The Impact of Different Lung Ultrasound Protocols in the Assessment of Lung Lesions in COVID-19 Patients: Is There an Ideal Lung Ultrasound Protocol?

BACKGROUND: In the past months, several lung ultrasonography (LUS) protocols have been proposed, mainly on previously validated schemes independent of coronavirus disease 2019 (COVID-19). OBJECTIVES: The main purpose of this study was to determine the impact and accuracy of different LUS protocols proposed in COVID-19. METHODS: Patients were evaluated with a standard sequence of LUS scans in 72 intercostal spaces along 14 anatomic lines in the chest. A scoring system of LUS findings was reported and then analyzed separately according to each proposed LUS protocol zones. This score was then correlated to a validated Pulmonary Inflammation Index (PII) on chest Computed Tomography (CT). RESULTS: Thirty-two patients were enrolled. The most frequent pattern was ground-glass opacities in the chest X-ray (53.1%), chest CT (59.1%) and subpleural or lobar consolidations (40.8%) in the posteroinferior areas (p < 0.001) on LUS. The Interclass Correlation Coefficient (ICC) was significantly correlated with almost every protocol analyzed except the 8-zone (p = 0.119) and the 10-zone protocol that only included one posterior point (p = 0.052). The highest ICC was obtained with a 12-zone protocol (ICC 0.500; p = 0.027) and decreased as more points were included. CONCLUSIONS: In conclusion, our study results suggest that performing an ultrasound protocol with 12-zone scanning, including the superior and inferior areas of the anterior, lateral and posterior regions of the chest was consistent with higher ICC and higher degree of concordance with CT. We emphasize the need of a more standardization technique to further implement and develop this imaging modality in COVID-19.

Usefulness of Lung Ultrasound Follow-up in Patients Who Have Recovered From Coronavirus Disease 2019.

Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2 infection, which tends to be mild. Even in these cases, our understanding is still incomplete, particularly regarding its sequelae and long-term outcomes. We describe 3 recovered patients who had coronavirus disease 2019, with long-persisting symptoms after recovery, in whom chest computed tomographic and concurrent lung ultrasound examinations were performed. It is possible to correlate the findings from lung ultrasound with the symptoms and the fibrosis or residual abnormalities present on chest computed tomography. Lung ultrasound, which is easy to use, without side effects or radiation, helps monitor the disease resolution or assess early progression to lung fibrosis, as exemplified in the cases reported.

Correlation between Chest Computed Tomography and Lung Ultrasonography in Patients with Coronavirus Disease 2019 (COVID-19).

There is growing evidence regarding chest X-ray and computed tomography (CT) findings for coronavirus disease 2019 (COVID-19). At present, the role of lung ultrasonography (LUS) has yet to be explored. The main purpose of this study was to evaluate the correlation between LUS findings and chest CT in patients confirmed to have (positive reverse transcription polymerase chain reaction [RT-PCR]) or clinically highly suspected of having (dyspnea, fever, myasthenia, gastrointestinal symptoms, dry cough, ageusia or anosmia) COVID-19. This prospective study was carried out in the emergency department, where patients confirmed of having or clinically highly suspected of having COVID-19 were recruited and underwent chest CT and concurrent LUS exam. An experienced emergency department physician performed the LUS exam blind to the clinical history and results of the CT scan, which were reviewed by two radiologists in consensus for signs compatible with COVID-19 (bilateral ground-glass opacities in peripheral distribution). A compatible LUS exam was considered a bilateral pattern of B-lines, irregular pleural line and subpleural consolidations. Between March and April 2020, 51 patients were consecutively enrolled. The indication for CT was a negative or indeterminate RT-PCR test (49.0%) followed by suspicion of pulmonary embolism (41.2%). Radiologic signs compatible with COVID-19 were present in 37 patients (72.5%) on CT scan and 40 patients (78.4%) on LUS exam. The presence of LUS findings was correlated with a positive CT scan suggestive of COVID-19 (odds ratio: 13.3, 95% confidence interval: 4.5-39.6, p < 0.001) with a sensitivity of 100.0%, specificity of 78.6%, positive predictive value of 92.5% and negative predictive value of 100.0%. There was no missed diagnosis of COVID-19 with LUS compared with CT in our cohort. The correlation between LUS score and CT total severity score was good (intraclass correlation coefficient: 0.803, 95% confidence interval: 0.60-0.90, p < 0.001). LUS exhibited similar accuracy compared with chest CT in the detection of lung abnormalities in COVID-19 patients.

A Cohort of Patients with COVID-19 in a Major Teaching Hospital in Europe.

BACKGROUND: Since the confirmation of the first patient infected with SARS-CoV-2 in Spain in January 2020, the epidemic has grown rapidly, with the greatest impact on the region of Madrid. This article describes the first 2226 adult patients with COVID-19, consecutively admitted to La Paz University Hospital in Madrid. METHODS: Our cohort included all patients consecutively hospitalized who had a final outcome (death or discharge) in a 1286-bed hospital of Madrid (Spain) from 25 February (first case admitted) to 19 April 2020. The data were manually entered into an electronic case report form, which was monitored prior to the analysis. RESULTS: We consecutively included 2226 adult patients admitted to the hospital who either died (460) or were discharged (1766). The patients' median age was 61 years, and 51.8% were women. The most common comorbidity was arterial hypertension (41.3%), and the most common symptom on admission was fever (71.2%). The median time from disease onset to hospital admission was 6 days. The overall mortality was 20.7% and was higher in men (26.6% vs. 15.1%). Seventy-five patients with a final outcome were transferred to the intensive care unit (ICU) (3.4%). Most patients admitted to the ICU were men, and the median age was 64 years. Baseline laboratory values on admission were consistent with an impaired immune-inflammatory profile. CONCLUSIONS: We provide a description of the first large cohort of hospitalized patients with COVID-19 in Europe. Advanced age, male sex, the presence of comorbidities and abnormal laboratory values were more common among the patients with fatal outcomes.

Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid / Consensus document for sepsis code implementation and development in the Community of Madrid

Se presenta aquí el documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid, cuya redacción se completó en abril de 2017. Este documento ha sido adoptado por la Consejería de Sanidad madrileña como base de trabajo para la puesta en marcha del Código Sepsis, tanto en el ámbito hospitalario (hospitales de agudos y de media y larga estancia) como en Atención Primaria y los Servicios de Emergencia Extrahospitalaria. Se publica ahora sin modificaciones con respecto a la versión original, añadiendo únicamente las referencias bibliográficas más significativas. El documento se estructura en cuatro partes: introducción, detección y valoración iniciales, tratamiento inicial y organización asistencial. En las partes segunda a cuarta se proponen 25 recomendaciones, consensuadas por los autores después de varias reuniones presenciales y una extensa discusión "online". Se incluyen nueve tablas que pretenden servir de guía práctica para la activación y aplicación del código sepsis. Tanto el contenido de las recomendaciones como su redacción formal se han realizado teniendo en cuenta su aplicabilidad en todos los ámbitos a los que se dirigen, que cuentan con recursos y características estructurales y funcionales muy dispares, por lo que deliberadamente se ha huido de un mayor grado de concreción: el objetivo no es que el código sepsis se organice y se aplique de forma idéntica en todos ellos, sino que los recursos sanitarios trabajen de forma coordinada alineados en la misma dirección

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive «online» discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction

Acute complications and outcomes of acute head injury in adult patients with haemophilia.

The aim of the present study is to describe the clinical and epidemiological characteristics, complications and outcome of patients with haemophilia and acute head injury (AHI) at the emergency department (ED), and develop a protocol to prevent early and late complications. This is a retrospective cohort study including all patients with haemophilia and AHI admitted to the ED. We identified 26 patients with AHI. A computed tomography scan was carried out on all patients at admission, and again on two patients (with neurosurgical complications) 48 h later. The discharge diagnosis was as follows: 3.8% subdural haematoma, 3.8% cerebellar epidural haematoma and 92.3% uncomplicated AHI. We propose the following protocol: a computed tomography scan upon arrival and another within 48 h post-AHI, unless there is an absence of clinical symptoms. In addition, all patients must self-administer a clotting factor as soon as possible and be observed in the ED for at least 48 h.

