Hasil untuk "Medical emergencies. Critical care. Intensive care. First aid"

Ka Lok Cheng, Kwan Leong Au Yeung, Chi Keung Chan

Abstract Objectives To present the epidemiology of suicidal charcoal burning in Hong Kong and long‐term outcomes for survivors presenting to the Accident and Emergency Department. Method Cases of suicidal charcoal burning were retrieved from databases of the Coroner's Court and Hong Kong Poison Information Centre. Pertinent demographic and clinical data were retrieved and analysed with R version 4.1.0, where statistical significance was defined as p < 0.05. Backward stepwise logistic regression was performed on gender (male), age (older than 50 years), coingestion, month (October to April) and day (weekend) to identify any outcome predictors. The post‐charcoal‐burning 9‐year medical record of the cases transferred to the hospital after charcoal burning was retrieved from the electronic patient record of the Hospital Authority and analysed. Results There were 429 cases of suicidal charcoal burning in Hong Kong from 1‐1‐2014 to 31‐12‐2015. The overall prehospital and in‐hospital case fatality rate was 59.4%. Gender (male), age (older than 50 years), coingestion and day (weekend) were identified to be predictors of fatality. Over half of the cases presented to the Accident and Emergency Department had no or a minor effect. Conclusion The epidemiology of suicidal charcoal burning in Hong Kong and long‐term outcomes for survivors were presented. Gender (male), age (older than 50 years), coingestion and day (weekend) were identified to be predictors of fatality. Selected cases of suicidal charcoal burning, especially those with no or minor effects, can be safely managed by the Accident and Emergency Department, avoiding unnecessary admission to the medical ward.

Erkan Boga

Introduction: Chronic kidney disease significantly increases the risk of acute kidney injury, and delays in diagnosing acute kidney injury in emergency departments can lead to adverse clinical outcomes. This study aimed to develop a practical and effective tool for assessing the risk of acute kidney injury in patients with chronic kidney disease. Materials and Methods: This retrospective cohort study was conducted at a state hospital over eight months in 2024, involving 1,500 patients aged 18 years and older with a confirmed diagnosis of chronic kidney disease. Data were extracted from electronic medical records, encompassing demographic, clinical, and laboratory parameters. Risk factors were analyzed using logistic regression, and significant variables were used to develop a scoring system. The model's performance was evaluated using the area under the receiver operating characteristic curve, as well as sensitivity, specificity, Results: The developed model achieved an operating characteristic curve of 0.75, with a sensitivity of 68% and a specificity of 72%. In univariate analysis, diabetes and hypertension were significant, but not in multivariate analysis. Subgroup analysis revealed improved model performance in patients under 50 years old and those without diabetes. Conclusion: This study presents a valuable tool for predicting the risk of acute kidney injury in patients with chronic kidney disease, thereby potentially enhancing clinical decision-making and improving patient outcomes. However, prospective studies and applications across diverse patient populations are necessary to enhance the model’s generalizability.

K. A. Egiazaryan, D. S. Ershov, A. P. Ratyev et al.

ABSTRACT Axillary artery injury as a result of total shoulder artroplasty is a fairly rare complication. Isolated clinical observations are described in foreign articles, there are no reports of domestic authors about this problem. There is a need for more extensive coverage of this problem in order to prevent similar situations in the future.THE AIM of this publication is to present a clinical case of intraoperative axillary artery injury in the process of reverse shoulder arthroplasty, and the medium­ term result of surgical treatment after replacement of the artery defect with a synthetic graft.MATERIAL AND METHODS We present a rare clinical case of intraoperative axillary artery injury in the process of reverse shoulder arthroplasty. After the replacement of the artery defect by a team of vascular surgeons, it was decided to continue the shoulder joint replacement surgery. In the postoperative period, computed tomography angiography revealed occlusion of the restored section of the axillary artery, but the presence of collateral blood flow distal to the injury zone, the preservation of active movements in the joints of the right upper limb, and the absence of sensitivity disorders in the right hand made it possible to refrain from repeated surgical intervention. When evaluating the medium­term results 15 months after surgical treatment, a significant limitation of the function of the right upper limb was noted in the complete absence of pain syndrome.CONCLUSION The presented clinical case demonstrates the experience of managing a patient with simultaneous reverse shoulder arthroplasty and an intraoperatively damaged section of the axillary artery with the achievement of complete absence of pain syndrome with significant restriction of function in the remote period. Bearing in mind the possible damage to the main arteries, particularly in age­related patients, and the amount of medical care required in the event of this complication, it is recommended that medical care be provided in a multidisciplinary hospital with a team of vascular surgeons.

