1/ Middle aged immunosuppressed man s/p remote renal transplant presents with fever, SOB and cough. History of DVT on Rivaroxaban. CXR and ECG below:

Apr 4, 2020 · 2:17 PM UTC

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2/ What is the next best step?
35% Primary PCI with full PPE
10% Thrombolytics
46% POCUS/Echo
9% Medical Rx
810 votes • Final results
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3/Case Resolution: #POCUS #echofirst Normal LV function -> Medical Rx. Tn -ve x3. #COVID19 +ve. Poll: 45% voted for PPCI/Lytics. Take home message: Be cautious when interpreting ST elevations esp in the setting of likely COVID. PPCI or lytics may not always be the best strategy.
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Thank you for posting this case. Follow-up?
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Will post tomorrow after others have had a chance to vote.
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Is he diabetic? Does he have chest pain and look like a person having a STEMI?
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Yes DM; atypical CP; looks unwell.
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Replying to @KaulP @SVRaoMD @jaygirimd @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
We need POCUS results. If normal, no Cath. If abnormal would Cath.
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
To everyone one of you guys out there making a difference and putting your own lives at risk to save thousands, words are not enough ! Thank you to every single one of you ! 👊♥️♥️👌👌♥️♥️
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson
We all love #POCUS but we should focus on what's the benefit of our intervention (Cath) & what's the harm (#COVID19 exposure risk and complications) 1. History 2. Ischemic symptoms 3. Hemodynamics 4. Arrhythmia But maybe a quick Cath prevents a bed being occupied? #pandemicmed
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
He presents with fever, SOB, cough - needs covid swab and echo - ? Myocarditis
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Ideally, Send 15 Covid test wTrop and BNP, Handheld echo shows lateral changes, lungs shows inf, PCI with full PPE. Echo NL or mild global with inf. Discuss. Echo not available - CL w PPE. Suspect diag/IM PCI. But, HR Pt, not HR territory
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Suspect myopericarditis despite localized STE 1/aVL, pr depression inf and 👆🏾aVR. CXR looks like bilat infiltrates without pulmonary edema/cardiomegaly. On riva so PE very unlikely. Would not lyse, POCUS = lateral wall alone down consider cath full PPE.
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Replying to @KaulP @medicalaxioms @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Fever and cough tips us to think of covid. Needs echo and covid test. Don’t forget tx related complications: bacterial pneumonia, pcp, non covid viral infections, aspergillosis. Lymphopenia (you will have baseline to compare to) would make me think covid
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
would you consider coronary CTA in this case? It could potentially distinguish pericarditis versus acs
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Start w/PoCUS of heart & lungs. Can/should be accomplished by most without delaying cath lab activation.
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Lateral STEMI; low risk would not rush to PPCI. Echo vs. TPA based on how the story sounds. Truly atypical pain ECHO would be my first option. Typical angina I will consider TPA right away in a good candidate. Since he is a diabetic, if otherwise healthy prior, TPA
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
PCR & ECHO
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Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
POCUS/Echo to confirm COVID myocarditis, then medical Rx.
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Replying to @KaulP @willsuh76 @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Echo, Regional WMA then cath full PPE
Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
POCUS/ECHO to determine further course.
Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
DI occlusion?!?
Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
If quickly available handheld echo showed lateral ischemia PCI w full PPE if normal or global decrease discuss... but if not available or unclear echo: CL with full PPE
Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
Biomarkers? cTnI? NT proBNP, EF? CT angio is preferred!
Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
he has hi lateral st elevation. chest pain? cardiac enzymes?
Replying to @KaulP @SVRaoMD @jaygirimd @SripalBangalore @ajaykirtane @DrMauricioCohen @HenrytTimothy @rajivxgulati @angioplastyorg @CMichaelGibson @PerwaizMeraj
What did you do ,,,is it some medium sized diagonal