IGS, MS, HM, BR, EL, AMR, RS collect data at the sites. VT drafted the article; all other authors revised it critically for important or intellectual content, and approved the final version. Pre-publication

history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-227X/14/8/prepub Supplementary Material Additional file 1: Causes of Syncope. Click here for file(31K, doc) Acknowledgments We gratefully acknowledge Dr. Monica Taljaard PhD for statistical help, and Cathy Clement RN and Angela Marcantonio for their help in manuscript review, formatting, editing and submission. Inhibitors,research,lifescience,medical This study was funded by the Physicians Services Incorporated Foundation, the Canadian Institutes of Health Research; and The Ottawa Hospital Academic Medical Organization Innovation Fund. Dr. Thiruganasambandamoorthy received

salary support from the Heart and Stroke Foundation of Canada through the Jump Start Resuscitation Scholarship. Dr. Stiell is a University Health Inhibitors,research,lifescience,medical Research Chair, University of Ottawa. Dr. Rowe is supported by the CIHR as a Tier I Canada Research Chair in Evidence-based Emergency Medicine through the Government of Canada.
Thoraco-abdominal impalement is one of the most severe types of penetrating trauma, which is an under-reported yet increasing source of worldwide morbidity [1-5]. The Inhibitors,research,lifescience,medical management of impalement injuries poses specific challenges in pre-hospital care and transport. There is uniform agreement that the impaling Inhibitors,research,lifescience,medical object should be left in situ until management at a tertiary trauma center can be started [1-6]. Furthermore, targeted examination in the hospital should expedite critical, definitive treatments. We report the successful management of Inhibitors,research,lifescience,medical a complex impalement case in a rural emergency setting in Nepal. We discovered that thoroughly prompt diagnostic and treatment decisions in conjunction with a collaborative trauma team leads to a favorable outcomes in non-trauma care settings. Case–presentation A 10-year-old boy fell approximately fifteen feet from a coconut tree and done landed on a bamboo stake. The stake penetrated

the child at the left lower abdomen and exited at zone 1 of the neck resulting in nearly vertical impalement in the caudo-cephaloid direction. Bystanders uprooted the bamboo stake from the ground as gently as possible to prevent movement of the stick within the child’s abdominal and thoracic cavities as instructed AV-951 by a local health worker on scene. Emergency Medical Services (EMS) personnel in Nepal are only beginning specialized training beyond basic assessment and transfer, so further interventions such fluid resuscitation was not performed on scene or enroute. Further, due to the poor internal infrastructure as a result of financial and political instability in Nepal as well as the native rugged terrain, the transport time was approximately 3 hours.