Clinical manifestation, investigation, management and outcomes of COVID-19 in emergency departments: a systematic review and meta-analysis

Authors

  • Witsanu Thonguthaisri Department of Emergency Medicine, King Chulalongkorn Memorial Hospital
  • Khrongwong Musikatavorn Department of Emergency Medicine, King Chulalongkorn Memorial Hospital
  • Paweena Susantitaphong Division of Nephrology, Department of Medicine, and Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University
  • Jutamas Saoraya -

Keywords:

COVID-19, Coronavirus, SARS-CoV-2, Clinical manifestation, Emergency department

Abstract

Introduction: Emergency departments are the frontline for managing patients suspected of having coronavirus disease 2019 (COVID-19).

Objective: To review the clinical manifestation, investigation and management of patients with COVID-19 in the emergency department (ED) setting.

Methods: We searched PubMed, Scopus and the Cochrane Library databases for case reports, case series and cohorts exploring the clinical manifestation, investigation and management of patients presenting to emergency department. We conducted a systematic review of the included studies and a meta-analysis of the cohorts.

Results: We included 40 case reports, 14 case series and 12 cohort studies in this systematic review. Based on cohort studies, patients typically presented with a history of sick contact (46%, 95% CI 42-49) or recent travel (24%, 95% CI 11-37). Cough (79%, 95% CI 71-86%), fever (61%, 95% CI 40-81%) and shortness of breath (48%, 95% CI 36-61) were the most common chief complaints. Although rarely present in ED patients, decreased taste and smell significantly increase the probability of testing positive for COVID-19 (risk ratio 6.20; 95% CI 1.82-21.14). Several rare clinical presentations of COVID-19 include stroke and skin rashes. Gastrointestinal symptoms could be found in up to 10-20% of patients. Although initial vital signs were not different between those who tested positive and negative for COVID-19, the intubation rate in the ED was triple in those with COVID-19 (risk ratio 3.59; 95% CI 1.48-8.69). Notable investigations were lymphopenia (71%, 95% CI 64-78) and bilateral infiltration on chest X-ray (60%, 95% CI 57-63). 

Conclusion: Patients with COVID-19 could present to EDs with typical respiratory symptoms as well as several unusual manifestations, including gastrointestinal, neurological and dermatological problems. Since the intubation rate tripled in those with COVID-19 compared to those without. Thus, emergency physicians should prepare for effective intubation while keeping patients and providers safe.

Downloads

Download data is not yet available.

References

Organization WH. WHO Coronavirus (COVID-19) Dashboard 2021 [cited 2021 26 August]. Available from: https://covid19.who.int/?gclid=CjwKCAiA_eb-BRB2EiwAGBnXXtCcYCYODVRJLucapY4LTY_RkcamKKlLcTaHu_4SnYSjnYuHCeLxxBoCwUEQAvD_BwE.

Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States. Health Affairs. 2020;39(11):2010-7.

Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, Xia L, Liu Z, Yang J, Yang BX. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health. 2020 Jun;8(6):e790-e798.

Uppal A, Silvestri DM, Siegler M, Natsui S, Boudourakis L, Salway RJ, et al. Critical Care And Emergency Department Response At The Epicenter Of The COVID-19 Pandemic. Health Affairs. 2020;39(8):1443-9.

Mathes T, Pieper D. Clarifying the distinction between case series and cohort studies in systematic reviews of comparative studies: potential impact on body of evidence and workload. BMC Medical Research Methodology. 2017;17(1):107.

Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603-5.

Moola S MZ, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu P-F. Systematic reviews of etiology and risk: The Joanna Briggs Institute; 2017 [cited 2020 October 15]. Available from: https://reviewersmanual.joannabriggs.org/

National Heart L, and Blood Institute. Quality Assessment Tool for Case Series Studies 2021 [cited 2020 October 15]. Available from: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools.

Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Medical Research Methodology. 2014;14(1):135.

Buenen AG, Wever PC, Borst DP, Slieker KA. [COVID-19 in the Emergency Department of Bernhoven hospital]. Ned Tijdschr Geneeskd. 2020;164.

Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED's Experience During the COVID-19 Pandemic. Acad Emerg Med. 2020;27(5):375-8.

Chua AJ, Charn TC, Chan EC, Loh J. Acute Olfactory Loss Is Specific for COVID-19 at the Emergency Department. Ann Emerg Med. 2020;76(4):550-1.

