Background: Pediatric out-of-hospital cardiac arrest (OHCA) is rare and associated with poor outcomes. Evidence from physician-staffed EMS systems remains limited. This study aimed to describe the incidence, presenting rhythms, EMS response intervals, and outcomes of pediatric OHCA, and to describe incidence, presenting rhythms, EMS response intervals, and prehospital outcomes in a local physician-staffed EMS system. Methods: We conducted a retrospective study of all pediatric (0-17 years) OHCA cases managed by the ASL Lecce physician-staffed EMS (southern Italy) between 2013 and 2025. Data were abstracted from standardized records. Variables included demographics, initial rhythm, EMS response intervals, temporal patterns, and return of spontaneous circulation (ROSC). The primary outcome was ROSC during prehospital care. Results: Twenty-seven cases were identified, corresponding to a cumulative incidence of 22.9 per 100,000 children over the study period (annualized incidence 1.73 per 100,000 children-year). Mean age was 11.9 ± 5.5 years (median 15); 59% were male. Initial rhythms were asystole in 81% and ventricular fibrillation (VF) in 19%; no pulseless ventricular tachycardia (pVT) or pulseless electrical activity (PEA) were recorded. Five patients had shockable rhythms, with seven shocks delivered overall. Mean time intervals were: event-to-call 1.0 ± 0.6 min, call-to-arrival 10.3 ± 4.1 min, event-to-arrival 11.3 ± 4.4 min. Arrests clustered during daytime (63%) and summer (41%). ROSC occurred in three patients (11%), two with VF and one with asystole; all arrests with ROSC were daytime events. In descriptive comparisons, ROSC cases showed a shorter call-to-arrival interval (T1-T2), whereas no consistent pattern was observed across all prehospital time intervals. Conclusions: Pediatric OHCA in this Italian physician-staffed EMS was infrequent, usually presented with asystole, and rarely achieved ROSC. Shockable rhythms were associated with better outcomes. Given the small sample size, findings related to response times should be interpreted with caution. System preparedness should include pediatric-specific training, early defibrillation access, and multicenter registries to improve care and track outcomes.

Cardiac arrest is defined as the sudden loss of heart activity, resulting in ineffective breathing and blood circulation. Point-of-care ultrasound (POCUS) provides real-time, evidence-based information during resuscitation and enables rapid identification of reversible conditions to guide ongoing resuscitative efforts. This mini-review focuses on the utility of POCUS during cardiac arrest, including its role in non-shockable rhythms such as pulseless electrical activity, pseudo-PEA, and asystole, where electrocardiographic findings alone may be misleading. POCUS can assist in the identification of reversible causes, including cardiac tamponade, massive pulmonary embolism, and tension pneumothorax. The review also addresses the role of serial ultrasound in monitoring cardiac activity and guiding advanced resuscitation, while emphasizing that ultrasound should not be used as the sole criterion for termination of resuscitation. We have also reviewed the practical aspects of performing POCUS during cardiac arrest, including probe selection, obtaining useful views, and strategies to minimize interruptions to chest compressions. Structured approaches such as the Cardiac Arrest Sonographic Assessment protocol are discussed to support efficient image acquisition within the 10-s pulse-check window.

(1) Background: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue, with survival largely determined by the initial rhythm and timeliness of resuscitation. Comprehensive population-based data are essential for guiding prevention, emergency medical services (EMS) planning, and improving outcomes. (2) Methods: We performed a retrospective observational study of all adult OHCA cases managed by EMS in Lecce (Italy) between January 2013 and March 2025. Demographics, arrest circumstances, initial rhythm, time intervals, and return of spontaneous circulation (ROSC) were analyzed across age, sex, temporal, and pandemic-related strata. Rhythm classification followed European Resuscitation Council guidelines. (3) Results: A total of 11,653 cases were analyzed (mean age 76.8 ± 15.5 years, 56.6% male). Asystole (AS) was the predominant rhythm (88.7%), followed by ventricular fibrillation (VF, 7.6%), pulseless electrical activity (PEA, 1.3%), and pulseless ventricular tachycardia (pVT, 0.08%). VF was more common in younger and male patients, while AS increased with age. Hour-level analysis revealed circadian peaks: VF in late afternoon and AS in early morning. Pandemic analysis showed reduced VF and increased AS during COVID-19, with partial recovery post-pandemic. ROSC occurred in 3.47% overall, strongly associated with shockable rhythms. EMS response times were stable across day-night and pandemic phases. (4) Conclusions: AS dominates OHCA presentations, especially among the elderly, whereas VF remains the strongest predictor of ROSC. Circadian variation at the hourly level suggests potential for EMS optimization. Pandemic-related shifts in rhythm highlight the vulnerability of the chain of survival to societal disruptions. Strengthening bystander CPR, expanding AED availability, and tailoring EMS strategies remain key priorities for improving OHCA outcomes.

