key: cord-0732403-2e6oyf3d
authors: Santiago, Mario; Abrams, Stacy; Truong, Jimmy
title: Use of US to expedite diagnosis of PE in COVID-19 Patient
date: 2020-06-04
journal: Vis J Emerg Med
DOI: 10.1016/j.visj.2020.100789
sha: cb627293f354d730585846dd8b3289fa07789db3
doc_id: 732403
cord_uid: 2e6oyf3d

nan

Use of US to expedite diagnosis of PE in COVID-19 Patient

New York-Presbyterian/Columbia University Medical Center Department of Emergency Medicine 622 W 168 th Street New York, NY 10032

COVID-19 is a newly discovered Coronavirus that was identified in Wuhan, Hubei Province, China. Coronaviruses are normally the cause of respiratory illnesses like the common cold, but also similar to more severe viruses like MERS and SARS. One of the more serious symptoms with COVID-19 is that it causes patients to have shortness of breath requiring supplemental oxygen with a nasal cannula or non-rebreather, and in more severe cases, intubation. Using bedside Ultrasound to assess these patients can be a useful tool in the emergency department to quickly rule out other causes of dyspnea including pulmonary embolism in patients with shortness of breath, and tachycardia. During the pandemic, it is very easy to have anchoring bias to diagnosing someone with COVID-19 as there are many other etiologies with similar presenting symptoms. We aim to provide an example of using POCUS (point of care ultrasound) to illustrate that presenting patients can have multiple emergent diagnoses.

A 56 year old female presented to a busy NYC ED at the height of the COVID-19 pandemic. The patient had a past medical history of hypertension and asthma, and presented with shortness of breath and nonproductive cough for about two weeks. At triage, the patient's vitals were as follows: Temp: 36.4 F, HR: 141bpm, RR: 24, 110/60, and 88% O2 sat on room air. The patient's O2 saturations improved to 92% on nasal canula, then 97% on 15L/min via nonrebreather. The patient initially appeared dyspneic and tachypneic, however she appeared much more comfortable on NRB. ECG was performed, which revealed sinus tachycardia with a S1Q3T3 pattern ( Figure 1 ). Portable CXR ( Figure 2 ) revealed bilateral patchy opacities, likely multifocal viral and/or bacterial pneumonia. Basic labs, blood cultures, and our institution's COVID-19 lab panel were drawn (of note, d-dimer was no longer on our panel at this time), along with a SARS-COV-2 swab. The patient's initial workup revealed leukocytosis with lymphopenia, elevated inflammatory markers along with LDH and ferritin, and an elevated high sensitivity troponin. While the patient appeared much more comfortable on the nonrebreather, she remained tachycardic. Bedside POCUS was performed. The IVC was noted to be plethoric with minimal respiratory variation. On the apical four cardiac view (Figure 3 ) right heart strain was evident, with a dilated RV, bowing of the intraventricular septum, and McConnell's sign [1, 2] . A pericardial effusion was also noted. Using these findings, the decision was made to obtain a CTA chest, which revealed "extensive central pulmonary emboli involving all five lobes". The patient's BP began slowly dropping, and the pulmonary embolism response team was consulted, who recommended medical management with thrombolysis. tPA was administered, and then unfractionated heparin was started. The patient was admitted to the ICU for massive PE, and was found to be COVID-19 positive. The patient had a good hospital course, and was able to be weaned off of oxygen and discharged after a 13 day admission, and transitioned to Apixaban as an outpatient. Figure 1 : ECG displaying sinus tachycardia with S1Q3T3 pattern. McConnell's sign is akinesia of the RV free wall with sparing of the apex, which seems hyperdynamic relatively. It is thought to be a sensitive and specific finding for acute right heart strain [3] .

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property.

We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). He is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author and which has been configured to accept email from mas2551@cumc.columbia.edu

Signed by all authors as follows: Mario Santiago PA-C Stacy Abrams PA-C Jimmy Truong DO, MS

Critical appraisal on the utility of echocardiography in the management of acute pulmonary embolism

Diagnostic utility of echocardiography in patients with suspected pulmonary embolism

Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism