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A 75-year-old woman with a past medical history of hypertension, presented to the emergency department (ED) with 12 h of persistent, non-radiating, diffuse abdominal pain. The patient had undergone a colonoscopy the day before. A chest X-ray study was done in the ED after the patient was sitting upright for at least 10 min, but shows no free air under the diaphragm (Fig. 1). The abdominal X-ray ( Fig. 2) shows air both on the inside and outside of the bowel wall consistent with free air, also known as the Rigler sign [1]. Additionally, there is a great amount of parahepatic air, outlining the lower liver edge. The Surgery service was consulted immediately for a possible bowel perforation, and the patient was taken to the operating room. Exploratory laparotomy revealed a perforated sigmoid colon. The patient underwent sigmoid colon resection, bowel re-anastomosis, and had an uncomplicated hospital course. She was discharged home in good condition. DiscussionPerforation of the bowel is a well-documented complication of colonoscopy. Recent estimates place perforation rates after a colonoscopy at 1 in 1,400 among all patients who have a colonoscopy [2]. Fortunately, the mortality rate Fig. 1 Upright chest X-ray with no free air under the diaphragm Fig. 2 Abdominal plain X-ray demonstrating two instances of Rigler sign (black arrows) and para-hepatic air (white arrow)

(ROSC) over the duration of resuscitation. Methods: We performed a retrospective cohort study of non-traumatic OHCA (<18 years) treated by EMS from the Toronto Regional RescuNET Epistry-Cardiac Arrest database from 2006 to 2015. We used competing risk analysis to calculate the probability of ROSC over the duration of resuscitation. We then used multivariable logistic regression to examine the role of Utstein factors and duration of resuscitation in predicting survival to hospital discharge. Candidate variables were limited to Utstein factors and duration of resuscitation due to the number of events. We used area under the receiver operating characteristic (ROC) curve (AUC) to determine the predictive ability of our logistic regression model. Results: A total of 658 patients met inclusion criteria. Survival to discharge was 10.2% with 70.1% of those children having a good neurologic outcome. The overall median time to ROSC was 23.9 min. (IQR 15.0,36.7). However, the median time to ROSC for survivors was significantly shorter than the time to ROSC for patients who died in hospital (15.9 (IQR 10.6 to 22.8) vs. 33.2 (IQR 22.0 to 48.6); P value <0.001). There was a decrease in the odds of survival of 14% per minute during the first 25 minutes of cardiac arrest. Older age (OR 0.9, 95% CI 0.86,0.99), and longer duration of resuscitation (OR 0.9, 95% CI 0.88,0.93) were associated with worse outcome while initial shockable rhythm (OR 5.8, 95% CI 2.0,16.5), and witnessed arrests (OR 2.4, 95% CI 1.10,5.30) were associated with improved patient outcome. The AUC for the Utstein factors was fair (0.77). Including duration of resuscitation improved the discrimination of the model to 0.85. Conclusion: Inclusion of duration of resuscitation improved the performance of our model compared to Utstein factors alone. However, our results suggest there are a number of other important factors for predicting patient outcome from pediatric OHCA.

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