"Underneath the visible" - COVID-19 Risk prediction tools in a high-volume, low-resource Emergency Department.

Objectives: Patient risk stratification is the cornerstone of COVID-19 disease management; that has impacted health systems globally. We evaluated the performance of the Brescia-COVID Respiratory Severity Scale (BCRSS), CALL (Co-morbid, age, Lymphocyte and Lactate dehydrogenase) Score, and World Health Organization (WHO) guidelines in Emergency department (ED) on arrival, as predictors of outcomes; Intensive care unit (ICU) admission and in-hospital mortality. Methods: A two-month retrospective chart review of 88 adult patients with confirmed COVID-19 pneumonia; requiring emergency management was conducted at ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan, (April 1 to May 31, 2020). The sensitivity, specificity, receiver operator characteristic curve (ROC) and area under the curve (AUC) for the scores were obtained to assess their predictive capability for outcomes. Results: The in-hospital mortality rate was 48.9 % with 59.1 % ICU admissions and with a mean age at presentation of 56 ± 13 years. Receiver operator curve for BCRSS depicted good predicting capability for in hospital mortality [AUC 0.81(95% CI 0.71-0.91)] and ICU admission [AUC 0.73(95%CI 0.62-0.83)] amongst all models of risk assessment. Conclusion: BCRSS depicted better prediction of in-hospital mortality and ICU admission. Prospective studies using this tool are needed to assess its utility in predicting high-risk patients and guide treatment escalation in LMIC's.

Combining Non-invasive Ventilation with timed position change in the Emergency Department to improve oxygenation and outcomes in patients with COVID-19: A prospective analysis from a low resource setup.

Background: Moving away from invasive ventilation towards timed position change and non-invasive ventilation is especially of benefit in low and middle income countries, where judicious use of the available healthcare resources is the need of the day. Our study was conducted prospectively to develop strategies for non-invasive ventilation in combination with timed position change of patients to see its impact on their outcome. Objectives: Non-invasive ventilation has proven to be of benefit in COVID-19 related acute lung injury. The objective of this prospective, cross sectional study was to develop a protocol for the use of non-invasive ventilation with timed position change to improve COVID-19 patients' outcomes in the Emergency Department (ED). Methods: All patients presenting with confirmed or suspected COVID-19 were enrolled in the study from March 2020 to October 2020. Data was collected to see the effect of timed position change and non-invasive ventilation on these patients and its effect on delaying or avoiding invasive ventilation. Results: Of the 207 COVID-19 patients presenting to the IHHN ED, 109(52.7%) had oxygen saturation in the nineties in supine position followed by right lateral in 37(17.9%), sitting up in 30(14.5%), left lateral in 29(14%) and prone position in 2(1%). Maximal oxygenation was achieved with non rebreather mask (NRM) and nasal prongs in 87(42%) of the patients, followed by the use of continuous positive airway pressure (CPAP) in 29(14%). Conclusion: Most of the patients preferred to stay in the supine position and described it as the position of comfort. When used in combination supine position, patients on NRM with nasal prongs and on CPAP, had oxygen saturation in the nineties. Central obesity was found to be the prime reason for the inability to prone our patients. This needs to be followed up in the current fourth wave of COVID-19 to see the effectiveness of the said modalities.

Epidemiology of in-hospital cardiac arrest in a Pakistani tertiary care hospital pre- and during COVID-19 pandemic.

Objectives: To determine epidemiology of in-hospital cardiac arrest (IHCA) in a tertiary care hospital, pre- and during pandemic. Methods: This is a cross-sectional study of inpatients who experienced an in-hospital-cardiac arrest at a tertiary care hospital in Karachi between August 2019 and August 2020. Outcome variables were return of spontaneous circulation (ROSC) and survival to discharge (StD) and analysis was also done comparing pre- and during pandemic period. Results: A total of 77 patients experienced at least one IHCA event during the 1-year study period. Comparing pre- and during pandemic, ROSC for women was higher during the pandemic albeit not significant (43% vs 50%) in comparison to men (54% vs 10%, p<0.001). During the pandemic, women with IHCA were significantly younger than men (µ ± sd; 36.8 ± 15.3 vs 55.9 ± 12.7, p=0.001,) whereas pre-pandemic, there was no gender differences in mean age. Non-shockable rhythm was more common (92.2%) than shockable rhythm (6.5%). Pre- and during pandemic, there were significant differences in the cause of IHCA for 4H4T (87% vs 100%) and cardiac (36% vs 9%). The proportion of hypoxic patients increased from 50% during pre-pandemic to 91% during the pandemic period, whereas hypo/hyperkalemia decreased from 53% to 34%. Conclusion: Despite the limitation of a small sample size, our study has provided important information regarding the epidemiology and outcomes of IHCA pre- and during pandemic in a busy Pakistani tertiary care hospital. Our finding that gender differences exist in survival pre- and during pandemic needs to be explored further with more hospitals doing comparative studies.