Heparin-based anticoagulation is the first-line therapy for pulmonary embolism and deep vein thrombosis. However, when thrombus progresses despite adequate anticoagulation, placement of an inferior vena cava (IVC) filter may be considered. Thrombus extension following IVC filter placement may complicate retrieval and necessitate thrombolytic therapy, which carries a risk of bleeding. Here, we report a case in which catheter-directed thrombolysis (CDT) using monteplase was successfully performed for thrombus progression after IVC filter placement without any haemorrhagic complications.

Proximal femur fractures in the elderly are associated with high mortality rates due to reduced physiological reserve and a high risk of thromboembolic events, where admission laboratory parameters can serve as early indicators of clinical vulnerability. This case highlights a catastrophic clinical deterioration in a 92-year-old man who was admitted following a fall resulting in a displaced right intertrochanteric fracture. On admission, the patient was hemodynamically stable, but laboratory findings revealed an elevated neutrophil-to-lymphocyte ratio (NLR) of 10.1 and significant hyponatremia (126 mmol/L), reflecting high physiological stress and reduced compensatory reserve. Approximately 10 hours after admission, during preoperative preparation, he developed sudden dyspnea, hypotension, and pulseless electrical activity (PEA). Despite 30 minutes of advanced cardiac life support, the patient died. Arterial blood gas analysis during resuscitation showed profound hypoxemia (PaO2 42 mmHg) and severe metabolic acidosis (pH 6.98). Early mortality in geriatric hip fractures can occur even before surgical intervention, and abnormal admission parameters like elevated NLR and electrolyte imbalances should alert clinicians to a reduced compensatory reserve. In cases of sudden PEA arrest in the emergency department (ED), both massive pulmonary embolism and early-onset fat embolism syndrome should be considered in the differential diagnosis as plausible but unconfirmed causes.

Pulseless electrical activity (PEA), also known as electromechanical dissociation, is a clinical condition characterized by unresponsiveness and impalpable pulse in the presence of sufficient electrical discharge. A lack of ventricular impulse often points to the absence of ventricular contraction, but the contrary is not always true. It means that the electrical activity is pertinent, but not sufficient, condition for contraction. In the case of cardiac arrest, the organized ventricular electrical activity does not usually follow sufficient ventricular response. The word “sufficient” is being used to describe a degree of ventricular mechanical activity that is adequate to generate a palpable pulse. Pulseless electrical activity does not necessarily mean the lack of mechanical activity. There can be ventricular contractions and detectable pressures in the aorta, which are also known as pseudo-PEA.[1] True pulseless electrical activity is a state in which cardiac contractions are lacking in the presence of coordinated electrical impulses. Pulseless electrical activity can include a number of organized cardiac rhythms that may be supraventricular in origin, sinus versus nonsinus, or ventricular in origin such as accelerated idioventricular or escape. An impalpable pulse should not always be taken as a pulseless electrical activity because it may be due to severe peripheral vascular abnormality.[2][3][4]

Fat embolism syndrome (FES) is a severe orthopedic complication leading to respiratory failure and neurological impairment. While bone marrow or fat entry into venous circulation is common during total hip arthroplasty (THA), cardiac arrest rarely results. An 82-year-old woman developed pulseless electrical activity (PEA) during elective THA. During femoral reaming, a sudden decline in peripheral oxygen saturation (SpO2: 100% to 89%) and end-tidal carbon dioxide (EtCO2: 28 to 12 mmHg) was observed, followed by precipitous circulatory collapse. Transesophageal echocardiography (TEE) captured real-time video of numerous microemboli in all cardiac chambers, confirming pulmonary and paradoxical embolism. Despite successful resuscitation and surgical termination, TEE showed persistent embolic flow from the inferior vena cava (IVC). Postoperatively, the patient remained unconscious due to extensive cerebral infarction, resulting in permanent neurological sequelae. Fat embolism during THA can be fatal. This case, documented via intraoperative imaging, highlights the need for rapid point-of-care diagnosis and proactive surgical techniques to minimize intramedullary pressure.

