Invasive Mechanical Ventilation in Traumatic Brain Injured Patients with Acute Respiratory Failure.

Patients with severe traumatic brain injury (TBI) need to be admitted to intensive care (ICU) because they require invasive mechanical ventilation (IMV) due to reduced consciousness resulting in loss of protective airway reflexes, reduced ability to cough and altered breathing control. In addition, these patients can be complicated by pneumonia and acute distress syndrome (ARDS). IMV allows these patients to be sedated, decreasing intracranial pressure and ensuring an adequate oxygen delivery and tight control of arterial carbon dioxide tension. However, IMV can also cause dangerous effects on the brain due to its interaction with intrathoracic and intracranial compartments. Moreover, when TBI is complicated by ARDS, the setting of mechanical ventilation can be very difficult as ventilator goals are often different and in conflict with each other. Consequently, close brain and respiratory monitoring is essential to reduce morbidity and mortality in mechanically ventilated patients with severe TBI and ARDS. Recently, recommendations for the setting of mechanical ventilation in patients with acute brain injury (ABI) were issued by the European Society of Intensive Care Medicine (ESICM). However, there is insufficient evidence regarding ventilation strategies for patients with ARDS associated with ABI. The purpose of this paper is to analyze in detail respiratory strategies and targets in patients with TBI associated with ARDS.

Pathophysiology and Therapy of High-Altitude Sickness: Practical Approach in Emergency and Critical Care.

High altitude can be a hostile environment and a paradigm of how environmental factors can determine illness when human biological adaptability is exceeded. This paper aims to provide a comprehensive review of high-altitude sickness, including its epidemiology, pathophysiology, and treatments. The first section of our work defines high altitude and considers the mechanisms of adaptation to it and the associated risk factors for low adaptability. The second section discusses the main high-altitude diseases, highlighting how environmental factors can lead to the loss of homeostasis, compromising important vital functions. Early recognition of clinical symptoms is important for the establishment of the correct therapy. The third section focuses on high-altitude pulmonary edema, which is one of the main high-altitude diseases. With a deeper understanding of the pathogenesis of high-altitude diseases, as well as a reasoned approach to environmental or physical factors, we examine the main high-altitude diseases. Such an approach is critical for the effective treatment of patients in a hostile environment, or treatment in the emergency room after exposure to extreme physical or environmental factors.

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications.

Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury's severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient's death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.

Surgical embolectomy in a 34-week pregnant woman with high risk pulmonary embolism and haemodynamic instability.

Pulmonary embolism represents the leading cause of maternal mortality in developed countries. The optimal treatment of high-risk pulmonary embolism with cardiovascular instability and at high hemorrhagic risk is still debated but surgical embolectomy represents an effective option. We describe the case of a 35-year-old woman in week 34 of pregnancy who was referred to our hospital because of exertional dyspnea and tachycardia and a few hours later became hypotensive and hypoxic. Pulmonary embolism was detected by performing an angio-computed tomography (CT) scan. After a successful cesarean section, emergent embolectomy was performed without inducing uterine hemorrhage. Both mother and the newborn recovered without postoperative sequelae.