¿Es segura la inyección de alto flujo a través de catéteres centrales para realizar estudios tomográficos? / Is thigh flow injection through central catherers safe for tomographic studies?

Objetivo: Demostrar la seguridad de la inyección mecánica de contraste a través de catéteres centrales, excluyendo catéteres de hemodiálisis y puertos de quimioterapia, a velocidades > 3 ml/seg. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo en pacientes hospitalizados, quienes tenían como única vía de acceso una línea central y en quienes se les realizó inyección mecánica de medio de contraste a una velocidad de 3 y 4 cm3/ seg. Se evaluaron las complicaciones hemodinámicas y relacionadas con la integridad de los catéteres. Resultados: Se inyectaron 20 pacientes a través de catéteres venosos centrales (CVC) y 35 pacientes a través de catéteres centrales de inserción periférica (CCIP). No se presentaron complicaciones hemodinámicas ni se observaron complicaciones relacionadas con la integridad del catéter. Conclusión: La inyección mecánica de medio de contraste a través de CVC y CCIP, utilizando velocidades entre 3 y 4,5 ml/seg es una alternativa segura y viable para tomografías contrastadas.

Objective: The objective is to demonstrate the safety of medium contrast mechanical injection through central lines, not through a hemotherapy port or a hemodialysis catherer, at rates > 3 ml/sec. Methods: We performed a descriptive, longitudinal and prospective injection in patients who had a central line as the only venous access, and who underwent a mechanical injection with medium contrast at a rate 3-4 cc / sec. We evaluated complications in hemodynamics and complications related to the integrity of catherers. Results: 20 patients were injected via central venous catheters (CVC) and 35 patients via peripherally inserted central catheters (PICC). No complications were observed related to the integrity of the catherer. Conclusion: Medium contrast mechanical injection, performed through CVC and PICC at rates between 3 and 4.5 ml / sec, is considered a safe and viable alternative to contrast-enhanced CT

Utilidad de la tomografía computarizada multidetector para identificar la localización de las perforaciones gastrointestinales / Use of multidetector computed tomography for locating the site of gastrointestinal tract perforations

Introducción Valorar la capacidad de la tomografía computarizada multidetector (TCMD) para identificar la localización de la perforación gastrointestinal (GI).Material y métodos Análisis retrospectivo de 98 pacientes con neumoperitoneo en la TCMD. Dos radiólogos expertos evaluaron la presencia o ausencia de signos radiológicos directos (extravasación del contraste oral; defecto focal de la pared; defecto focal en reconstrucciones multiplanares) e indirectos (aire libre supramesocólico; inframesocólico; supra- e inframesocólico; burbujas de gas adyacentes a la pared; líquido libre; engrosamiento parietal segmentario; trabeculación de la grasa; abscesos) de perforación para identificar su ubicación. Se determinó la concordancia kappa entre los radiólogos para identificar el lugar de la perforación y la presencia o ausencia de cada uno de los signos radiológicos; así como la correlación kappa de la localización detectada mediante TCMD y su confirmación o no en la intervención quirúrgica. Se calculó para cada signo radiológico su frecuencia, sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN).Resultados Se diagnóstico correctamente el sitio de la perforación en un 80% de los casos. El índice kappa entre radiólogos para la localización fue excelente (0,919), variando para cada signo radiológico entre 0,5 y 1. La localización más frecuente de la perforación en la intervención quirúrgica (33,7%) y en la TCMD (40,8%) fue colon sigmoideo/recto. «Burbujas de gas adyacentes a la pared” fue el signo con mayor S (91%) y el «engrosamiento parietal segmentario» el que tuvo un mayor VPP (90%).Conclusión La TCMD permite localizar las perforaciones gastrointestinales con una alta sensibilidad (80%) y excelente correlación interobservador (AU)