Di Micco P, Russo V, Carannante N, Imparato M, Rodolfi S, Cardillo G, et al. Clotting Factors in COVID-19: Epidemiological Association and Prognostic Values in Different Clinical Presentations in an Italian Cohort. J Clin Med. 2020;9(5).

Duanmu Y, Brown IP, Gibb WR, Singh J, Matheson LW, Blomkalns AL, et al. Characteristics of Emergency Department Patients With COVID-19 at a Single Site in Northern California: Clinical Observations and Public Health Implications. Acad Emerg Med. 2020;27(6):505-9.

Ferrari D, Motta A, Strollo M, Banfi G, Locatelli M. Routine blood tests as a potential diagnostic tool for COVID-19. Clin Chem Lab Med. 2020;58(7):1095-9.

O'Reilly GM, Mitchell RD, Rajiv P, Wu J, Brennecke H, Brichko L, et al. Epidemiology and clinical features of emergency department patients with suspected COVID-19: Initial results from the COVID-19 Emergency Department Quality Improvement Project (COVED-1). Emerg Med Australas. 2020;32(4):638-45.

Poggiali E, Dacrema A, Bastoni D, Tinelli V, Demichele E, Mateo Ramos P, et al. Can Lung US Help Critical Care Clinicians in the Early Diagnosis of Novel Coronavirus (COVID-19) Pneumonia? Radiology. 2020;295(3):E6-E.

Singer AJ, Morley EJ, Meyers K, Fernandes R, Rowe AL, Viccellio P, et al. Cohort of Four Thousand Four Hundred Four Persons Under Investigation for COVID-19 in a New York Hospital and Predictors of ICU Care and Ventilation. Ann Emerg Med. 2020;76(4):394-404.

Tolia VM, Chan TC, Castillo EM. Preliminary Results of Initial Testing for Coronavirus (COVID-19) in the Emergency Department. West J Emerg Med. 2020;21(3):503-6.

Toussie D, Voutsinas N, Finkelstein M, Cedillo MA, Manna S, Maron SZ, et al. Clinical and Chest Radiography Features Determine Patient Outcomes in Young and Middle-aged Adults with COVID-19. Radiology. 2020;297(1):E197-E206.

Zhu W, Xie K, Lu H, Xu L, Zhou S, Fang S. Initial clinical features of suspected coronavirus disease 2019 in two emergency departments outside of Hubei, China. J Med Virol. 2020;92(9):1525-32.

A Beccara L, Pacioni C, Ponton S, Francavilla S, Cuzzoli A. Arterial Mesenteric Thrombosis as a Complication of SARS-CoV-2 Infection. Eur J Case Rep Intern Med. 2020;7(5):001690.

Alkhafaji M, Ward T, Truong J. A case of lung ultrasound findings in a 73-year-old male with COVID-19. Vis J Emerg Med. 2020;21:100796.

Amatore F, Macagno N, Mailhe M, Demarez B, Gaudy-Marqueste C, Grob JJ, et al. SARS-CoV-2 infection presenting as a febrile rash. J Eur Acad Dermatol Venereol. 2020;34(7):e304-e6.

Arashiro T, Nakamura S, Asami T, Mikuni H, Fujiwara E, Sakamoto S, et al. SARS-CoV-2 and Legionella co-infection in a person returning from a Nile cruise. J Travel Med. 2020;27(3).

Burhan E, Prasenohadi P, Rogayah R, Isbaniyah F, Reisa T, Dharmawan I. Clinical Progression of COVID-19 Patient with Extended Incubation Period, Delayed RT-PCR Time-to-positivity, and Potential Role of Chest CT-scan. Acta Med Indones. 2020;52(1):80-3.

Caly L, Druce J, Roberts J, Bond K, Tran T, Kostecki R, et al. Isolation and rapid sharing of the 2019 novel coronavirus (SARS-CoV-2) from the first patient diagnosed with COVID-19 in Australia. Med J Aust. 2020;212(10):459-62.

Casey K, Iteen A, Nicolini R, Auten J. COVID-19 pneumonia with hemoptysis: Acute segmental pulmonary emboli associated with novel coronavirus infection. Am J Emerg Med. 2020;38(7):1544 e1- e3.