Sunil Chhajwani

Akira Suekane, Wataru Takayama, Koji Morishita et al.

Abstract Aim Retrospective analysis of clinical characteristics and outcomes of patients with out‐of‐hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) requiring extracorporeal membrane oxygenation (ECMO) reinsertion or not. Methods Data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in the Japan II database were reviewed. Patients who received ECPR after OHCA between January 2015 and July 2021 and underwent ECPR weaning were divided into reinsertion and no‐reinsertion groups. The primary outcome was the 30‐day survival rate. Results Data from 1011 patients who underwent ECMO weaning ≥1 time and survived were analyzed (12 [1.2%], reinsertion; 999 [98.8%] no‐reinsertion). The reinsertion group had a longer time to first ECMO weaning (median [interquartile range, IQR]: 3.0 [2.0–5.0] vs. 4.5 [3.2–6.8] days; p = 0.02). The survival rates at 30 days (25.0% vs. 55.1%; p = 0.08) and favorable neurological outcomes at discharge (8.3% vs. 30.5%; p = 0.18) tended to be lower in the reinsertion group. Among patients who died within 30 days, medical costs were significantly higher in the reinsertion group (median [IQR]: $36,628.2 [26,012.9–45,885.6] vs. $16,456.6 [9341.2–24,880.6]; p < 0.01). Intensive care unit (ICU) stay and mechanical ventilation duration were significantly longer in the reinsertion group. Conclusion Patients requiring ECMO reinsertion tended to have poor clinical outcomes and higher healthcare costs, highlighting the need for large‐scale studies to develop ECPR protocols and optimize clinical benefits and resource allocation.

Slagt C, Van Kuijk SM, Bruhn J et al.

Cornelis Slagt,1,2 Sander MJ Van Kuijk,3 Jörgen Bruhn,1 Geert Jan Van Geffen,1,2 Lars Mommers2,4 1Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; 2Helicopter Emergency Medical Service Lifeliner 3, Radboud University Medical Centre, Nijmegen, the Netherlands; 3Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, Maastricht, the Netherlands; 4Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, the NetherlandsCorrespondence: Cornelis Slagt, Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, Postbus 9101, Nijmegen, 6500 hB, the Netherlands, Tel +31-635632459, Fax +31-243613585, Email cor.slagt@radboudumc.nlObjective: Treatment of refractory ventricular fibrillation (rVF) is a clinical challenge. If rVF is still present after standard advanced life support (ALS) guideline care, including amiodaron administration, other therapeutic options might be necessary. Based on the available evidence and expertise, our Helicopter Emergency Medical Service (HEMS) team developed a local practice guide for the prolonged resuscitation of patients in rVF and implemented this as standard HEMS care in March 2022.Methods: This database study contains all patients treated with our local practice guide during out of hospital cardiac arrest (OHCA) with rVF beyond the fifth regular ALS shock-block. This local practice HEMS treatment algorithm consisted of, among others, cessation of epinephrine and alternating administration of esmolol and norepinephrine combined with enoximone. Data were derived from the HEMS database and the treating hospitals. Primary outcome was the return of spontaneous circulation. Secondary outcome was defined as survival to hospital discharge and cerebral performance. This outcome was compared to the literature to analyze for inferiority of treatment.Results: In a 21-month period, HEMS was 761 times deployed for OHCA. Nineteen patients were treated with the local practice guide, nine patients (47%) were admitted to hospital with return of spontaneous circulation. Median resuscitation time was 22min. Hospital survival with good neurology was achieved in 42% vs 17% as expected. Exact Clopper-Pearson and logistic regression analysis revealed non-inferiority of the local practice guide. Withholding epinephrine was achieved in 84% of patients. A total of 79% and 90% of patients received esmolol and norepinephrine/enoximone mixture, respectively. Alternative defibrillation positions were indicated in 18 patients but applied in only 6 (33%).Conclusion: In patients with persisting VF despite prolonged advanced life support care, a multifaceted bundle of care approach shows promising results and warrants further research. Alternative drug administrations were found to be substantially easier to achieve compared to alternative defibrillation positions.Keywords: out-of-hospital cardiac arrest, ventricular fibrillation, cardiopulmonary resuscitation, emergency medical services, electric countershock, norepinephrine, enoximone