Introduction The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) for locating the site of gastrointestinal tract perforations and to determine the most predictive signs in this diagnosis. Material and methods A total of 98 patients with pneumoperitoneum on MDCT were retrospectively analysed. Two experienced radiologists reviewed the presence or absence of direct signs (extravasation of oral contrast, focal defect in the bowel wall, focal defect with multiplanar reformations images) and indirect signs (free air in supramesocolic, inframesocolic, supramesocolic and inframesocolic compartments, concentration of extraluminal air bubbles adjacent to the bowel wall, extraluminal fluid, segmental bowel-wall thickening, perivisceral fat stranding, abscess) to identify the site of the perforation. The Kappa index was evaluated between radiologists to determine the site of perforation and for each predictive sign, as well as Kappa index between the site of perforation detected with MDCT and the site proven at surgery. The frequency, sensitivity, specificity and positive and negative predictive value (PPV and NPV, respectively) were calculated. Results The perforation site was identified correctly in 80.4% of cases. Kappa index between radiologists to identify the site was excellent (0.919), varying between 0.5-1.0 for each radiological sign. The most frequent site of perforation at surgery (33.7%) and in MDCT (40.82%) was the sigmoid colon/rectum. Concentration of extraluminal air bubbles adjacent to the bowel wall was the most sensitive (91%) sign and “segmental bowel-wall thickening” had the highest PPV (90%).Conclusion MDCT is useful for locating the site of GI perforation, with a high sensitivity (80%) and an excellent agreement between radiologists (AU)

Tromboembolismo pulmonar agudo masivo con trombo atrapado en foramen oval permeable / Acute massive pulmonary embolism with thrombus entrapped in patent foramen ovale

La enfermedad tromboembólica es un proceso potencialmente grave que puede poner en riesgo la vida del paciente, si no se diagnostica precozmente, sobre todo cuando la reserva cardiopulmonar es limitada. Una oclusión masiva del árbol arterial pulmonar, que provoque una disfunción cardiaca, puede implicar un grave riesgo vital, incluso en pacientes jóvenes. Situaciones menos frecuentes, como la trombosis de la aurícula derecha o de la aurícula izquierda, implican una complejidad más alta, con mayor morbilidad y mortalidad. Presentamos el caso de una paciente joven con insuficiencia respiratoria aguda; la angio-TC de arterias pulmonares reveló un tromboembolismo pulmonar masivo con un trombo en la aurícula derecha, que se extendía a la aurícula izquierda a través de un foramen oval permeable. Se exponen las características de las pruebas de imagen y la importancia de la información precisa aportada por la angio-TC, determinante en la rápida aplicación del tratamiento y el establecimiento del pronóstico del paciente. Presentamos el caso de una paciente joven con insuficiencia respiratoria aguda; la angio-TC de arterias pulmonares reveló un tromboembolismo pulmonar masivo con un trombo en la aurícula derecha, que se extendía a la aurícula izquierda a través de un foramen oval permeable. Se exponen las características de las pruebas de imagen y la importancia de la información precisa aportada por la angio-TC, determinante en la rápida aplicación del tratamiento y el establecimiento del pronóstico del paciente(AU)

Thromboembolic disease is a potentially severe pathology, which can represent a life threat if it is not diagnosed early, especially when the cardiopulmonary backup is limited. When its clinical feature implies a massive occlusion of the arterial pulmonary tree and a cardiac failure is ensued, it can be seriously life threatening, even for young patients. Less frequent features as right or left atrium thrombosis could increase de morbidity and mortality of this disease. We present the case of a young woman with severe respiratory insufficiency. The CT pulmonary angiography revealed an acute massive pulmonary embolism, with a right atrium thrombus extending towards the left atrium, through a patent foramen ovale. We discuss the imaging characteristics and the importance of the precise information obtained with the CT pulmonary angiography, essential in the rapid establishment of a given treatment protocol and an outcome prognosis for the patient(AU)

[Acute massive pulmonary embolism with thrombus entrapped in patent foramen ovale]. / Tromboembolismo pulmonar agudo masivo con trombo atrapado en foramen oval permeable.

