In this study, we review outcomes for 15 patients with self-inflicted submental gunshot wounds requiring free flap reconstruction. Patients presented to two tertiary care centers over a 7-year period. Mean age was 46 years (range, 16 to 76 years), 67% (n ¼ 10) had a psychiatric history, and four were known to abuse illicit substances. Patients with oromandibular involvement required on average a total of 2.8 procedures, and those with midface (3.7) or combined defects (6) required more total procedures (p ¼ 0.21). Donor sites included osteocutaneous radial forearm (n ¼ 8), fibula (n ¼ 4), fasciocutaneous radial forearm (n ¼ 5), and anterior lateral thigh (n ¼ 1). Median length of hospitalization was 8 days. Overall complication rate was 33% (n ¼ 5), and included hematoma (n ¼ 1), fistula (n ¼ 1), and mandibular malunion (n ¼ 2). Most patients were able to tolerate a regular or soft diet (92%), maintain oral competency (58%), and demonstrate intelligible speech (92%) at a median time to follow-up of 12 months. Despite the devastating nature of this injury, free flap reconstruction of self-inflicted submental gunshot wounds results in acceptable functional results for the majority of patients.

Pediatric stroke is relatively rare, with approximately 1000 childhood strokes in the United States per year. However, the occurrence of stroke in children leads to significant morbidity and mortality, warranting the development proven screening tools, protocols, and treatment options. Because significant delays in seeking medical attention can occur, time to recognition of pediatric stroke in the emergency department is uniquely challenging and critical. Once recognized, a trained multidisciplinary team with a multifaceted approach is needed to provide the best possible outcome for the patient. Key elements of the pediatric stroke protocol should include recognition tools, stroke alert mechanism, stroke order sets, timely imaging, laboratory evaluation, and treatment options. Substantial advancements have been made in the field of pediatric stroke protocols mainly due to formation of international consortiums and clinical trial. Despite significant progress, treatment options remain controversial.

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randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these).Results: A total of 204 patients with biphasic anaphylaxis were identified with follow-up. All patients either experienced confirmed biphasic or protracted reactivity. Average time to onset of the second phase was 10.2 hours (CI: 2-38). Time to resolution of initial symptoms was significantly longer for biphasic reactors (112 vs 133 minutes; P ¼ .03). All biphasic and protracted anaphylactoid reactions received corticosteroids. Most importantly, patients who received steroid administration vs those who did not were equally as likely to experience protracted and biphasic reactions (P¼.04).Conclusions: Biphasic and protracted anaphlyaxis is a potential outcome for those experiencing anaphylactoid reactions. Prevention of this outcome is primarily unproven and based on observed data; there is no beneficence of steroid administration in the prevention of biphasic/protracted anaphlaxis. This neccessitates the need for further investigation into their efficacy.