Characteristics of chest pain in COVID-19 patients in the emergency department.

INTRODUCTION: Patients with coronavirus disease 2019 (COVID-19) can present with chest pain. However, the characteristics of this chest pain are unknown. We performed a single-centre observational study to review and summarise chest pain characteristics in COVID-19 patients at first presentation to the emergency department (ED). METHODS: We collected data on characteristics of 'chest pain' reported by COVID-19 patients who attended the ED of Bernhoven Hospital, the Netherlands from 4 through 30 March 2020. RESULTS: We included 497 COVID-19 patients, of whom 83 (17%) reported chest pain upon presentation to the ED. Chest pain characteristics were: present since disease onset (88%), retrosternal location (43%), experienced as compressing/pressure pain (61%), no radiation (61%) and linked to heavy coughing (39%). Patients who reported chest pain were younger than those without chest pain (61 vs 73 years; p < 0.001). Patients with syncope were older (75 vs 72 years; p = 0.017), had a shorter duration of symptoms (5 vs 7 days; p < 0.001) and reported fewer respiratory complaints (68% vs 90%; p < 0.001) than those without syncope. Patients with new-onset atrial arrhythmias presented with a shorter duration of symptoms (5 vs 7 days; p = 0.013), experienced fewer respiratory complaints (72% vs 89%; p = 0.012) and more frequently had a history of cardiovascular disease (79% vs 50%; p = 0.003) than patients who presented without arrythmias. CONCLUSION: Chest pain and other cardiac symptoms were frequently observed in COVID-19 patients. Treating physicians should be aware that chest pain, arrhythmias and syncope can be presenting symptoms of COVID-19.

Community-acquired bacteraemia in COVID-19 in comparison to influenza A and influenza B: a retrospective cohort study.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic in the Netherlands it was noticed that very few blood cultures from COVID-19 patients turned positive with clinically relevant bacteria. This was particularly evident in comparison to the number of positive blood cultures during previous seasonal epidemics of influenza. This observation raised questions about the occurrence and causative microorganisms of bacteraemia in COVID-19 patients, especially in the perspective of the widely reported overuse of antibiotics and the rising rate of antibiotic resistance. METHODS: We conducted a retrospective cohort study on blood culture results in influenza A, influenza B and COVID-19 patients presenting to two hospitals in the Netherlands. Our main outcome consisted of the percentage of positive blood cultures. The percentage of clinically relevant blood cultures, isolated bacteria and 30-day all-cause mortality served as our secondary outcomes. RESULTS: A total of 1331 viral episodes were analysed in 1324 patients. There was no statistically significant difference (p = 0.47) in overall occurrence of blood culture positivity in COVID-19 patients (9.0, 95% CI 6.8-11.1) in comparison to influenza A (11.4, 95% CI 7.9-14.8) and influenza B patients (10.4, 95% CI 7.1-13.7,). After correcting for the high rate of contamination, the occurrence of clinically relevant bacteraemia in COVID-19 patients amounted to 1.0% (95% CI 0.3-1.8), which was statistically significantly lower (p = 0.04) compared to influenza A patients (4.0, 95% CI 1.9-6.1) and influenza B patients (3.0, 95% CI 1.2-4.9). The most frequently identified bacterial isolates in COVID-19 patients were Escherichia coli (n = 2) and Streptococcus pneumoniae (n = 2). The overall 30-day all-cause mortality for COVID-19 patients was 28.3% (95% CI 24.9-31.7), which was statistically significantly higher (p = <.001) when compared to patients with influenza A (7.1, 95% CI 4.3-9.9) and patients with influenza B (6.4, 95% CI 3.8-9.1). CONCLUSIONS: We report a very low occurrence of community-acquired bacteraemia amongst COVID-19 patients in comparison to influenza patients. These results reinforce current clinical guidelines on antibiotic management in COVID-19, which only advise utilization of antibiotics when a bacterial co-infection is suspected.

Prior use of anticoagulation is associated with a better survival in COVID-19.