Sigmoid volvulus is a well-documented cause of large bowel obstruction, often occurring in elderly or neurologically impaired individuals. While typically straightforward in diagnosis, concurrent anatomical abnormalities can obscure the clinical presentation and lead to catastrophic outcomes. This report presents an exceptionally rare case of simultaneous gastric and sigmoid volvulus with incarceration of the sigmoid colon within a left inguinal hernia, resulting in cardiac tamponade-like physiology and cardiac arrest. A 78-year-old man with cognitive impairment and bilateral inguinal hernias was found in pulseless electrical activity (PEA) arrest at his group home. Return of spontaneous circulation (ROSC) was achieved twice following cardiopulmonary resuscitation. On arrival at the emergency department, the patient was profoundly unstable, with a markedly distended abdomen and tense bilateral hernias. Computed tomography revealed a distended sigmoid colon consistent with volvulus, with the proximal sigmoid incarcerated within the left inguinal hernia. The entire stomach was also herniated into the thoracic cavity, causing severe left atrial compression. Laboratory results showed a serum lactate level of 18 mmol/L, consistent with global tissue hypoperfusion. Emergent exploratory laparotomy revealed a torsed, ischemic sigmoid colon and gastric volvulus with mechanical cardiac compression. Surgical management included reduction of the sigmoid and hiatal hernias, sigmoid colectomy with end colostomy, and anterior gastropexy. Despite aggressive resuscitation, the patient developed refractory metabolic acidosis and multiorgan failure, culminating in death on postoperative day one. This case demonstrates a rare and lethal confluence of gastrointestinal and cardiovascular pathophysiology. The sigmoid volvulus and gastric herniation produced both obstructive and compressive hemodynamic compromise, culminating in circulatory collapse. The patient's outcome was further worsened by the physiologic insult of preceding cardiac arrests and the systemic inflammatory state characteristic of post-cardiac arrest syndrome. This case highlights the importance of early imaging and a high index of clinical suspicion for complex anatomic causes of obstructive shock. Simultaneous gastric and sigmoid volvulus with herniation can produce catastrophic hemodynamic consequences, including cardiac tamponade physiology. Multidisciplinary coordination and rapid intervention are essential, although prognosis remains poor in patients presenting with severe ischemia and post-resuscitation instability.

Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by autoantibodies against factor VIII. COVID-19 infection has emerged as a potential trigger, though reported cases remain limited, with variable inhibitor titers. We report a 70-year-old African American man who developed AHA following documented COVID-19 infection in October 2023, presenting with an exceptionally high factor VIII inhibitor titer of 561 Bethesda Units (BU) that peaked at 677 BU during initial treatment. His course was complicated by migratory spontaneous hematomas and a massive chest wall hematoma leading to hemorrhagic shock and pulseless electrical activity (PEA) cardiac arrest, which he survived. Despite the severity, he achieved complete immunological remission with factor VIII normalization to 343% and inhibitor eradication (0 BU) following treatment with FEIBA, rituximab, cyclophosphamide, and corticosteroids. However, approximately three months after his initial diagnosis, he died from multiorgan failure secondary to overwhelming sepsis (procalcitonin 747.64 ng/mL) in the setting of profound treatment-induced immunosuppression. This case represents one of the highest reported inhibitor titers in COVID-19-associated AHA and demonstrates that complete remission is achievable even in severe cases. Yet this case underscores a critical therapeutic paradox: the aggressive immunosuppression necessary for inhibitor eradication carries a substantial risk of infectious mortality. Emerging therapies such as emicizumab may help mitigate this paradox by allowing reduced-intensity immunosuppression, though cost and off-label status currently limit accessibility.

ST-segment elevation on a post-cardiac arrest electrocardiogram (ECG) is traditionally viewed as a hallmark of acute coronary occlusion. However, this finding can also arise from non-coronary etiologies like massive pulmonary embolism (PE), creating a high-stakes diagnostic dilemma. An 83-year-old woman hospitalized for trauma developed cardiac arrest with pulseless electrical activity (PEA). Immediate post-resuscitation ECG showed marked ST-segment elevation in leads V1-V4, II, III, and aVF, suggesting extensive myocardial infarction. A point-of-care echocardiogram showed severe right ventricular dilation, raising the suspicion of PE, which was confirmed by computed tomography. Fortuitously, a Holter monitor was attached, capturing the sequence of ECG changes before and after the onset of PE. It revealed that ST-segment elevation appeared after the onset of cardiac arrest and gradually decreased thereafter. The patient was successfully treated with anticoagulation. This case suggests that post-arrest ST-segment elevation in PE may reflect dynamic right ventricular strain and supply-demand mismatch, rather than fixed coronary occlusion. Recognizing the "dynamic" nature of these ECG changes, alongside rapid echocardiographic assessment, is essential to avoid unnecessary emergent coronary angiography and ensure timely treatment for PE.