Background Coronavirus disease 2019 (COVID‐19) is characterized by severe lung involvement and hemodynamic alterations. Critical care ultrasonography is vital because it provides real time information for diagnosis and treatment. Suggested protocols for image acquisition and measurements have not yet been evaluated. Methods This cross‐sectional study was conducted at two centers from 1 April 2020 to 30 May 2020 in adult patients with confirmed COVID‐19 infection admitted to the critical care unit. Cardiac and pulmonary evaluations were performed using the ORACLE protocol, specifically designed for this study, to ensure a structured process of image acquisition and limit staff exposure to the infection. Results Eighty‐two consecutively admitted patients were evaluated. Most of the patients were males, with a median age of 56 years, and the most frequent comorbidities were hypertension and type 2 diabetes, and 25% of the patients had severe acute respiratory distress syndrome. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), E/e’ ratio > 14 (29.3%), and right ventricular dilatation (28%) and dysfunction (26.8%). A high rate of fluid responsiveness (82.9%) was observed. The median score (19 points) on pulmonary ultrasound did not reveal any variation between the groups. Elevated pulmonary artery systolic pressure was associated with higher in‐hospital mortality. Conclusion The ORACLE protocol was a feasible, rapid, and safe bedside tool for hemodynamic and respiratory evaluation of patients with COVID‐19. Further studies should be performed on the alteration in pulmonary hemodynamics and right ventricular function and its relationship with outcomes.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its associated coagulopathy are particularly worrisome in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), as these diseases carry an increased risk of thrombotic complications. Mathian et al recently reported the clinical course of COVID-19 in a series of 17 patients with SLE under chronic hydroxychloroquine therapy. 1 Of note, only one patient (6%) presented thrombosis despite the fact that four patients (24%) had a history of secondary APS, and five patients (29%) were receiving oral anticoagulants. Antiphospholipid (aPL) antibodies were not measured in these patients during active SARS-CoV-2 infection. 1 The American Society of Hematology recently stated that 'at the current time, there are only very limited data on aPL antibodies in COVID-19 and it is unclear if they represent an epiphenomenon or are actually involved in any haemostatic abnormalities seen in COVID-19 disease'. 2 Furthermore, almost all the available information refers to the lupus anticoagulant, with frequencies ranging from 45% to 87%. 3 4 This paucity of data led us to test a panel of aPL antibodies in blood specimens from 21 patients hospitalised in the intensive care unit between 12 and 19 April, due to severe or critical COVID-19, and received at our laboratory on 20 April to measure interleukin-6 levels. Anticardiolipin, anti-β 2 glycoprotein I, antiprothrombin, antiphosphatidylserine, antiphosphatidylinositol and antiannexin V antibodies were measured, each in IgM and IgG isotypes. Subsequently, demographic and clinical data were obtained from electronic medical records. Sera collected before the SARS-CoV-2 pandemic from 12 healthy individuals, matched for age and sex, were tested as controls.Pertinent results are summarised in table 1. The median age of patients was 62 years; 43% were men; and a high number of comorbidities were observed (median Charlson Comorbidity Index of 3). A total of 19 patients (90%) had shortness of breath on admission, and 12 (57%) eventually required invasive mechanical ventilation during hospitalisation. Elevated levels of D-dimer, ferritin and C reactive protein were found at presentation.Of the 21 patients with COVID-19 studied, 12 had at least one circulating aPL antibody, whereas only 1 of the 12 controls yielded a positive result (57% vs 8%; Fisher's exact test, p=0.009). The most frequently detected aPL antibodies were antiannexin V IgM (19%), anticardiolipin IgM (14%), antiphosphatidylserine IgM (14%), anticardiolipin IgG (10%) and antiphosphatidylserine IgG (10%) antibodies. One patient had triple positivity (8%); three patients had double positivity (25%); and the remaining eight had a single positivity (67%). Age and number of comorbidities tended to be lower in patients with aPL antibodies. In contrast, levels of D-dimer, ferritin and C reactive protein were higher both on admission and throughout the hospital stay in these patients. Elevated levels of interleukin-6 (>40 pg/mL) wer...

Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Objective To investigate whether a simplified inflammation-based risk scoring system comprising three readily available biomarkers (albumin, C-reactive protein, and leukocytes) may predict major adverse outcomes in patients with COVID-19. Methods Upon admission to the emergency room, the inflammation-based risk scoring system was applied and patients were classified as having mild, moderate, or severe inflammation. In-hospital occurrence of thrombosis, need for mechanical ventilation, and death were recorded. Results One-hundred patients (55 ± 13 years; 71% men) were included and classified as having mild (29%), moderate (12%), or severe (59%) inflammation. The need for mechanical ventilation differed among patients in each group (16%, 50%, and 71%, respectively; P < 0.0001), yielding a 4.1-fold increased risk of requiring mechanical ventilation in patients with moderate inflammation and 5.4 for those with severe inflammation. On the contrary, there were no differences for the occurrence of thrombosis (10%, 8%, and 22%, respectively; P = 0.142) or death (21%, 42%, and 39%, respectively; P = 0.106). In the multivariate analysis, only severe inflammation (hazard ratio [HR] = 4.1), D-dimer > 574 ng/mL (HR = 3.0), and troponin I ≥ 6.7 ng/mL (HR = 2.4) at hospital admission were independent predictors of the need for mechanical ventilation. Conclusion The inflammation-based risk scoring system predicts the need for mechanical ventilation in patients with severe COVID-19.

Atrial fibrillation (AF) is the most frequent arrhythmia in the post-operative period of cardiac surgery. It is associated with heart failure, renal insufficiency, systemic embolism, and increase in days of in-hospital and mortality. AF in the post-operative period of cardiac surgery (FAPCC) usually appears in the first 48 h after surgery. The main mechanisms involved in the appearance and maintenance of FAPCC are the increase in sympathetic tone and the inflammatory response. The associated risk factors are advanced age, chronic obstructive pulmonary disease, chronic kidney disease, valve surgery, fraction of ejection of the left ventricle < 40%, and the withdrawal of β-blocker (BB) drugs. There are instruments that have been shown to predict the appearance of FAPCC. Prophylactic treatment with BBs and amiodarone is associated with a decrease in the appearance of FAPCC. Given its transient nature, it is suggested that the initial treatment of FAPCC be the heart rate control and only if the treatment does not achieve a return to sinus rhythm, the use of electrical cardioversion is suggested. It is unknown what should be the long-term follow-up and complications beyond this period are little known. FAPCC is not a benign or isolated arrhythmia in patients undergoing cardiac surgery, so the identification of risk factors, their prevention, and follow-up in the outpatient setting, should be part of the units dedicated to the care and care of these patients.