In patients visiting the emergency department (ED), a potential association between electrolytes disturbance and coronavirus disease 2019 (COVID-19) has not been well studied. We aim to describe ...electrolyte disturbance and explore risk factors for COVID-19 infection in patients visiting the ED. We carried out a case–control study in three hospitals in France, including adult ED inpatients (≥ 18 years old). A total of 594 ED case patients in whom infection with COVID-19 was confirmed, were matched to 594 non-COVID-19 ED patients (controls) from the same period, according to sex and age. Hyponatremia was defined by a sodium of less than 135 mmol/L (reference range 135–145 mmol/L), hypokalemia by a potassium of less than 3.5 mmol/L (reference range 3.5–5.0 mmol/L), and hypochloremia by a chloride of less than 95 mmol/L (reference range 98–108 mmol/L). Among both case patients and controls, the median (IQR) age was 65 years (IQR 51–76), and 44% were women. Hyponatremia was more common among case patients than among controls, as was hypokalemia and hypochloremia. Based on the results of the multivariate logistic regression, hyponatremia, and hypokalemia were associated with COVID-19 among case patients overall, with an adjusted odds ratio of 1.89 95% CI 1.24–2.89 for hyponatremia and 1.76 95% CI 1.20–2.60 for hypokalemia. Hyponatremia and hypokalemia are independently associated with COVID-19 infection in adults visiting the ED, and could act as surrogate biomarkers for the emergency physician in suspected COVID-19 patients.
The optimal diagnosis strategy for pulmonary embolism (PE) in the emergency department (ED) remains complex. This review summarizes PE diagnosis with clinical presentation, decision rules and ...investigations for acute PE.
This review was performed using studies published between January 1, 2010, and September 1, 2023.
PE should be considered in ED in patients with chest pain, shortness of breath, syncope or signs of deep veinous thrombosis. Definitive diagnosis of PE relies on thoracic imaging, with the use of CTPA or ventilation/perfusion lung scintigraphy. To limit the continuous increased use of chest imaging, the clinical probability should be the first step for PE work out. The Pulmonary Embolism Rule-out Criteria (PERC rule) can rule out PE at this stage. If not, for low or intermediate probability, several clinical decision rules (CDR) have been validated, either by ruling out PE on clinical signs, or by raising D-Dimer thresholds (YEARS or PEGeD) or by combination of these different rules. It is recommended that patients with a high clinical probability of PE should undergo chest imaging without the need for D-dimer testing. The PE diagnostic approach can be tailored in specific populations such as pregnant, younger, COVID-19, or cancer patients.
PE diagnosis workout illustrates the complexity of modern probabilistic-based approaches of decision-making in medicine. It is recommended to use a Bayesian approach with the evaluation of clinical probability, then order D-Dimer if the PERC rule is positive, then adapt the D-Dimer threshold for ordering chest imaging using CDR.
To evaluate the diagnostic performance of the initial chest CT to diagnose COVID-19 related pneumonia in a French population of patients with respiratory symptoms according to the time from the onset ...of country-wide confinement to better understand what could be the role of the chest CT in the different phases of the epidemic.
Initial chest CT of 1064 patients with respiratory symptoms suspect of COVID-19 referred between March 18th, and May 12th 2020, were read according to a standardized procedure. The results of chest CTs were compared to the results of the RT-PCR.
546 (51%) patients were found to be positive for SARS-CoV2 at RT-PCR. The highest rate of positive RT-PCR was during the second week of confinement reaching 71.9%. After six weeks of confinement, the positive RT-PCR rate dropped significantly to 10.5% (p<0.001) and even 2.2% during the two last weeks. Overall, CT revealed patterns suggestive of COVID-19 in 603 patients (57%), whereas an alternative diagnosis was found in 246 patients (23%). CT was considered normal in 215 patients (20%) and inconclusive in 1 patient. The overall sensitivity of CT was 88%, specificity 76%, PPV 79%, and NPV 85%. At week-2, the same figures were 89%, 69%, 88% and 71% respectively and 60%, 84%, 30% and 95% respectively at week-6. At the end of confinement when the rate of positive PCR became extremely low the sensitivity, specificity, PPV and NPV of CT were 50%, 82%, 6% and 99% respectively.
At the peak of the epidemic, chest CT had sufficiently high sensitivity and PPV to serve as a first-line positive diagnostic tool but at the end of the epidemic wave CT is more useful to exclude COVID-19 pneumonia.
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