Found the needle in the haystack! The case of a fishbone causing vasovagal syncopes and abdominal pain: a case report

Foreign body ingestion is a very common reason for access to the Emergency Department and in most cases, it doesn't cause symptoms; in case of fishbones, intestinal perforation is rare but possible. In this report, besides the typical picture of bowel perforation, we found atypical symptoms due to the specific location. We present a case of a 70-year-old man who presented to the Emergency Department complaining abdominal pain and several syncopes; a CT scan of the abdomen revealed the presence of a foreign body in the pyloric area, which was removed by surgical intervention and resulted to be a fishbone. Both abdominal and neurological symptoms disappeared. Results and conclusion We suppose that the specific location of fishbone, in the area when the pyloric branches of left vagus nerve run, can explain both the abdominal symptoms and the vasovagal syncope, through a sympathetic inhibition mechanism: Emergency physicians and emergency surgeons must be aware when dealing with symptoms apparently discordant that could be attributable to one common factor

Outcomes and indications for Emergency Thoracotomy after adoption of a more liberal policy in a western European level 1 Trauma Center: 8-years experience.

Background: The role of Emergency Thoracotomy (ET) in blunt trauma is still a matter of debate and in Europe only small studies have been published. We report our experience about ET both in penetrating and blunt trauma, discussing indications, outcomes and proposing an algorithm for patient selection. Materials and methods: We retrospectively analysed patients who underwent ET at Maggiore Hospital Trauma Center over two periods: from January 1st, 2010 to December 31st, 2012, and from January 1st, 2013 to May 31st, 2017. Demographic and clinical data, mechanism of injury, Injury Severity Score, site of injury, time of witnessed cardiac arrest, presence/absence of signs of life, length of stay, were considered, as well as survival rate and neurological outcome. Results: 27 ETs were performed; 21 after blunt trauma and six after penetrating trauma. Motor vehicle accident was the main mechanism of injury, followed by fall from height. The mean age was 40,5 years and the median Injury Severity Score was of 40. The most frequent injury was cardiac tamponade. The overall survival rate was 10% during the first period and 23.5% during the second period, after the adoption of a more liberal policy. No long term neurological sequelae were reported. Conclusions: The outcomes of ET in trauma patient, either after penetrating or blunt trauma, are poor but not negligible. To date, only small series of ET from European trauma centers have been published, although larger series are available from USA and South Africa. However, in selected patients, all efforts must be made for the patient's survival; the possibility of organ donation should be taken into consideration as well

Postoperative pain management in non-traumatic emergency general surgery : WSES-GAIS-SIAARTI-AAST guidelines

Background Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. Material and methods An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. Conclusion Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.Peer reviewe

Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines

Background Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team. Material and methods An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript. Conclusion Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies

Hydrogen atom abstraction from C-H bonds of benzylamides by the aminoxyl radical BTNO: a kinetic study

The aminoxyl radical BTNO (benzotriazole-N-oxyl; >N–O?) is generated from HBT (1-hydroxybenzotriazole; >N–OH) by oxidation with a CeIV salt. BTNO presents a broad absorption band with lmax 474 nm that lends itself to investigate the kinetics of H-abstraction from H-donor substrates by spectrophotometry. Thus, rate constants (kH) of H-abstraction by BTNO from CH2-groups a to the nitrogen atom in X-substituted-(N-acetyl)benzylamines (X-C6H4CH2NHCOCH3) have been determined in MeCN solution at 25 ?C. Correlation of the kH X data with the Hammett s+ parameters gives a small value for r (-0.65) that is compatible with a radical H-abstraction step. The sizeable value (kH/kD = 8.8) of the kinetic isotope effect from a suitably deuteriated amide substrate further confirms H-abstraction as rate-determining. Evidence is acquired for the relevance of stereoelectronic effects that speed up the H-abstraction whenever the scissile C–H bond is co-linear with either the nitrogen lone-pair of the amide moiety or an adjacent aromatic group. An assessment of the dissociation energy value of the benzylic C–H bond in ArCH2NHCOMe is accordingly reported

Oxidation of amides by laccase-generated aminoxyl radicals

The enzyme laccase from the fungus Trametes villosa catalyses the oxidation of two hydroxylamines ( NO H), i.e., HPI (N-hydroxyphthalimide) and HBT (1-hydroxy-benzotriazole), into their corresponding aminoxyl radicals ( NO•) PINO and BTNO. The ensuing oxidation of a few amides and lactames by PINO and BTNO has been investigated in buffered water solution (pH 5) at room temperature. The results from this chemo-enzymatic approach have been compared with a literature method that generates the aminoxyl radical PINO by the HPI/Co(II)/O2 chemical system, and uses it for the oxidation of similar amides. The merits of the aminoxyl radicals PINO and BTNO have been comparatively assessed in the chemo-enzymatic method, and the mechanism investigated. A Hammett treatment of the relative reactivity of oxidation of X-substituted-N-acetylbenzylamides in competition experiments supports a rate-determining H-abstraction route. With a few of the investigated substrates, stereoelectronic effects have been uncovered, and a rationalisation of their contribution to the reactivity of the H-abstraction route is offered, and supported by semiempirical calculations

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Non-Traumatic Cardiac Arrest: A Narrative Review of Known and Potential Physiological Effects

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is widely used in acute trauma care worldwide and has recently been proposed as an adjunct to standard treatments during cardiopulmonary resuscitation in patients with non-traumatic cardiac arrest (NTCA). Several case series have been published highlighting promising results, and further trials are starting. REBOA during CPR increases cerebral and coronary perfusion pressure by increasing the afterload of the left ventricle, thus improving the chances of ROSC and decreasing hypoperfusion to the brain. In addition, it may facilitate the termination of malignant arrhythmias by stimulating baroreceptor reflex. Aortic occlusion could mitigate the detrimental neurological effects of adrenaline, not only by increasing cerebral perfusion but also reducing the blood dilution of the drug, allowing the use of lower doses. Finally, the use of a catheter could allow more precise hemodynamic monitoring during CPR and a faster transition to ECPR. In conclusion, REBOA in NTCA is a feasible technique also in the prehospital setting, and its use deserves further studies, especially in terms of survival and good neurological outcome, particularly in resource-limited settings

Angioedema after rt-PA infusion led to airwayemergency: a case report of rescue treatment withfresh frozen plasma

The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid