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Unusual clinical course Background: Foreign body aspiration is one of the life-threatening conditions seen in the adult and pediatric population with most cases occurring within the first 3 years of life. It can result in serious complications or even lead to death. Bronchoscopic removal has been described as the management of choice. Spontaneous expectoration could happen, though it is extremely rare. Case Report: A 7-year-old male presented to the Emergency Department within 3 hours of aspirating a metallic nail. He had a brief choking episode at the beginning and remained asymptomatic thereafter. The initial chest x-ray showed a metallic foreign body (nail) at the retrocardiac area with patent centralized tracheobronchial tree. No radiologic signs of pneumothorax nor pleural or pericardial effusion. Computed tomography (CT) scan was performed the night of admission and revealed a 2 cm nail at the posterior basal segment of the left lower lobe bronchus. Bronchoscopy, thoracoscopic-removal, and possible thoracotomy were discussed. Management options and complications were explained. The parents preferred to wait and observe before making any decision regarding surgical intervention. Surprisingly, while in the hospital, the patient had repetitive cough and the nail was spontaneously expectorated. Conclusions: Urgent bronchoscopy for foreign body aspiration is mandatory as early as possible, however, expectant management in asymptomatic distal airway foreign body aspiration is reasonable. Spontaneous expectoration is a possible outcome though extremely rare.

Background Trauma in pediatric age group is a major cause of morbidity and mortality. The causes and magnitude of pediatric trauma differs from region to region. Many studies have focused on blunt injuries but not on penetrating trauma. Our aim is to identify the patterns, and outcome of pediatric thoracic penetrating injuries in a single trauma center. Methods We conducted a retrospective chart review of pediatric patients who presented with thoracic penetrating injuries from the year 2001 till 2016 in a level 1 trauma center. Patients aged 18 years or less who presented to our emergency department with thoracic penetrating injury were included. Those transferred from other institutions were excluded Results The total number of patients included with penetrating thoracic injuries were 89. Mean age was 15.5 years. One female the rest were males. The most common mechanism of injury is stab wound by knives in 80%, then Gunshot in 12%. Main mode of transport to emergency department was by private vehicles in 75.3%. Type of injuries sustained were pneumothorax 70.7%, hemothorax 25.8%, diaphragmatic injury 5.6%, hemopericardium 4.49%, lung contusion and laceration 7.8%, cardiac injury 4.49%, major vessel injury 3.4%, pneumomediastinum 2.2%, esophageal injury 1.1%, and rib Fractures 1.1%. In the emergency department, endotracheal intubation required in 13.5%, chest tube insertion 73%, blood transfusion for resuscitation 16.8%, emergency thoracotomy 2.2%, pericardiocentesis 1.1%. Surgical intervention was required in 17%. Mean length of hospital stay 3.87 days ± 4.86 SD. 93% of patients did not require intensive care unit admission. Mortality was observed in 3.4% were all had injuries to either heart, aorta or inferior vena cava. Conclusion In our institution, thoracic injuries were found uncommon and represent 25% of all penetrating trauma. Most sustained penetrating thoracic injuries can be managed nonoperatively safely. However, prompt resuscitation and intervention are required to identify and manage life-threatening ones.

Purpose To evaluate saline enema success and the effectiveness of irrigation system in managing fecal soiling in pediatric patients with colorectal condition. Methods A retrospective cohort chart review of pediatric patients attending a bowel management clinic in a tertiary center in Riyadh, Saudi Arabia over 15months period (January 2022- March 2023). We included all pediatric patients (age 3–18 years) enrolled in bowel management program at our center, who are on saline enema protocol using the available irrigation system. Antegrade colonic enema or retrograde enema were used in managing fecal soiling. Patients with colorectal conditions having true fecal incontinence or constipation with pseudo incontinence were enrolled. Idiopathic constipation, spina bifida, neurogenic disorder and cloaca exstrophy were excluded. Results Forty-one patients who attended the clinic over one year were included. Thirty- five (85.4%) had true fecal incontinence, and 6 (14.6%) had constipation (overflow pseudo-incontinence). The majority were boys 30 (73.2%). Underlying disorders were anorectal malformation 27 (65.9%), cloaca anomaly 8 (19.5%), and Hirschsprung’s disease 6 (14.6%). Methods used in irrigation/saline enema administration varied, 31 (12.7%) were on trans-anal (regular Foley catheter, balloon tip catheter, cone tip catheter), 8 (19.5%) were on antegrade irrigation (Malone, neo-Malone and cecostomy) using (Nelton/feeding tube catheter), and 2 (4.9%) were on trans-stoma (cone tip catheter). Thirty-five (85.4%) succeeded and remained completely clean in the underwear for 24 hours till the next enema, 3 (7.3%) failed and were not clean between enema, 2 lost follow up, and 1on hold. The reasons for failure were either compliance or short colon or damaged internal canal. The utilization of different irrigation systems improved the noncompliance rate in 7 patients (2.9%). Conclusion Bowel management program has proved successful in many countries since its implementation. The underlying conditions remain the main determinant of success as well as a significant factor in the failure of any program. However, considering the compliance in pediatric age group, few are still facing some degree of social embarrassment with accidents. When it comes to compliance, utilizing different available irrigation systems is helpful.