Thromboembolic disease is a potentially severe pathology, which can represent a life threat if it is not diagnosed early, especially when the cardiopulmonary backup is limited. When its clinical feature implies a massive occlusion of the arterial pulmonary tree and a cardiac failure is ensued, it can be seriously life threatening, even for young patients. Less frequent features as right or left atrium thrombosis could increase de morbidity and mortality of this disease. We present the case of a young woman with severe respiratory insufficiency. The CT pulmonary angiography revealed an acute massive pulmonary embolism, with a right atrium thrombus extending towards the left atrium, through a patent foramen ovale. We discuss the imaging characteristics and the importance of the precise information obtained with the CT pulmonary angiography, essential in the rapid establishment of a given treatment protocol and an outcome prognosis for the patient.

[Use of multidetector computed tomography for locating the site of gastrointestinal tract perforations]. / Utilidad de la tomografía computarizada multidetector para identificar la localización de las perforaciones gastrointestinales.

INTRODUCTION: The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) for locating the site of gastrointestinal tract perforations and to determine the most predictive signs in this diagnosis. MATERIAL AND METHODS: A total of 98 patients with pneumoperitoneum on MDCT were retrospectively analysed. Two experienced radiologists reviewed the presence or absence of direct signs (extravasation of oral contrast, focal defect in the bowel wall, focal defect with multiplanar reformations images) and indirect signs (free air in supramesocolic, inframesocolic, supramesocolic and inframesocolic compartments, concentration of extraluminal air bubbles adjacent to the bowel wall, extraluminal fluid, segmental bowel-wall thickening, perivisceral fat stranding, abscess) to identify the site of the perforation. The Kappa index was evaluated between radiologists to determine the site of perforation and for each predictive sign, as well as Kappa index between the site of perforation detected with MDCT and the site proven at surgery. The frequency, sensitivity, specificity and positive and negative predictive value (PPV and NPV, respectively) were calculated. RESULTS: The perforation site was identified correctly in 80.4% of cases. Kappa index between radiologists to identify the site was excellent (0.919), varying between 0.5-1.0 for each radiological sign. The most frequent site of perforation at surgery (33.7%) and in MDCT (40.82%) was the sigmoid colon/rectum. Concentration of extraluminal air bubbles adjacent to the bowel wall was the most sensitive (91%) sign and "segmental bowel-wall thickening" had the highest PPV (90%). CONCLUSION: MDCT is useful for locating the site of GI perforation, with a high sensitivity (80%) and an excellent agreement between radiologists.

Trapped on the "whirl": diagnostic sign on emergency CT.

The "whirl sign" is an uncommon finding on emergency CT. However, it is easy to overlook if not kept in mind. Its recognition is of capital importance, being most of its causes potentially lethal. Surgical treatment is also mandatory when signs of complication are found. The whirl sign is usually found associated to midgut, cecal and sigmoid volvulus, small-bowel volvulus and closed-loop obstructions, and post-surgical mesenteric windows (including retroanastomotic hernias). CT is an optimal imaging technique to depict the so-called sign and associated CT features suggesting complication (circumferential wall thickening, pneumatosis intestinalis, pneumoperitoneum, mesenteric fat stranding, free intraperitoneal fluid, mesenteric haziness). Radiologists must be able to recognize the whirl sign and seek associated findings that strongly support the diagnosis of a spectrum of entities, some of them lethal if no treatment is established.

Subcutaneous emphysema: diagnostic clue in the emergency room.

The objective of this study was to illustrate the wide spectrum of subcutaneous emphysema in the emergency room; to show the key findings on computed tomography, plain radiographs, and echography; and to discuss the differential diagnoses. Subcutaneous emphysema is a common finding in emergency department imaging studies. It has a great importance due to its broad casualty, some of them totally benign, but others potentially lethal. We retrospectively reviewed our database of emergency pathology, analyzing its origins and associated features. SE was associated to traumatic, iatrogenic, or infectious causes (necrotizing fasciitis, Fournier gangrene). It also was found associated with thoracic (causing pneumothorax and pneumomediastinum) and abdominal pathology related to intraperitoneal and retroperitoneal gas. Diagnostic difficulties and differential diagnoses are emphasized. Radiologists must be aware of abnormal gas in soft tissue because it may be the main or unique sign leading to an underlying pathology, which can be lethal.