Dimitrios Tsiftsis, Andrew Ulrich, George Notas et al.

Abstract Greece is a parliamentary republic in southeastern Europe populated by over 10 million permanent residents: 9 million reside on the mainland, with almost 4 million in the greater Athens area. The remaining 1 million populate the over 1200 Greek islands. In addition, more than 160,000 asylum-seekers reached Greece in 2022, and more than 25 million tourists have visited Greece in the last two years. Modern Greek Emergency Medicine (EM) is now in its 4th decade. The Greek government has focused the last few years on enhancing the quality of emergency services provided in public hospitals. Emergency Departments (EDs) are being modernized, undergraduate medical education gradually incorporates EM, and a specialty training program in emergency nursing has been established. However, the late recognition of the critical importance of EM as a specialty in Greece has resulted in the subsequent need to create three alternative pathways to EM, none of which are direct from residency. The first is a 24-month Emergency Medicine fellowship after completing a residency in another specialty and then passing the national exam. The second is for physicians who have worked in a public hospital ED (Gr: Ethniko Systima Ygeias (ESY) ESY for at least three years and successfully passed the national exam. The third, which no longer exists, is a ‘grandfather’ pathway for those physicians who worked in an ESY ED for five years prior to the creation of the fellowship training program. As a result, there is a critical shortage of EM-trained physicians, resulting in most care being provided by physicians without formal training in EM. This is further confounded by the country’s challenging geography, with frequent air transfers from the islands to mainland hospitals. Creating an EM Residency training program is a critical next step to overcoming many of the challenges facing EM provision in Greece today: it would address the shortage of EM-trained providers, decrease the need for costly ground and air transfers, and improve the quality of emergency care throughout Greece.

K. S. Belyakov, Irina A. Ruslyakova, V. A. Marinin et al.

АКТУАЛЬНОСТЬ: Катетерная абляция (КА) является болезненной процедурой, требующей оценки баланса между ноцицепцией, ассоциированной с хирургической травмой, и антиноцицепцией, связанной с анестезией. ЦЕЛЬ ИССЛЕДОВАНИЯ: Оценить эффективность системы мониторинга «ANI Monitor» для анестезиологии, реанимации, интенсивной терапии у пациентов с синусовым ритмом и кратковременно-индуцируемой (< 1 мин) предсердной аритмией (КИПА). МАТЕРИАЛЫ И МЕТОДЫ: В исследовании основную группу составили 94 пациента с КА и ANI Monitor. Группу контроля составили 94 пациента со стандартным (гемодинамическим) мониторингом, отобранные по методу «копи-пара». Интенсивность боли оценивалась по цифровой рейтинговой шкале (ЦРШ). На этапе катетеризации бедренной вены у всех пациентов использована регионарная анестезия, тогда как на этапе КА процедурная седация и/или анальгезия (ПСА) поддерживалась введением пропофола и фентанила (под контролем ANI Monitor). Статистическую обработку информации проводили с использованием программ Statistica 10.0 и SPSS. РЕЗУЛЬТАТЫ: Отрицательная корреляция между ЦРШ и ANIm зарегистрирована на этапе КА под ПСА у пациентов с синусовым ритмом и КИПА (r = −0,37). Пороговое значение ANIm, равное 56,0, определило пациентов с ЦРШ ˃ 3 баллов с чувствительностью 60 %, специфичностью 100 % и площадью под ROC-кривой AUC 0,81. Значимых изменений гемодинамической реактивности зарегистрировано не было. Введение фентанила под контролем ANI Monitor демонстрирует снижение дозы у пациентов основной группы (0,04 ± 0,02 и 0,05 ± 0,03 мкг/кг/мин соответственно, p < 0,001). ВЫВОДЫ: ANI Monitor при проведении КА пациентам с синусовым ритмом и КИПА более эффективен в выявлении ноцицептивных повреждающих стимулов в ходе КА сердца по сравнению со стандартным (гемодинамическим) мониторингом. Использование ANI Monitor для контроля введения фентанила создает условия для проведения опиоидсберегающей анестезии.

