Pseudo-pulseless electrical activity (p-PEA) is a clinical condition where cardiac output drops severely enough to produce a non-palpable pulse in the setting of organized electrical activity of the heart, but imaging or monitors display evidence of cardiac motion. It may be seen in shock states such as anaphylactic shock. We describe a case where a previously healthy teenage patient presenting for operative removal of orthopedic hardware developed p-PEA after anaphylaxis to antibiotics. Despite loss of pulses and severe mottling of the skin, the patient's pulse oximetry (plethysmography) and capnometry (measurement of end-tidal carbon dioxide) displayed visually normal, reassuring waveforms. The condition responded to chest compressions and administration of epinephrine and vasopressin; the patient was ultimately able to be discharged home on postoperative day (POD) 2. Prompt recognition, diagnosis, and clinical management of p-PEA and anaphylaxis are key to good patient outcomes. Epinephrine is the mainstay of treatment for anaphylactic reactions and is indicated during cardiopulmonary resuscitation (CPR) for p-PEA.

Pulmonary infarction (PI) is a recognized but relatively uncommon complication of pulmonary embolism (PE). Because its clinical presentation and imaging findings often overlap with those of community-acquired pneumonia (CAP), PI is frequently misdiagnosed. Progression to cavitation is exceedingly rare and typically reflects extensive, irreversible parenchymal necrosis. We describe a 66-year-old woman with heart failure with reduced ejection fraction (HFrEF) and coronary artery disease (CAD) who initially presented with symptoms consistent with CAP. Although she initially improved, she re-presented ten days later with acute hypoxemic respiratory failure and a newly developed smooth-walled cavitary lung lesion. Chest computed tomography confirmed a submassive PE complicated by necrotizing PI and secondary abscess formation. Given the failure of conservative management and evidence of parenchymal gangrene with the need for source control, she underwent urgent right lateral thoracotomy with bilobectomy for source control. The post-operative course was complicated by refractory shock and pulseless electrical activity (PEA) arrest. Following goals-of-care discussions, the family elected to pursue comfort-focused care. This case shows the importance of systemic-to-pulmonary collateral circulation in preserving lung parenchymal viability. In patients with limited cardiovascular reserve, failure of bronchial arterial compensation can precipitate catastrophic necrotizing infarction. Clinicians should maintain a high index of suspicion for PI in cases of "nonresolving pneumonia," as early recognition may be critical in preventing progression to cavitary disease.

Massive pulmonary embolism (PE) is a life-threatening emergency often presenting with hemodynamic collapse or cardiac arrest. Despite advances in resuscitation and reperfusion therapies, outcomes remain poor. We report the case of a 74-year-old man with a history of hypertension, hyperlipidemia, and diabetes mellitus who presented with acute severe dyspnea leading to pulseless electrical activity (PEA) cardiac arrest. Return of spontaneous circulation was achieved with advanced cardiac life support, but he subsequently experienced recurrent PEA arrest requiring intubation, vasopressors, and antiarrhythmic therapy. Electrocardiography showed sinus tachycardia with right bundle branch block and repolarization abnormalities. Laboratory evaluation revealed marked troponin elevation, leukocytosis, thrombocytopenia, and hypokalemia. Duplex ultrasound demonstrated bilateral lower extremity deep vein thromboses. Echocardiography showed preserved left ventricular function with an enlarged, hypokinetic right ventricle and apical sparing. Chest computed tomography angiography revealed a large burden of bilateral pulmonary emboli with right ventricular strain and wedge-shaped pulmonary infarctions. The patient was treated with systemic thrombolysis (tenecteplase), complicated by transient oral and urinary bleeding that resolved spontaneously. Over several days, he stabilized, was weaned from vasopressors and mechanical ventilation, and discharged on full anticoagulation to outpatient follow-up. This case highlights the diagnostic challenge of massive PE, the value of bedside echocardiography, and the importance of prompt reperfusion therapy in unstable patients.

Pulseless electrical activity (PEA) arrest in patients with end-stage heart failure with reduced ejection fraction (HFrEF) most commonly reflects profound circulatory collapse rather than a primary arrhythmogenic event. Although post-resuscitation encephalopathy often prompts early neurologic prognostication, myocardial dysfunction and refractory shock frequently dominate outcomes in this population. We report the case of a 59-year-old woman with end-stage HFrEF, severe multivessel coronary artery disease, chronic lung disease, HIV infection, and active cocaine use who presented with acute hypoxic respiratory failure and decompensated heart failure and subsequently developed prolonged PEA arrest. Her post-arrest course was complicated by refractory cardiogenic shock, focal cerebellar infarction with delayed MRI due to hemodynamic instability and vasopressor dependence, and multisystem organ failure. Taken together, these findings underscore an important post-resuscitation diagnostic pitfall: neurologic abnormalities may coexist; however, refractory hemodynamic collapse often predominates. An integrated framework incorporating shock physiology, substance-associated cardiotoxicity, and competing neurologic injury is essential for accurate clinical assessment and informed goals-of-care discussions.

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.