Co COC, Yu JRT, Laxamana LC, David-Ona DIA. Intravenous Thrombolysis for Stroke in a COVID-19 Positive Filipino Patient, a Case Report. J Clin Neurosci. 2020;77:234-6.

Craver R, Huber S, Sandomirsky M, McKenna D, Schieffelin J, Finger L. Fatal Eosinophilic Myocarditis in a Healthy 17-Year-Old Male with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2c). Fetal Pediatr Pathol. 2020;39(3):263-8.

Douedi S, Alshami A, Costanzo E. Extracorporeal Membrane Oxygenation as Treatment of Severe COVID-19 Infection: A Case Report. Cureus. 2020;12(4):e7714.

Douedi S, Miskoff J. Novel coronavirus 2019 (COVID-19): A case report and review of treatments. Medicine (Baltimore). 2020;99(19):e20207.

Farrow R, 2nd, Becherer-Bailey G, Mantuani D, Nagdev A. Early Multi-organ Point-of-Care Ultrasound Evaluation of Respiratory Distress During SARS-CoV-2 Outbreak: Case Report. Clin Pract Cases Emerg Med. 2020;4(2):129-33.

Ferrey AJ, Choi G, Hanna RM, Chang Y, Tantisattamo E, Ivaturi K, et al. A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease. Am J Nephrol. 2020;51(5):337-42.

Flower L, Carter JL, Rosales Lopez J, Henry AM. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep. 2020;13(5).

Giacomelli E, Dorigo W, Fargion A, Calugi G, Cianchi G, Pratesi C. Acute Thrombosis of an Aortic Prosthetic Graft in a Patient with Severe COVID-19-Related Pneumonia. Ann Vasc Surg. 2020;66:8-10.

Gonzalez-Pinto T, Luna-Rodriguez A, Moreno-Estebanez A, Agirre-Beitia G, Rodriguez-Antiguedad A, Ruiz-Lopez M. Emergency room neurology in times of COVID-19: malignant ischaemic stroke and SARS-CoV-2 infection. Eur J Neurol. 2020;27(9):e35-e6.

Hadadi A, Mortezazadeh M, Kolahdouzan K, Alavian G. Does recombinant human erythropoietin administration in critically ill COVID-19 patients have miraculous therapeutic effects? J Med Virol. 2020;92(7):915-8.

Hellinger JCMDMBA, Sirous RMDMPH, Hellinger RLBA, Krauthamer AMD. Abdominal Presentation of COVID-19. Applied Radiology. 2020;49(3):24-6.

Hornuss D, Laubner K, Monasterio C, Thimme R, Wagner D. [COVID-19 associated pneumonia despite repeatedly negative PCR-analysis from oropharyngeal swabs]. Dtsch Med Wochenschr. 2020;145(12):844-9.

Hunt M, Koziatek C. A Case of COVID-19 Pneumonia in a Young Male with Full Body Rash as a Presenting Symptom. Clin Pract Cases Emerg Med. 2020;4(2):219-21.

Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):819-24.

Jahan Y, Rahman S, Rahman A. COVID-19: A case report from Bangladesh perspective. Respir Med Case Rep. 2020;30:101068.

Jansen JH, Day RL. A novel presentation of COVID-19 via community acquired infection. Vis J Emerg Med. 2020;20:100760.

Kim J, Thomsen T, Sell N, Goldsmith AJ. Abdominal and testicular pain: An atypical presentation of COVID-19. Am J Emerg Med. 2020;38(7):1542 e1- e3.

Lee NY, Li CW, Tsai HP, Chen PL, Syue LS, Li MC, et al. A case of COVID-19 and pneumonia returning from Macau in Taiwan: Clinical course and anti-SARS-CoV-2 IgG dynamic. J Microbiol Immunol Infect. 2020;53(3):485-7.

Mayor-Ibarguren A, Feito-Rodriguez M, Quintana Castanedo L, Ruiz-Bravo E, Montero Vega D, Herranz-Pinto P. Cutaneous small vessel vasculitis secondary to COVID-19 infection: a case report. J Eur Acad Dermatol Venereol. 2020;34(10):e541-e2.

Mehta H, Ivanovic S, Cronin A, VanBrunt L, Mistry N, Miller R, et al. Novel coronavirus-related acute respiratory distress syndrome in a patient with twin pregnancy: A case report. Case Rep Womens Health. 2020;27:e00220.

