Covid-19 Cardiac Arrest: Resuscitate Or Not?

Introduction: Coronavirus disease 2019 (COVID-19) has been associated with high in-hospital mortality. Since the implementation of guidelines and improvement in the quality of cardiopulmonary resuscitation (CPR), the survival rate for non-COVID-19 patients has improved. There is, however, scarce data regarding in-hospital cardiac arrest outcomes in COVID-19 patients. This study aimed to investigate cardiac arrest outcomes in patients hospitalized for COVID-19. Method(s): Retrospective study of the data of 994 adult patients admitted to a single-center high acuity critical care COVID-19 unit between March 2020 and February 2022 with COVID-19 diagnosis. Patients who underwent CPR were identified. Resuscitation registers and demographic information were obtained. The primary outcome was survival to hospital discharge. Secondary assessments were the initial rhythm and duration of CPR. Descriptive statistics were utilized. Result(s): A total of 994 COVID-19 patients were included in the study. 129 (13%) had a cardiac arrest and underwent CPR. Two patients survived hospital discharge (1.6%). Of them, 91(70.5%) were male. Mean age was 68.6 (+/-13.5) years. Median BMI was 29.1 [25.8-35.7] Kg/m2. The most frequent comorbidity was hypertension in 59 patients (46.1%), followed by diabetes type 2 in 30 patients (23.4%), and there were 37 (28.9%) patients with no comorbidities. The median time from admission to cardiac arrest was 12[6-18.5] days, the most common rhythm at the time of cardiac arrest was asystole in 94 (72.9%) patients, followed by pulseless electrical activity in 25 (19.4%);Ventricular dysrhythmias occurred in 7 (5.5%)of the cases. Finally, the median duration of CPR was 20[13.7-29] minutes. Conclusion(s): Survival of COVID-19 patients after in-hospital cardiac arrest was dismal, despite the adequate implementation of resuscitation protocols. Many of these patients were overweight or obese with comorbid conditions. The most common presenting rhythm was a non-shockable rhythm.

COVID-19-INDUCED AORTIC THROMBOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: As of April 2021, Coronavirus disease (COVID-19) has infected over 147 million people and claimed the lives of over 3 million globally. Despite becoming a significant burden on the healthcare community, complications and sequalae of this lethal virus are still not fully known. While primarily being defined as a respiratory illness, COVID-19 has been known to cause venous thrombotic events and less commonly increased arterial clot burden. CASE PRESENTATION: A 63-year-old female with a history of 30 pack year tobacco use presented to the emergency department (ED) complaining of shortness of breath, chest tightness, and right lower extremity pain starting 2-3 hours prior to presentation. In the ED she was noted to be COVID-19 positive and found to be hypoxic with an oxygen saturation of 84% on room air for which she was placed on 4 liters of oxygen per minute via nasal cannula for a goal oxygen saturation of >92%. The remainder of her vitals were unremarkable and physical exam did not reveal any pathology or acute findings. An emergent CT angiogram of the chest, abdomen, and pelvis was obtained which showed a large focus of thrombus in the ascending thoracic aorta measuring up to 2.2 x 1.3 cm in the axial plane, which appears free-floating abutting the anterior wall of the aorta. There were also some smaller scattered eccentric thrombi in the descending thoracic and infrarenal abdominal aorta. A focus of thrombus extending from the distal abdominal aorta into the right common iliac artery results in severe stenosis of the right common iliac artery. Venous doppler studies revealed diminished velocity in the right popliteal and posterior tibial arteries without identified thrombosis. Vascular surgery was consulted however the patient remained clinically stable and was started on a heparin drip prior to being bridged to warfarin with a goal international normalized ratio of 2.5 to 3.5 for a total of 6 months duration. At her 1 and 3 month outpatient follow-up she remained in stable condition and her presenting symptoms resolved. DISCUSSION: COVID-19 is known to bind to the peptidase domain of the angiotensin-converting enzyme 2 receptor leading to severe respiratory disease and an overwhelming activation of cytokines and complements. Through this process, a hypercoagulable state is induced leading to venous and arterial thrombotic events. Our patient had no risk factors for thrombotic disease and hypercoagulable work-up was largely unremarkable leading to the suspicion of COVID-19 infection as the cause. CONCLUSIONS: COVID-19 infection is a lethal viral disease affecting millions of people globally. As this disease continues to spread, it is imperative clinicians become aware of the devastating complications such as venous and arterial thrombosis risk and appropriately anti-coagulate their patients. REFERENCE #1: Ji YL, Wu Y, Qiu Z, et al. The Pathogenesis and Treatment of COVID-19: A System Review. Biomed Environ Sci. 2021;34(1):50-60. doi:10.3967/bes2021.007 REFERENCE #2: Cevik M, Kuppalli K, Kindrachuk J, Peiris M. Virology, transmission, and pathogenesis of SARS-CoV-2. BMJ. 2020;371:m3862. doi: 10.1136/bmj.m3862. DISCLOSURES: No relevant relationships by Abbas Alshami, source=Web Response No relevant relationships by Steven Douedi, source=Web Response No relevant relationships by Mihir Odak, source=Web Response No relevant relationships by Swapnil Patel, source=Web Response

ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION SECONDARY TO COVID-19

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus disease (COVID-19) is known to cause severe respiratory pathology such as acute respiratory distress syndrome. Although the pathophysiology of this lethal virus is still not fully understood, it has been suspected to attach to the ACE2 receptors leading to its deadly pathogenesis. Found to be the cause of venous thrombotic and embolic events, arterial thrombotic events such as ST-segment elevation myocardial infarction (STEMI) have been an unusual phenomenon. CASE PRESENTATION: A 37-year-old female with a past medical history of COVID-19 infection 12 days prior to admission presented to the emergency department (ED) complaining of shortness of breath for 2 to 3 days prior to admission. In the ED she was hypoxic with an oxygen saturation of 80% on room air for which she was placed on 90% FiO2 via OptiFlow and nonrebreather mask. Her D-Dimer on admission was noted to be 506 ng/mL (normal value <500 ng/mL). Unfortunately, due to worsening respiratory distress the decision was made to intubate the patient and she was transferred to the intensive care unit (ICU) for further management. An electrocardiogram was also obtained showing ST-segment elevations in leads II, III, aVF, and V1-V6 (Figure 1). An emergent bedside echocardiogram was obtained showing wall motion abnormalities consistent septal and anterior apical hypokinesis. A cardiac troponin level was obtained and was >80.00 ng/mL (normal value <0.04 ng/mL). The decision was made to proceed with cardiac catheterization for which complete stenosis of the left anterior descending (LAD) artery was noted. She received one drug eluding stent to the proximal LAD and due to severe cardiogenic shock an Impella was placed for hemodynamic support. Despite aggressive intervention and multiple vasopressors and Impella support she continued to decompensate and ultimately succumbed to her condition. DISCUSSION: STEMI is a rare complication of COVID-19 infection with an incidence of about 1%. The pathophysiology of STEMI in this setting is still not yet understood;however, COVID-19 infection is known to cause a hypercoagulable state through cytokine and complement activation as well as endothelial damage. CONCLUSIONS: Although uncommon, COVID-19 should be considered as a cause for arterial thrombotic events such as STEMI. It is imperative that clinicians are aware of the complications of this deadly virus and aggressively manage the hypercoagulable state observed in these patients to prevent morbidity and mortality. REFERENCE #1: Lodigiani C, Iapichino G, Carenzo L, et al. Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. doi: 10.1016/j.thromres.2020.04.024. REFERENCE #2: Abou-Ismail MY, Diamond A, Kapoor S, at al. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. REFERENCE #3: Bangalore S, Sharma A, Slotwiner A, et al. ST-Segment Elevation in Patients with Covid-19 - A Case Series. N Engl J Med. 2020;382(25):2478-2480. doi:10.1056/NEJMc2009020 DISCLOSURES: No relevant relationships by Nasam Alfraji, source=Web Response No relevant relationships by Abbas Alshami, source=Web Response No relevant relationships by Eric Costanzo, source=Web Response No relevant relationships by Steven Douedi, source=Web Response No relevant relationships by matthew meleka, source=Web Response No relevant relationships by Matthew Saybolt, source=Web Response

INCIDENCE OF INFLUENZA VIRUS PNEUMONIA DURING THE TIME OF CORONOVIRUS-2019 PANDEMIC

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Since the beginning of coronarvirus-2019 pandemic, prevention has been the core measure to mitigate the spread of the virus. Prevention measures included universal masking, frequent hand sanitization, and social distancing are among the measures that proved to be effective. However, these measures are also known to be effective against transmission of influenza virus. We hypothesize that during the times of Covid-19 pandemic, the incidence of influenza pneumonias will also decrease. METHODS: We utilized the Jersey Shore University Medical Center Laboratory database to identify the number of influenza tests sent before and during the pandemic. We extracted the data over the last six months in 2019 to represent the pre-pandemic period and compared them to the data of the last six months in the year of 2020 to represent the during-pandemic period. In addition, we compared the rate of decrease in monthly incidences of Influenza cases between Feb-April 2020 in our hospital (when preventive measures were applied state wide in NJ) to Feb-April of 2017 in the Mid-Atalatnic District (obtained from the Healthcare Cost and Utilization Project National Inpatient Sample 2017) to better elicit the effect of preventive measures as opposed to the natural course. RESULTS: During the last six months of 2019, there was a total of 10,304 flu tests sent inpatient. Of them, 674 tests were positive (6.5%). In comparison, there was a total of 5,406 total tests of influenza A and B sent during the last six months of year 2020;among them, only 1 case was positive (0.02%). Relative risk was 0.003. By examining the Mid-atalantic district trend of monthly incidences of influenza, it appears that influenza cases in all hospitalizations decreased from 2.5% in Feburary 2017 to 1.2% in March 2017 to 0.7% in April 2017 (Monthly decrease of 40-50%);while the incidence in our hospital decreased from 9.6% in Feburary 2020 to 2.7% in March 2020 to 0.7% (Monthly decrease of 70-75%). CONCLUSIONS: The incidence of influenza virus pneumonia has decreased significantly during the time of Covid-19 pandemic, likely due to widely encouraged preventive measures. CLINICAL IMPLICATIONS: Masking, frequent hand sanitization and social distancing proved to be very effective in reducing the incidence of influenza pneumonia. Preventive measures may be adopted in patients with high risk of mortality from influenza pneumonia, even if Covid-19 pandemic resolves. DISCLOSURES: No relevant relationships by Abbas Alshami, source=Web Response No relevant relationships by Steven Douedi, source=Web Response No relevant relationships by Ali Nadhim, source=Web Response No relevant relationships by Swapnil Patel, source=Web Response No relevant relationships by Daniel Shenouda, source=Web Response No relevant relationships by Joseph Varon, source=Web Response