Diaphragmatic injury. A clinical review.

OBJECTIVE: Recent experience at King Fahad Hospital of the University, Al-Khobar University, Kingdom of Saudi Arabia was reviewed to identify the pitfalls in the diagnosis of diaphragmatic injuries, and attempt to develop a scheme by which early diagnosis is achieved in order to avoid the sequelae of delayed presentations. METHODS: A retrospective chart review of patients admitted to the surgical service, with the diagnosis of diaphragmatic injury was undertaken during the period June 1994 through to June 1999. RESULTS: The total number was 8 patients, and the age ranged between 6-71 years. Of these patients 5 were diagnosed immediately post-traumatic, 2 with delayed presentation, and one with recurrent post-traumatic repair. This case was excluded. Six patients presented following blunt and one after penetrating trauma. Rupture occurred mainly on the left dome of the diaphragm in 5 patients and on the right in 2. Complications ranged from mild chest symptoms to severe respiratory and multi-system involvement. CONCLUSION: Diaphragmatic injuries occurred in 2%-5% of multiple trauma victims. It is considered a predictor of serious associated injuries, However, as many as 10%-30% are missed during the initial evaluation. A high index of suspicion is required, and judicious use of diagnostic aids should be employed to reach early diagnosis to avoid the sequelae of missed injuries.

Microbiology of postoperative wound infection: a prospective study of 1770 wounds.

A prospective study of postoperative wound infection was carried out over a 12-month period. Intra-operative swabs from the patients' anterior nares, the opened viscus and parietes were cultured using standard bacteriological techniques. Of the 1770 wounds studied, 167 (9.4%) became infected. Wound infection rates, according to clinical wound types, were clean 5.9%, clean-contaminated 10.7%, contaminated 24.3% and dirty 52.9%. The figures according to microbiological wound types were clean 4.7%, and potentially, lightly and heavily contaminated 15.3%, 22.1% and 30.2% respectively. The commonest causative organisms were Staphylococcus aureus 23.7%, Escherichia coli 16.9%, Staphylococcus epidermidis 13.5% and Pseudomonas aeruginosa 13.0%. When isolated intra-operatively, Enterobacter spp., Proteus spp., Klebsiella spp. and P. aeruginosa appeared to have a high probability of causing postoperative wound infection, but the intra-operative isolation of Bacteroides sp. was a poor predictor of subsequent wound infection.

Prophylaxis against post-appendicectomy wound infection. A controlled clinical trial of intravenous (i.v.) metronidazole versus i.v. metronidazole-ampicillin-gentamicin.

A controlled clinical trial has been conducted on three doses of intravenous (I.V.) metronidazole alone and of I.V. metronidazole-gentamicin-ampicillin combined in wound infection following appendicectomy for non-perforated appendicitis. Of the 205 patients entered, 154 were evaluable. There were 118 males and 36 females (3.3:1), their mean age was 24 +/- 9.8 years, and mean Quetelet index was 23 +/- 5. The two groups were comparable in terms of seven potential risk factors: age, sex, Quetelet index, mean duration of operation, wound contamination, nasal carriage of S. aureus, and operating surgeon's rank. The over-all wound infection rate was 10.4%. There were two delayed infections in each treatment group. We found no difference between the two treatment groups in terms of wound infection and delayed wound infection. No adverse drug reaction was seen. We conclude that the two regimens are equally convenient, safe, effective, and reliable. But, metronidazole alone is the less expensive of the two.