician, and final disposition.ResultsTwenty-one patients were identified, most of whom were Hispanic, male, and aged 50-70. The most common medical comorbidities were diabetes and hypertension. Most patients suffered respiratory arrest, with an initial rhythm of pulseless electrical activity or asystole. Return of spontaneous circulation (ROSC) was achieved in 3/9 patients already receiving mechanical ventilation, but all 3 expired within the following 24 h. ROSC was achieved in 10/12 patients not already intubated, though most also expired within a few days. The only 2 patients who survived to discharge suffered respiratory arrest after their oxygen delivery device dislodged.ConclusionAt a small rural hospital with limited resources and a predominantly Hispanic population, cardiac arrest in a COVID-19 patient portends an extremely poor prognosis. A better appreciation of these outcomes should help inform emergency providers and patients when discussing code status and attempts at resuscitation, particularly in resource limited settings

Large Cerebellar Stroke in a Young COVID-19-Positive Patient: Case Report.

BackgroundCoronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), most frequently presents with respiratory symptoms, such as fever, dyspnea, shortness of breath, cough, or myalgias. There is now a growing body of evidence that demonstrates that severe SARS-CoV-2 infections can develop clinically significant coagulopathy, inflammation, and cardiomyopathy, which have been implicated in COVID-19-associated cerebrovascular accidents (CVAs).Case reportWe report an uncommon presentation of a 32-year-old man who sustained a large vessel cerebellar stroke associated with a severe COVID-19 infection. He presented with a headache, worse than his usual migraine, dizziness, rotary nystagmus, and dysmetria on examination, but had no respiratory symptoms initially. He was not a candidate for thrombolytic therapy or endovascular therapy and was managed with clopidogrel, aspirin, and atorvastatin. During hospital admission he developed COVID-19-related hypoxia and pneumonia, but ultimately he was discharged to home rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the growing number of reports of neurologic and vascular complications, such as ischemic CVAs, in otherwise healthy individuals who are diagnosed with SARS-CoV-2 infection. A brief review of the current literature will help elucidate possible mechanisms, risk factors, and current treatments for CVA associated with SARS-CoV-2

Interobserver agreement between emergency clinicians and nurses for Clinical Opiate Withdrawal Scale.

ObjectivesThe Clinical Opiate Withdrawal Scale (COWS) is a validated, commonly used tool to objectively quantify withdrawal symptoms, often in anticipation of treatment with buprenorphine. Our primary aim was to determine the agreement between emergency department (ED) nurses compared with emergency physicians in determining this score in ED patients who presented for opioid withdrawal treatment. Secondarily, we wanted to investigate the safety of buprenorphine induction in the ED setting.MethodsScoring for opioid withdrawal using the COWS was performed by ED clinicians and ED nurses independently on 120 patients. In addition to overall concordance, agreement (weighted kappa) was calculated between the 2 scores by various cutoffs: overall severity, COWS ≥ 5, and the 11 different individual measures. Patient documents also were reviewed for complications that could be possibly linked to buprenorphine induction.ResultsOur study sample of 120 subjects was 77% Hispanic and 78.3% male. The clinicians assigned a median interquartile range overall COWS score of 6 (2-12), which categorizes as mild withdrawal. Seventy-eight (65%) subjects met the criteria of withdrawal (≥ 5 COWS) and 69 (58%) received an induction dose of buprenorphine (range 2 mg-24 mg) during the ED visit. No adverse effects or worsening withdrawal were reported. The overall observed concordance, based on severity withdrawal categorization, for all clinician pairs, was 67.5% (81/120) (95% confidence interval [CI], 58.7-75.2%). The weighted kappa for that concordance was 0.55 (95% CI, 0.43-0.67), giving a moderate strength of agreement. When data are dichotomized by COWS score ≥5, concordance was 82.5% (99/120) (95% CI, 74.7%-88.3%) and the weighted kappa was 0.65 (95% CI, 0.51-0.78), indicating substantial agreement. The breakdown by the 11 factors that constitute COWS showed only substantial agreement for pulse measurement.ConclusionThe agreement between ED clinicians and nurses for the overall COWS scoring in patients presenting for opioid withdrawal treatment was substantial. COWS scoring by ED nurses may help expedite treatment with buprenorphine on presentation

Use of sotrovimab in vaccinated versus unvaccinated COVID‐19 patients in a resource‐limited emergency department during the omicron surge

