Franco Lai

Introduction: Non-compressible torso hemorrhage (NCTH) is a major cause of preventable mortality in trauma, particularly when immediate surgical intervention is not available. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a promising technique to control severe hemorrhaging and stabilize patients until definitive surgical care can be performed. Case Presentation: We report the case of a 45-year-old woman who sustained multiple traumatic injuries—including thoracic, pelvic, and aortic damage—after a fall from approximately 5 m in an apparent suicide attempt. She arrived at a secondary-level trauma center in profound hemorrhagic shock, unresponsive to standard resuscitation. Interventions: As the patient’s condition deteriorated to cardiac arrest, an emergent REBOA procedure was performed by emergency physicians. This intervention rapidly restored hemodynamic stability, enabling damage control resuscitation and safe transfer to a Level 1 Trauma Center for definitive surgical management, including thoracic endovascular aortic repair and splenectomy. Outcomes: After prolonged intensive care, the patient recovered sufficiently to be discharged for rehabilitation. This case illustrates the life-saving potential of early REBOA deployment in a non-surgical, resource-limited setting to bridge patients to definitive care. Conclusions: This case supports integrating REBOA into emergency trauma protocols, particularly in centers without immediate surgical capabilities. Further research is warranted to refine REBOA deployment strategies, balloon positioning, patient selection, and the role of imaging guidance.

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an emerging technique in trauma care for managing severe hemorrhage when conventional resuscitation is inadequate. Methods: We report a case involving a 45 yo female patient who sustained multiple traumatic injuries—including thoracic, pelvic, and aortic damage—after a fall from approximately 5 meters. The timely insertion of a REBOA device provided critical hemodynamic support, allowing for temporary stabilization in the emergency department according to the principles of Damage Control Resuscitation. Results: This intervention facilitated her subsequent transfer to a Level 1 Trauma Center for definitive surgical intervention.Although the patient's prognosis remained poor due to the severity of her injuries, the use of REBOA illustrated its potential utility in improving hemodynamic stability in critically injured patients. Conclusions: Our findings suggest that REBOA can be a valuable adjunct in trauma management, offering a life-saving option in critical hemorrhagic cases where traditional methods are insufficient. Further research is warranted to refine REBOA application, particularly concerning optimal balloon positioning and integration with imaging techniques.

Procedural sedation and analgesia (PSA) in the emergency department (ED) presents a crucial aspect of emergency medicine, enabling the execution of painful or distressing procedures with minimal patient discomfort. This narrative review delineates the pharmacological framework, methodologies, and clinical considerations integral to optimizing PSA, with a particular focus on pediatric and geriatric populations. Through a comprehensive review and analysis of current practices, this work evaluates the pharmacokinetics and pharmacodynamics of widely utilized sedatives and analgesics, including propofol, ketamine, dexmedetomidine, fentanyl, midazolam, etomidate, nitrous oxide, and remimazolam. Special attention is dedicated to the selection criteria based on patient-specific risk factors, procedural requirements, and the management of potential adverse effects. The manuscript also explores innovative sedation techniques and the integration of new pharmacological agents, emphasizing evidence-based approaches to enhance patient safety and outcome. The results underscore the significance of tailored sedation strategies, especially for vulnerable groups such as pediatric and geriatric patients, highlighting the need for meticulous pre-procedural assessment and monitoring to mitigate risks. The conclusions drawn advocate for a nuanced application of PSA, guided by current evidence and clinical guidelines, to improve the quality of care in emergency settings. This research reinforces the imperative for ongoing education, skill development, and the adaptation of new evidence into clinical practice to advance procedural sedation and analgesia in the ED.

Procedural Sedation and Analgesia (PSA) in the Emergency Department (ED) presents a crucial aspect of emergency medicine, enabling the execution of painful or distressing procedures with minimal patient discomfort. This narrative review delineates the pharmacological framework, methodologies, and clinical considerations integral to optimizing PSA, with a particular focus on pediatric and geriatric populations. Through a comprehensive review and analysis of current practices, this work evaluates the pharmacokinetics and pharmacodynamics of widely utilized sedatives and analgesics, including propofol, ketamine, dexmedetomidine, fentanyl, midazolam, etomidate, nitrous oxide, and remimazolam. Special attention is dedicated to the selection criteria based on patient-specific risk factors, procedural requirements, and the management of potential adverse effects. The manuscript also explores innovative sedation techniques and the integration of new pharmacological agents, emphasizing evidence-based approaches to enhance patient safety and outcome. Results underscore the significance of tailored sedation strategies, especially for vulnerable groups such as pediatric and geriatric patients, highlighting the need for meticulous pre-procedural assessment and monitoring to mitigate risks. Conclusions drawn advocate for a nuanced application of PSA, guided by current evidence and clinical guidelines, to improve the quality of care in emergency settings. This research reinforces the imperative for ongoing education, skill development, and adaptation of new evidence into clinical practice to advance procedural sedation and analgesia in the ED.

A patient presenting an ST-segment elevation could represent a life-threatening condition in Emergency Department (ED). This case shows how sometimes, a chronic, and more often, an acute abuse of alcohol is related to important harmful effects on myocardial contractility. The authors present a case of a 19-year-old male of oriental-Asiatic origin admitted unconscious to ED with alcoholic fetor: on electrocardiogram a significant and widespread STsegment elevation was observed. A bedside echocardiography showed no abnormalities in segmental kinetics; therefore electrocardiogram- alterations could be related to a coronary spasm. The literature is poor about this effect induced by acute alcohol ingestion: the pathophysiological mechanism at the base of the abnormal muscle contractility, seems to be related to an impairment in cyclic guanosine monophosphate production, although a second and less probable hypothesis could be an altered intracellular concentration of calcium levels.