Molina MF, Al Saud AA, Al Mulhim AA, Liteplo AS, Shokoohi H. Nitrous oxide inhalant abuse and massive pulmonary embolism in COVID-19. Am J Emerg Med. 2020;38(7):1549 e1- e2.

Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978 e1- e3.

Moriguchi T, Harii N, Goto J, Harada D, Sugawara H, Takamino J, et al. A first case of meningitis/encephalitis associated with SARS-Coronavirus-2. Int J Infect Dis. 2020;94:55-8.

Nakamura K, Hikone M, Shimizu H, Kuwahara Y, Tanabe M, Kobayashi M, et al. A sporadic COVID-19 pneumonia treated with extracorporeal membrane oxygenation in Tokyo, Japan: A case report. J Infect Chemother. 2020;26(7):756-61.

O'Kelly B, McGettrick P, Angelov D, Fay M, McGinty T, Cotter AG, et al. Outcome of a patient with refractory Hodgkin lymphoma on pembrolizumab, infected with SARS-CoV-2. Br J Haematol. 2020;190(1):e1-e3.

Polat V, Bostanci GI. Sudden death due to acute pulmonary embolism in a young woman with COVID-19. J Thromb Thrombolysis. 2020;50(1):239-41.

Prince G, Sergel M. Persistent hiccups as an atypical presenting complaint of COVID-19. Am J Emerg Med. 2020;38(7):1546 e5- e6.

Quintana-Castanedo L, Feito-Rodriguez M, Valero-Lopez I, Chiloeches-Fernandez C, Sendagorta-Cudos E, Herranz-Pinto P. Urticarial exanthem as early diagnostic clue for COVID-19 infection. JAAD Case Rep. 2020;6(6):498-9.

Shah K, Kamler J, Phan A, Toy D. Imaging & other potential predictors of deterioration in COVID-19. Am J Emerg Med. 2020;38(7):1547 e1- e4.

Siddamreddy S, Thotakura R, Dandu V, Kanuru S, Meegada S. Corona Virus Disease 2019 (COVID-19) Presenting as Acute ST Elevation Myocardial Infarction. Cureus.

;12(4):e7782.

Touzard-Romo F, Tapé C, Lonks JR. Co-infection with SARS-CoV-2 and Human Metapneumovirus. R I Med J (2013). 2020;103(2):75-6.

Tsao HS, Chason HM, Fearon DM. Immune Thrombocytopenia (ITP) in a Pediatric Patient Positive for SARS-CoV-2. Pediatrics. 2020;146(2).

Wang H, Das S, Wieruszewski PM, Taji J, Bartlett B, Azad N, et al. Unexpected BP Sensitivity to Angiotensin II in a Patient With Coronavirus Disease 2019, ARDS, and Septic Shock. Chest. 2020;158(2):e55-e8.

Avula A, Nalleballe K, Narula N, Sapozhnikov S, Dandu V, Toom S, et al. COVID-19 presenting as stroke. Brain Behav Immun. 2020;87:115-9.

Catellani F, Coscione A, D'Ambrosi R, Usai L, Roscitano C, Fiorentino G. Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy. J Bone Joint Surg Am. 2020;102(12):e58.

Chan KH, Farouji I, Abu Hanoud A, Slim J. Weakness and elevated creatinine kinase as the initial presentation of coronavirus disease 2019 (COVID-19). Am J Emerg Med. 2020;38(7):1548 e1- e3.

Erika P, Andrea V, Cillis MG, Ioannilli E, Iannicelli T, Andrea M. Triage decision-making at the time of COVID-19 infection: the Piacenza strategy. Intern Emerg Med. 2020;15(5):879-82.

Fistera D, Risse J, Manegold R, Pabst D, Konik M, Dolff S, et al. [COVID-19 Triage: Who is an inpatient? The Essen triage model]. Dtsch Med Wochenschr. 2020;145(15):e87-e92.

Gahide G, Frandon J, Vendrell J-F. COVID-19 patients presenting with afebrile acute abdominal pain. Clin Med (Lond). 2020;20(3):e4-e6.

Jimenez-Cauhe J, Ortega-Quijano D, Carretero-Barrio I, Suarez-Valle A, Saceda-Corralo D, Moreno-Garcia Del Real C, et al. Erythema multiforme-like eruption in patients with COVID-19 infection: clinical and histological findings. Clin Exp Dermatol. 2020;45(7):892-5.