ObjectiveThe treatment of outpatient COVID-19 patients at high risk of disease progression has been challenging, as both the virus and available therapeutics change. Here, we sought to evaluate the effect of vaccination status on the use of sotrovimab during the early phase of the Omicron surge.MethodsThis was a retrospective observational study performed at El Centro Regional Medical Center, a rural hospital on the southern Californian border. The electronic medical record was queried for all emergency department (ED) patients who received an infusion of sotrovimab between January 6 and February 6, 2022. We obtained patient demographics, COVID-19 vaccination status, medical comorbidities, and whether patients returned to the ED within 30 days. We stratified our cohort according to vaccination status and performed a multivariable logistic regression model to evaluate the relationship between these factors.ResultsOne hundred seventy patients received an infusion of sotrovimab in the ED. The patient cohort had a median age of 65 years, 78.2% were Hispanic, and obesity (63.5%) was the most common comorbidity. A total of 73.5% of patients were vaccinated against COVID-19. A total of 12/125 (9.6%) of vaccinated patients returned to the ED within 30 days, versus 10/45 (22.2%) in the unvaccinated cohort, which was statically significant (P = 0.03). The presence of medical comorbidities was not associated with the primary outcome.ConclusionOf patients who received sotrovimab, those who were vaccinated were less likely to return to the ED within 30 days compared to those who were unvaccinated. Given the effectiveness of the COVID-19 vaccination campaign, and with the emergence of new variants, it is unclear what role monoclonal antibody therapy should play in the treatment of outpatient COVID-19 patients

Disparities Exist in the Application of Low Tidal-volume Ventilation in the Emergency Department

Introduction: Low tidal-volume ventilation (LTVV), defined as a maximum tidal volume of 8 milliliters per kilogram (mL/kg) of ideal body weight, is a key component of lung protective ventilation. Although emergency department (ED) initiation of LTVV has been associated with improved outcomes, disparities in LTVV application exist. In this study our aim was to evaluate whether rates of LTVV are associated with demographic and physical characteristics in the ED.Methods: We conducted a retrospective observational cohort study using a dataset of patients who underwent mechanical ventilation at three EDs in two health systems from January 2016–June 2019. Demographic, mechanical ventilation, and outcome data including mortality and hospital-free days were abstracted by automatic query. A LTVV approach was defined as a tidal volume ≤8 mL/kg ideal body weight. We performed descriptive statistics and univariate analysis as indicated, and created a multivariate logistic regression model.Results: Of 1,029 patients included in the study, 79.5% received LTVV. Tidal volumes of 400-500 mL were used in 81.9% of patients. Approximately 18% of patients had tidal volumes changed in the ED. Female gender (adjusted odds ratio [aOR] 4.17, P< 0.001), obesity (aOR 2.27, P< 0.001), and first-quartile height (aOR 12.2, P < 0.001) were associated with receiving non-LTVV in multivariate regression analysis. Hispanic ethnicity and female gender were associated with first quartile height (68.5%, 43.7%, P < 0.001 for all). Hispanic ethnicity was associated with receiving non-LTVV in univariate analysis (40.8% vs 23.0%, P < 0.001). This relationship did not persist in sensitivity analysis controlling for height, weight, gender, and body mass index. Patients who received LTVV in the ED had 2.1 more hospital-free days compared to those who did not (P = 0.040). No difference in mortality was observed.Conclusion: Emergency physicians use a narrow range of initial tidal volumes that may not meet lung-protective ventilation goals, with few corrections. Female gender, obesity, and first-quartile height are independently associated with receiving non-LTVV in the ED. Using LTVV in the ED was associated with 2.1 fewer hospital-free days. If confirmed in future studies, these findings have important implications for achieving quality improvement and health equality.&nbsp

Use of sotrovimab in vaccinated versus unvaccinated COVID‐19 patients in a resource‐limited emergency department during the omicron surge

Abstract Objective The treatment of outpatient COVID‐19 patients at high risk of disease progression has been challenging, as both the virus and available therapeutics change. Here, we sought to evaluate the effect of vaccination status on the use of sotrovimab during the early phase of the Omicron surge. Methods This was a retrospective observational study performed at El Centro Regional Medical Center, a rural hospital on the southern Californian border. The electronic medical record was queried for all emergency department (ED) patients who received an infusion of sotrovimab between January 6 and February 6, 2022. We obtained patient demographics, COVID‐19 vaccination status, medical comorbidities, and whether patients returned to the ED within 30 days. We stratified our cohort according to vaccination status and performed a multivariable logistic regression model to evaluate the relationship between these factors. Results One hundred seventy patients received an infusion of sotrovimab in the ED. The patient cohort had a median age of 65 years, 78.2% were Hispanic, and obesity (63.5%) was the most common comorbidity. A total of 73.5% of patients were vaccinated against COVID‐19. A total of 12/125 (9.6%) of vaccinated patients returned to the ED within 30 days, versus 10/45 (22.2%) in the unvaccinated cohort, which was statically significant (P = 0.03). The presence of medical comorbidities was not associated with the primary outcome. Conclusion Of patients who received sotrovimab, those who were vaccinated were less likely to return to the ED within 30 days compared to those who were unvaccinated. Given the effectiveness of the COVID‐19 vaccination campaign, and with the emergence of new variants, it is unclear what role monoclonal antibody therapy should play in the treatment of outpatient COVID‐19 patients