K. Fuest, Hugo Lanz, J. Schulz et al.

Background Muscle ultrasound represents a promising approach to aid diagnoses of neuromuscular diseases in critically ill patients. Unfortunately, standardization of ultrasound measurements in clinical research is lacking, making direct comparisons between studies difficult. Protocols are required to assess qualitative muscle changes during an ICU stay in patients at high risk for the development of neuromuscular acquired weakness (ICUAW). Methods We conducted a retrospective, observational analysis comprised of three prospective observational studies with the aim of diagnosing muscle changes by ultrasound measurement of the quadriceps muscle. Different protocols were used in each of the three studies. In total, 62 surgical, neurocritical care and trauma intensive care patients were serially assessed by different ultrasound protocols during the first week of critical illness. The relative change in ultrasound measurements was calculated for all possible locations, methods and sides. Comparison was obtained using mixed effect models with the location, the height and the side as influencing variables and patients as fixed effect. The relationship between variables and outcomes was assessed by multivariable regression analysis. Results Ultrasound methods and measurement sites of the quadriceps muscles from all protocols were equally effective in detecting muscle changes. During the first week of an ICU stay, two groups were identified: patients with decreased muscle mass on ultrasound (n = 42) and a cohort with enlargement (n = 23). Hospital mortality was significantly increased in the cohort with muscle swelling (8 (19%) versus 12 (52%), p = .013). Conclusions Different approaches of ultrasound measurement during critical-illness are equally able to detect muscle changes. While some patients have a decrease in muscle mass, others show swelling, which may result in a reduced probability of surviving the hospital stay. Causative reasons for these results still remain unclear.

Shyam lal

Objective: Perforation peritonitis is a common surgical emergency which is treated by surgery and antibiotics. Candida isolation in peritoneal fluid and antifungal treatment is not a norm. The aim of this study was to determine the incidence of Candida in peritoneal fluid and its role in the outcome of patients with perforation peritonitis. Methods: This prospective observational study was conducted on 70 patients with perforation peritonitis from October 2016 to February 2018. Intraoperatively, peritoneal fluid was taken and sent for microbiological culture and sensitivity. Perforation was managed according to the site of perforation and condition of bowel. Results: The mean age of the patients was 38.74 years with male predominance (58, 82.85%). Forty-seven (67.14%) patients had positive peritoneal cultures. Escherichia coli was the most common bacteria (n=29), while Candida was found to be the most common fungi and was found in 18 patients. The incidence of Candida was higher in upper gastroduodenal perforation (30, 42.85%). Patients found positive for Candida had APACHE II severity score 10 or more which was higher than the rest of the patients. The mortality was higher in patients with positive peritoneal cultures (10/47) as compare to negative ones (2/23, P<0.001). The mortality in mixed bacterial and fungal-positive cultures (7/18) was also higher as compared to isolated bacterial culture (3/29, P <0.001). The overall mortality rate was 17.14%. Conclusion: Patients with Candida positive peritoneal culture had a significant mortality and morbidity as compared to Candida negative. Peritoneal fluid culture and sensitivity for bacterial and fungal were helpful in the early diagnosis and treatment

Massimo Quarenghi, Samantha Citrini, Rosamaria Turri Quarenghi

L Shams, Gh, T Nasiri et al.