Lorenzo Villalba N, Maouche Y, Alonso Ortiz MB, Cordoba Sosa Z, Chahbazian JB, Syrovatkova A, et al. Anosmia and Dysgeusia in the Absence of Other Respiratory Diseases: Should COVID-19 Infection Be Considered? Eur J Case Rep Intern Med. 2020;7(4):001641.

Poggiali E, Bastoni D, Ioannilli E, Vercelli A, Magnacavallo A. Deep Vein Thrombosis and Pulmonary Embolism: Two Complications of COVID-19 Pneumonia? Eur J Case Rep Intern Med. 2020;7(5):001646.

Poggiali E, Mateo Ramos P, Bastoni D, Vercelli A, Magnacavallo A. Abdominal Pain: A Real Challenge in Novel COVID-19 Infection. Eur J Case Rep Intern Med. 2020;7(4):001632.

Siegel A, Chang PJ, Jarou ZJ, Paushter DM, Harmath CB, Arevalo JB, et al. Lung Base Findings of Coronavirus Disease (COVID-19) on Abdominal CT in Patients With Predominant Gastrointestinal Symptoms. AJR Am J Roentgenol. 2020;215(3):607-9.

Spezzani V, Piunno A, Iselin HU. Benign COVID-19 in an immunocompromised cancer patient - the case of a married couple. Swiss Med Wkly. 2020;150:w20246.

Turbin RE, Wawrzusin PJ, Sakla NM, Traba CM, Wong KG, Mirani N, et al. Orbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID-19. Orbit. 2020;39(4):305-10.

Zhang Q, Pan J, Zhao MX, Lu YQ. Clinical value of the emergency department in screening and diagnosis of COVID-19 in China. J Zhejiang Univ Sci B. 2020;21(5):388-93.

O'Reilly GM, Mitchell RD, Mitra B, Akhlaghi H, Tran V, Furyk JS, et al. Epidemiology and clinical features of emergency department patients with suspected and confirmed COVID-19: A multisite report from the COVID-19 Emergency Department Quality Improvement Project for July 2020 (COVED-3). Emerg Med Australas. 2020;33(1):114-24.

Borakati A, Perera A, Johnson J, Sood T. Diagnostic accuracy of X-ray versus CT in COVID-19: a propensity-matched database study. BMJ Open. 2020;10(11):e042946.

Hossein H, Ali KM, Hosseini M, Sarveazad A, Safari S, Yousefifard M. Value of chest computed tomography scan in diagnosis of COVID-19; a systematic review and meta-analysis. Clin Transl Imaging. 2020:1-13.

European Center for Disease Prevention and Control. Options for the use of rapid antigen tests for COVID-19 in the EU/EEA and the UK. Technical Report 2020. Available from: https://www.ecdc.europa.eu/en/publications-data/options-use-rapid-antigen-tests-covid-19-eueea-and-uk.

Ni W, Yang X, Yang D. Role of angiotensin-converting enzyme 2 (ACE2) in COVID-19. Crit Care 24, 422 (2020).

Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-15.

Vargas G, Medeiros Geraldo LH, Gedeão Salomão N, Viana Paes M, Regina Souza Lima F, Carvalho Alcantara Gomes F. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and glial cells: Insights and perspectives. Brain Behav Immun Health. 2020;7:100127.

Orser BA. Recommendations for Endotracheal Intubation of COVID-19 Patients. Anesthesia & Analgesia. 2020;130(5).

Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, et al. Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial. JAMA. 2021;325(17):1731-43.

Papoutsi E, Giannakoulis VG, Xourgia E, Routsi C, Kotanidou A, Siempos II. Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. Critical Care. 2021;25(1):121.

Downloads

Published

2022-07-06

How to Cite

1.
Thonguthaisri W, Musikatavorn K, Susantitaphong P, Saoraya J. Clinical manifestation, investigation, management and outcomes of COVID-19 in emergency departments: a systematic review and meta-analysis. TJEM [Internet]. 2022 Jul. 6 [cited 2022 Aug. 15];4(1):52-84. Available from: https://he02.tci-thaijo.org/index.php/TJEM/article/view/256901

Issue

Section

RESEARCH ARTICLE

Categories