Utility of ED triage tools in predicting the need for intensive respiratory or vasopressor support in adult patients with COVID-19.

BACKGROUND: Serum and radiological parameters used to predict prognosis in COVID patients are not feasible in the Emergency Department. Due to its damaging effect on multiple organs and lungs, scores used to assess multiorgan damage and pneumonia such as Pandemic Medical Early Warning Score (PMEWS), National Early Warning Score 2 (NEWS2), WHO score, quick Sequential Organ Failure Assessment (qSOFA), and DS-CRB 65 can be used to triage patients in the Emergency Department. They can be used to predict patients with the highest risk of seven-day mortality and need for intensive respiratory or vasopressor support (IRVS). PURPOSE: The primary purpose was to find the score with the highest AUC in predicting IRVS and mortality at seven days. Additional objective was to find out any independent factors associated with IRVS and mortality. METHODS: The data of adult patients who presented to the Emergency Department (ED) between April 1, 2021 and June 30, 2021 were collected. The WHO score, CRB-65, DS-CRB 65, PMEWS, NEWS2, and qSOFA score were calculated for all patients. Statistical analysis was done and an ROC curve was calculated for all the tools for mortality and need for IRVS at seven days. FINDINGS: 677 patients presented to the Emergency Department with COVID-19 during the period above. Presence of Diabetes Mellitus (p = 0.001), Hypertension (p = 0.001), and chronic kidney disease(CKD) (p = 0.04) was significantly associated with need for IRVS. Age, duration of symptoms, pulse rate, respiratory rate, room air saturation, mental status at admission, and time to IRVS need were identified as independent predictors of in-hospital mortality. The longer the time to IRVS need from ED arrival, the higher the likelihood of mortality. PMEWS (0.830) had the highest AUC, followed by NEWS2 (0.805). A PMEWS cut-off of 6.5 was 74.2% sensitive and 78.3% specific in predicting the need for IRVS. ROC analysis to predict 7-day mortality showed that PMEWS had an AUC of 0.802 (0.766-0.839). QSOFA performed poorly in predicting IRVS (AUC 0.645) and 7-day mortality (AUC 0.677). CONCLUSION: PMEWS may be used for triaging patients presenting to the Emergency Department with COVID-19 and accurately predicts the need for IRVS and seven day mortality.

'Hydro-point' - The forgotten and unspoken entity in hydropneumothorax.

Effusive pneumothorax is an abnormal collection of air and fluid within the pleural space: blood, pus, or serous fluid. Thus, effusive pneumothorax can be categorized as hemopneumothorax, pyopneumothorax, or hydropneumothorax, depending on the type of fluid accumulation. Hydropneumothorax is a clinical condition defined by the presence of air and serous fluid within the pleura space. Hydropneumothorax is one of the common respiratory emergencies encountered in the emergency department in India. Etiologies can be classified into infectious and non-infectious causes, among which tuberculosis being the most common one. Point of care ultrasound (POCUS) can help diagnose hydropneumothorax at the bedside rather than shift the patient for an X-ray. Here, we describe a case of hydropneumothorax, which was diagnosed using POCUS by characteristic sonographic signs, namely "Hydro-point" and "barcode-hydro point-sinusoidal sign." Sonographic hydro-point is the transition zone of the air-fluid interface, which is seen in hydropneumothorax. Targhetta et al., in 1992, introduced the term "Hydro-point" in lung ultrasound for diagnosing hydropneumothorax but has been under-reported/unspoken much in the literature. With the use of POCUS, we diagnosed and stabilized the patient in the Emergency Department.