Background and Objectives: The aim of this study was to investigate the relationship between socioeconomic status and non-communicable diseases (NCD) risk factors in one of the northern counties of Iran. Methods: A descriptive-analytical cross-sectional study was conducted in Langrud County in 2019. In this study, 906 rural and urban households were surveyed using mixed sampling. The data collection tool was the standard questionnaire of "NCD disease care system". Households’ exposure to NCD behavioral risk factors (including unhealthy diet, sedentary lifestyle and smoking) in different socio-economic groups was examined and compared with logistic regression models using the STATA software. Results: The probability of smoking in illiterate subjects and those with unfinished high school education and high school diploma was 5.1, 7.5 and 4.2 times higher than those with university education (OR = 5.1,7.5,4.2; P <0.05). The probability of unhealthy diets in the first and second quartiles of income (very low and low income) was 3.4 and 2.6 times higher compared to the people in the fourth quartile of income (high income) (P <0.05; OR = 3.4, 2.6). Conclusion: The micro-level socioeconomic inequalities (within the county) have a significant relationship with households’ exposure to NCD risk factors. Reducing socio-economic inequalities at the micro level should be considered as an appropriate tool to reduce health inequality at the macro level.

H. Aygun, Suna Eraybar

It is necessary to identify critical patients requiring hospitalization early due to the rapid increase in the number of COVID-19 cases. This study aims to evaluate the effectiveness of scoring systems such as emergency department triage early warning score (TREWS) and modified early warning score (MEWS) in predicting mortality in COVID-19 patients. In this retrospective cohort study, PCR positive patients evaluated for COVID-19 and decided to be hospitalized were evaluated. During the first evaluation, MEWS and TREWS scores of the patients were calculated. Intensive care needs as well as 24-h and 28-day mortality rates were evaluated. A total of 339 patients were included in the study. While 30 (8.8%) patients were hospitalized in the intensive care unit, 4 (1.2%) died in the emergency. The number of patients who died within 28 days was found to be 57 (16.8%). In 24-h mortality, the median MEWS value was found to be 7 (IQR 25–75) while the TREWS value was 11.5 (IQR 25–75). In the ROC analysis made for the diagnostic value of 28-day mortality of MEWS and TREWS scores, the area under the curve (AUC) for the MEWS score was found to be 0.833 (95% CI 0.777–0.888, p < 0.001) while it was identified as 0.823 (95% CI 0.764–0.882, p < 0.001) for the TREWS. MEWS and TREWS calculated at emergency services are effective in predicting 28-day mortality in patients requiring hospitalization due to COVID-19.

M. Dunn, M. Sheehan, J. Hordern et al.

As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles that staff are being allocated to in the intensive care unit and emergency department pose additional risks to themselves, and new policies for staff reallocation are causing distress and uncertainty to the professionals concerned. In this paper, we analyse a range of ethical issues associated with changes to staff allocation processes in the face of COVID-19. In line with a dominant view in the medical ethics literature, we claim, first, that no individual health professional has a specific, positive obligation to treat a patient when doing so places that professional at risk of harm, and so there is a clear ethical tension in any reallocation process in this context. Next, we argue that the changing asymmetries of health needs in hospitals means that careful consideration needs to be given to a stepwise process for deallocating staff from their usual duties. We conclude by considering how a justifiable process of reallocating professionals to high-risk clinical roles should be configured once those who are ‘fit for reallocation’ have been identified. We claim that this process needs to attend to three questions that we consider in detail: (1) how the choice to make reallocation decisions is made, (2) what justifiable models for reallocation might look like and (3) what is owed to those who are reallocated.

Sofie Van Ackerbroeck, Lynn Rutsaert, Ella Roelant et al.

Mathew Brun, Shane Brun, David Pearson et al.

