Impaling injury in perineum with wooden foreign body leading to extensive Necrotizing Soft Tissue Infection: A Case ReportIntroductionPenetrating perineal trauma is rare but carries high risk due to contamination, hidden tracts, and proximity to major vessels and viscera. Retained organic foreign bodies, particularly wood, are often radiolucent and can perpetuate infection or erode into vascular structures. Necrotizing soft tissue infection (NSTI) is a devastating complication with significant mortality.Case PresentationA 53-year-old woman from rural Nepal presented eight days after falling onto a tree branch, sustaining a perineal impalement. Her wound had been sutured primarily at a local center. She developed severe pain, swelling, foul discharge, and rectal bleeding. On exploration, extensive necrotic tissue and foul collections were found. MRI revealed a pelvic extension of infection but missed the wooden fragments. During subsequent staged debridements, two retained wooden pieces were discovered. Their removal precipitated massive pelvic hemorrhage requiring ligation of the right internal iliac artery. A loop colostomy was fashioned to prevent fecal contamination. After multiple surgeries and 53 days of inpatient care, she was discharged in stable condition.DiscussionThis case demonstrates how premature closure of contaminated wounds and missed radiolucent foreign bodies can lead to life-threatening NSTI and vascular injury. Diagnosis is primarily clinical, as systemic signs may be late.ConclusionManagement of penetrating perineal trauma requires early suspicion, avoidance of primary closure, aggressive staged debridement, and preparedness for vascular complications.Keywords: Perineal injury, Wooden foreign body, Necrotizing soft tissue infection, Impalement, Vascular complication

IntroductionTransorbital Penetrating Intracranial Injury (TOPI) is one of the rare cases of traumatic brain injury. The major cause of TOPI is the missiles such as bullets in the war. Non-missile foreign bodies such as iron rods, wood, nails, and needles are even more rare. 1-3Penetrating Brain Injuries are associated with high mortality and morbidity due to damage to important structures such as major vessels, and brainstem, as well as risk of infection. Vascular injury or injury to the brainstem might be fatal. The risk of infection is increased in the case of a wooden foreign body, although infection almost always occurs in delayed treatment. However, early treatment with surgical and nonsurgical approaches can reduce chances of infection and hemorrhage, therefore morbidity and mortality significantly. 3Here we present a unique case of transorbital penetrating intracranial injury caused by a wooden foreign body. Despite the complexity of such injury, our case demonstrated a successful clinical outcome with no long-term morbidity or mortality. This case report was prepared in line with SCARE guidelines. 4

INTRODUCTION Type 1 diabetes mellitus (T1DM) is an autoimmune disorder leading to the destruction of insulin producing pancreatic beta cells, resulting in elevated blood sugar levels 1. Polyuria, polydipsia and weight loss are the key presenting symptoms 2. A systematic review and meta-analysis reported the global T1DM prevalence of 9.5%, with an incidence of 15 per 100,000 people3. Diabetic ketoacidosis (DKA) is a grievous complication of diabetes mellitus caused by insufficient insulin, resulting in elevated blood glucose, ketonemia and acidosis. The overall DKA prevalence across 13 countries over 13 years was 29.9%, with a 3.5% prevalence in Nepal. 4,5.The most common risk factors leading to DKA include missed insulin doses and infections, while other factors like stress-inducing events or the initial onset of diabetes can also trigger DKA. The clinical manifestations of DKA encompass a range of symptoms, including nausea, severe vomiting, dehydration, polyuria, polydipsia, abdominal pain or discomfort, presence of acetone breath odor, Kussmaul breathing, overall profound fatigue with altered consciousness, disorientation, confusion or occasionally coma when the condition is severe 6. Typical diagnosing criteria for DKA include blood glucose greater than 250 mg/dl, arterial pH less than 7.3, serum bicarbonate less than 15 mEq/l, and the presence of ketonemia or ketonuria 7.Immediate intervention is crucial that includes restoring the circulatory volume, correcting electrolyte abnormalities, insulin therapy and addressing the underlying cause 8. Failure to promptly treat DKA can result in the breakdown of compensatory mechanisms and cause electrolyte abnormalities like hyponatremia, hyperkalemia and ultimately lead to life threatening complications including cerebral edema, acute respiratory distress syndrome, and sepsis.  Nursing management for a patient with Diabetic Ketoacidosis (DKA) involves a comprehensive approach that involves monitoring vital signs, blood sugar levels, and electrolytes, administering fluids, assessing renal function and mental status, monitoring intake output, checking for signs of infection, assessing lung sound; educating the patient on insulin injection techniques, medication compliance, promoting lifestyle changes like smoking cessation and diabetic diet9.In DKA, dilutional hyponatremia is common due to rising glucose level that creates osmolar gradient causing water to shift from cells into the intravascular space. However, on rare occasion, hypernatremia is found that happens when there’s a deficit of water intake and excessive loss of free water, which outweighs electrolyte loss through various factors10. This report emphasizes the significance of a fluid management strategy for DKA patients, even when encountering the unusual occurrence of hypernatremia.