Coronavirus disease 2019 (COVID-19) is associated with a high incidence of venous and arterial thromboembolic events. The role of anticoagulation (AC) prior to hospital admission and how different types of oral AC influences the outcome of COVID-19 is currently unknown. This observational study compares the outcome in COVID-19 patients with prior use of direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA), and without prior use of AC. We collected the baseline characteristics and outcomes of COVID-19 patients presented to the emergency department of Bernhoven Hospital, the Netherlands. The primary outcome was all-cause mortality within 30 days and analyzed in a multivariable Cox proportional hazards model including age, sex, symptom duration, home medication, and comorbidities. We included 497 patients, including 57 patients with DOAC (11%) and 53 patients with VKA (11%). Patients with AC had a lower body temperature and lower C-reactive protein levels. Comparing the primary outcome in patients with AC (DOAC or VKA) and no AC, the adjusted hazard ratio (aHR) was 0.64 (95% CI 0.42-0.96, P = 0.03). Comparing DOAC and no AC, the aHR was 0.53 (95% CI 0.32-0.89, P = 0.02) and comparing VKA and no AC, the aHR was 0.77 (95% CI 0.47-1.27, P = 0.30). In a subgroup analysis of DOAC, all nine patients with prior use of dabigatran survived within 30 days. In this observational study, the prior use of AC is associated with a better survival of COVID-19. DOAC, especially dabigatran, might have additional beneficial effects.

Putting ICU triage guidelines into practice: A simulation study using observations and interviews.

BACKGROUND: The COVID-19 pandemic has prompted many countries to formulate guidelines on how to deal with a worst-case scenario in which the number of patients needing intensive care unit (ICU) care exceeds the number of available beds. This study aims to explore the experiences of triage teams when triaging fictitious patients with the Dutch triage guidelines. It provides an overview of the factors that influence decision-making when performing ICU triage with triage guidelines. METHODS: Eight triage teams from four hospitals were given files of fictitious patients needing intensive care and instructed to triage these patients. Sessions were observed and audio-recorded. Four focus group interviews with triage team members were held to reflect on the sessions and the Dutch guidelines. The results were analyzed by inductive content analysis. RESULTS: The Dutch triage guidelines were the main basis for making triage decisions. However, some teams also allowed their own considerations (outside of the guidelines) to play a role when making triage decisions, for example to help avoid using non-medical criteria such as prioritization based on age group. Group processes also played a role in decision-making: triage choices can be influenced by the triagists' opinion on the guidelines and the carefulness with which they are applied. Intensivists, being most experienced in prognostication of critical illness, often had the most decisive role during triage sessions. CONCLUSIONS: Using the Dutch triage guidelines is feasible, but there were some inconsistencies in prioritization between teams that may be undesirable. ICU triage guideline writers should consider which aspects of their criteria might, when applied in practice, lead to inconsistencies or ethically questionable prioritization of patients. Practical training of triage team members in applying the guidelines, including explanation of the rationale underlying the triage criteria, might improve the willingness and ability of triage teams to follow the guidelines closely.

[COVID-19 in the Emergency Department of Bernhoven hospital]. / COVID-19 op de Spoedeisende Hulp in Bernhoven.

OBJECTIVE: To describe disease presentation and clinical characteristics of patients with COVID-19 presenting to the Emergency Department (ED) of Bernhoven hospital in Uden, the Netherlands. DESIGN: Prospective, descriptive study. METHOD: The registry focused on atypical symptoms and co-infections. We hypothesized that patients older than 70 years more often have atypical symptoms. The number of co-infections is unknown. Therefore, we prospectively registered medical history, duration of symptoms, symptoms, temperature, lab results and co-infections of patients with confirmed COVID-19 in the period March 4-16th. RESULTS: The clinical characteristics of 107 patients were registered. The average age was 71 years and 41% was female. The median duration of symptoms was 5 days. 19% of patients had not been referred to pulmonary or internal medicine. Symptoms were fever (78%), respiratory complaints (78%), chest pain (28%), abdominal pain (13%), and diarrhea (34%). In 54% of the COVID-19 patients at the ED, the temperature was ≥ 38,0°C, CRP ≥ 50 in 51%, leucocytosis in 12% and elevated LD in 61%. Of 31 patients 24 (77%) had an absolute lymphopenia. Co-infections were seen in 16% of patients. The mortality in the ED was 2% and ICU-admission 5%. On March 25th, 2020 the overall mortality was 22% and ICU-admission 15%. CONCLUSION: We have seen patients with a very serious disease resulting in a high mortality and ICU-admission. Over 35% of patient did not have the typical symptoms of fever and respiratory complaints; atypical symptoms like chest pain, abdominal pain and diarrhea are frequently seen. There is no difference between patients over and under 70 years. COVID-19 patients can present with atypical symptoms, co-infections and distributed over various medical specialties.