Abstract Background There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma. Case presentation We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms. Conclusions This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Ryan P. Strum, Fabrice I. Mowbray, Andrew Worster et al.

Abstract Background Increasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission. Methods We conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics. Results During the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74–3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems. Conclusions Transport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management.

Bangchuan Hu, R. Sun, A. Wu et al.

BackgroundIn 2012, the European Society of Intensive Care Medicine proposed a definition for acute gastrointestinal injury (AGI) based on current medical evidence and expert opinion. The aim of the present study was to evaluate the feasibility of using the current AGI grading system and to investigate the association between AGI severity grades with clinical outcome in critically ill patients.MethodsAdult patients at 14 general intensive care units (ICUs) with an expected ICU stay ≥24 h were prospectively studied. The AGI grade was assessed daily on the basis of gastrointestinal (GI) symptoms, intra-abdominal pressures, and feeding intolerance (FI) in the first week of admission to the ICU.ResultsAmong the 550 patients enrolled, 456 patients (82.9%) received mechanical ventilation, and 470 patients were identified for AGI. The distribution of the global AGI grade was 24.5% with grade I, 49.4% with grade II, 20.6% with grade III, and 5.5% with grade IV. AGI grading was positively correlated with 28- and 60-day mortality (P < 0.0001). Univariate Cox regression analysis showed that age, sepsis, diabetes mellitus, coronary artery disease, the use of vasoactive drugs, serum creatinine and lactate levels, mechanical ventilation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the global AGI grade were significantly (P ≤ 0.02) associated with 60-day mortality. In a multivariate analysis including these variables, diabetes mellitus (HR 1.43, 95% CI 1.03–1.87; P = 0.05), the use of vasoactive drugs (HR 1.56, 95% CI 1.12–2.11; P = 0.01), serum lactate (HR 1.15, 95% CI 1.06–1.24; P = 0.03), global AGI grade (HR 1.65, 95% CI 1.28–2.12; P = 0.008), and APACHE II score (HR 1.04, 95% CI 1.02–1.06; P < 0.001) were independently associated with 60-day mortality. In a subgroup analysis of 402 patients with 7-day survival, in addition to clinical predictors and the AGI grade on the first day of ICU stay, FI within the first week of ICU stay had an independent and incremental prognostic value for 60-day mortality (χ2 = 41.9 vs. 52.2, P = 0.007).ConclusionsThe AGI grading scheme is useful for identifying the severity of GI dysfunction and could be used as a predictor of impaired outcomes. In addition, these results support the hypothesis that persistent FI within the first week of ICU stay is an independent determinant for mortality.Trial registrationChinese Clinical Trial Registry identifier: ChiCTR-OCS-13003824. Registered on 29 September 2013.

Engelbert A. Nonterah, Solomon Atindama, Emmanuel Achumbowina et al.

Introduction. Isolated jejunal perforation from blunt abdominal trauma is an extremely rare intra-abdominal injury that poses a huge diagnostic challenge. Delay in diagnosis and initiation of treatment often leads to significant morbidity and mortality. Diagnosis particularly in resource-poor settings may be extremely challenging and often relies on a high index of suspicion. This is due to lack of adequate diagnostic facilities and human resource to deal with the condition with resulting high occurrence of adverse outcomes. Case Presentation. We report a case of isolated jejunal perforation with associated mesentery injury in a young college student who sustained a kick to his abdomen while playing soccer. This is an unusual presentation since most reported cases often resulted from motor vehicular accidents, bicycle handlebar, and fall from a height. We emphasized the role of critical level of suspicion with a good history and physical examination as the major source of diagnosis since diagnostic procedures, such as abdominal ultrasonography and computed tomography, are largely unavailable in most resource-constraint settings. Early surgical intervention following diagnosis leads to good recovery and reduced mortality. Conclusion. Sufficient vigilance and suspicions of small bowel perforation should always be considered after blunt trauma even when symptoms and physical findings are minimal and when diagnostic capacity is limited.

Stephanie Listerfelt, Isabell Fridh, Berit Lindahl