[CAFFEINE POISONING AND FATAL ARRHYTHMIAS: A CASE REPORT].

INTRODUCTION: Study Summary: In today's world, caffeine is the most commonly consumed psychostimulant globally. While moderate caffeine intake is generally safe, there have been reported cases of significant toxicity and even fatal outcomes. Although rare, increased awareness and clinical suspicion are crucial in identifying such cases and providing timely life-saving interventions. In this report, we present a case of a 27-year-old female patient who was hospitalized due to severe systemic and cardiac effects resulting from the ingestion of a large quantity of caffeine capsules as a suicide attempt. We provide a detailed account of the clinical presentation and the management of the patient, including the emergency room's life-saving interventions and the complex care provided in the intensive care unit until the patient's complete recovery. Our aim with this case presentation is to raise awareness about the severe consequences of caffeine intoxication, particularly the cardiac injury, and to highlight the state-of-the-art treatment approaches in addressing this issue.

Multiple rib fractures: does flail chest matter?

BACKGROUND: Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures. METHODS: This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality. RESULTS: The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest. CONCLUSION: In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.

Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry.

BACKGROUND: Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS: Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS: Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION: Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Is computed tomography cystography indicated in children with pelvic fractures?

PURPOSE: Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images. METHODS: A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age<14) between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry. Statistical analysis was performed using SAS statistical software version 9.4 via the tests of Chi-square test and two-sided Fisher's exact test. A p value of less than 0.05 was considered statistically significant. RESULTS: A total of 1072 children were identified from the registry for inclusion. Mean age of patients was 7.7 years (range 0-14) and 713 (66.5%) were male. Overall mortality in this population was 4.1% (44/1072). Only 2.1% (23) of pediatric patients with pelvic fractures had bladder injury identified, with just 9 children having intraperitoneal bladder rupture (0.8% of all the patients). CONCLUSION: The vast majority of blunt pediatric trauma victims with pelvic fractures do not have urine bladder injuries. Based on our study results we do not recommend the routine utilization of CT cystography in this unique population.

Wandering spleen: a rare complication of sleeve gastrectomy.

The spleen is an intraperitoneal organ typically located in the left upper quadrant. Ectopic ('wandering') spleen refers to the displacement of the spleen from its normal anatomical location to another region in the abdominal cavity or pelvis. It's a relatively rare condition with no clear aetiology. We present, here, a case of a wandering spleen following sleeve gastrectomy in a 23-year-old female patient, whose spleen, prior to this event, was demonstrated by imaging in a normal anatomical position. A splenectomy was performed, and after an uneventful postoperative period, the patient was discharged. No similar case description was found in the relevant medical literature. Possible causes and decision-making process are discussed. We conclude that the wandering spleen phenomenon should be considered in the differential diagnosis of patients presenting with abdominal pain and new abdominal mass following sleeve gastrectomy.

[CONTRIBUTION OF CONVENTIONAL CHEST/ABDOMINAL PLAIN FILMS FOR THE DECISION-MAKING PROCESS IN PATIENTS WITH PREVIOUS ABDOMINAL SURGERIES, WHO HAVE SUSPECTED GASTROINTESTINAL PERFORATION].

INTRODUCTION: Gastrointestinal perforation is a well-known phenomenon among patients presented to emergency rooms. Common causes for perforation are gastric and duodenal ulcers, colon tumors and trauma. Some patients are operated on immediately due to the clear clinical picture of acute abdomen. The most accurate imaging is the abdominal CT scan. Conventional X-rays remain the first choice in the case of GI tract perforations. Our clinical observation is that in many cases X-ray studies are not sufficient for the decision-making process in patients with previous abdominal surgeries. AIMS: The purpose of this study was to evaluate the impact of X-rays on the decision-making process in patients with previous abdominal surgery. METHODS: A retrospective evaluation was conducted of chest/abdominal X-rays, computed tomography findings and the surgeries reports of patients admitted due to GI perforation. RESULTS: The study population of 69 patients was divided into two groups. In group 1: patients without previous abdominal surgery, X-rays of 27 patients (69.2%) were found positive for free air. In group 2: patients with previous abdominal surgeries, 16 patients demonstrated free air on chest/abdominal X-rays. The sensitivity in group 2 (53.3%) was found significantly lower compared to group 1 (69.2 %). The difference between the groups was not statistically significant; 19 of 30 (63.3%) patients with previous abdominal operations needed abdominal CT scan before final surgical decision in comparison to 38.5% of the patients without previous abdominal operations. CONCLUSIONS: Based on these results we recommend not routinely performing X-rays in patients with previous abdominal surgery. Urgent computed tomography should be the first imaging modality. DISCUSSION: In patients with previous abdominal surgeries, free air is visible only in half the patients in routine X-ray imaging. A significant number of those patients needed abdominal CT scan. Our study demonstrated that chest and abdominal plain radiography films are insufficient for the decision-making process in patients with previous abdominal operations. A multi-center prospective study is required in order to validate our findings.

[HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]

INTRODUCTION: Electrical injury is an infrequent but potentially devastating form of multisystem injury associated with high morbidity and mortality. Despite significant improvement in injury prevention and implementation of safety protocols at work places, electrical injury accounts for more than 500 deaths per year in the United States with a mortality rate of 10-30%. Electrical injuries are traditionally divided into low-voltage electric power injuries (less than 1,000V) and high-voltage )more than 1,000V). In contrast with other types of trauma, high voltage injuries present some rather unique problems that require a high index of suspicion and awareness of all possible manifestations. Electrical injury should be viewed and managed as a multisystem injury, since there is virtually no organ that is protected against it. The most essential concept of successful management of patients who sustain high voltage injury is that there is no relationship between skin burn, vital organs involvement and severity of injuries. This review aims to provide a comprehensive overview of reported high voltage electrical injury manifestations in an attempt to gain a better understanding of the distribution of morbidity and clinical features of the injury. We tried to encompass most of the reported cases of high voltage electrical injuries in order to give the readers a general view of the spectrum of injuries that can be encountered in victims suffering high voltage current, aiming to increase the awareness of emergency care and trauma teams to this rare but dangerous and potentially fatal type of injury.

Abdominal stab wound injury in children: Do we need a different approach?

BACKGROUND: Penetrating stab wounds in children are relatively rare and no clear recommendations for the optimal evaluation have been devised. An acceptable traditional approach to the patient with an abdominal stab wound who does not require urgent surgery is selective nonoperative management and serial exams. The use of routine computed tomography remains an actively utilized investigation for these patients at many institutions. PURPOSE: We hypothesize that the approach to pediatric stab wound victims should be distinctly different than that of adult counterparts in order to minimize radiation exposure. METHODS: A retrospective cohort study involving abdominal stab wounds among pediatric trauma patients (age < 14) compared with adults between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry. RESULTS: A total of 92 children and 4444 adults were identified from the registry for inclusion. Among the children 20 (21.7%) patients had intraabdominal injury compared to 1730 (38.9%) among adult counterparts. Four children were hemodynamically unstable, two of them were referred directly to operating room and two others were treated without surgery. Among the remaining 88 children there was no observed mortality. CONCLUSIONS: The majority of pediatric stab wounds trauma victims have minor abdominal injuries. We do not recommend the routine utilization of abdominal CT scan in the evaluation of abdominal stab wounds. Observation with serial exams and minimization of radiation exposure from CT are warranted in this unique population. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: 3.

Evaluation of differences in injury patterns according to seat position in trauma victims survived traffic accidents.

PURPOSE: Investigation of injury patterns epidemiology among car occupants may help to develop different therapeutic approach according to the seat position. The aim of the study was to evaluate and compare differences in the incidence of serious injuries, between occupants in different locations in private cars. METHODS: A retrospective study including trauma patients who were involved in motor vehicle accidents and admitted alive to 20 hospitals (6 level Ⅰ trauma centers and 14 level Ⅱ trauma centers). We examined the incidence of injures with abbreviated injury score 3 and more, and compared their occurrence between seat locations. RESULTS: The study included 28,653 trauma patients, drivers account for 60.8% (17,417). Front passenger mortality was 0.47% higher than in drivers. Rear seat passengers were at greater risk (10.26%) for traumatic brain injuries than front seat passengers (7.48%) and drivers (7.01%). Drivers are less likely to suffer from serious abdominal injuries (3.84%) compared to the passengers (front passengers - 5.91%, rear passengers - 5.46%). CONCLUSION: Out of victims who arrived alive to the hospital, highest mortality was found in front seat passengers. The rate of serious chest injuries was higher as well. Rear seat passengers are at greater risk for serious traumatic brain injuries. All passengers have a greater incidence of abdominal injuries. These findings need to be addressed in order to develop "customized" therapeutic policy in trauma victims.

Evaluation of nasogastric tubes to enable differentiation between upper and lower gastrointestinal bleeding in unselected patients with melena.

Gastrointestinal (GI) bleeding is a common surgical problem. The aim of this study was to evaluate how insertion of the nasogastric tube may enable differentiation between upper and lower GI bleeding in patients with melena. A retrospective study involving patients admitted to our surgery division with a melena was carried out between the years 2010 and 2012. A total of 386 patients were included in the study. Of these, 279 (72.2%) patients had negative nasogastric aspirate. The sensitivity of examination of nasogastric aspirate to establish the upper GI as the source of bleeding was only 28% and the negative predictive value of a negative nasogastric aspirate was less than 1%. Most patients who initially presented with melena and were found to have upper GI bleeding had a negative nasogastric aspirate. Insertion of a nasogastric tube does not affect the clinical decision to perform upper endoscopy and should not be routinely carried out.