Delayed presentation of traumatic right-sided diaphragmatic hernia after abdominoplasty.

Traumatic diaphragmatic hernias are rare and challenging to diagnose. Following trauma, diagnosis may occur immediately or in a delayed fashion. It is believed that left traumatic diaphragmatic hernias are more common as a result of the protective right-sided anatomic lie of the liver. If unrecognized, traumatic diaphragmatic injuries are subject to enlarge over time as a result of the normal pressure changes observed between the thoracic and abdominal cavities. Additionally, abrupt changes to the pressure gradients, such as those which occur with positive pressure ventilation or surgical manipulation of the abdominal wall, can act as a nidus for making an asymptomatic hernia symptomatic. We report our experience with a delayed traumatic right-sided diaphragmatic hernia presenting with large bowel incarceration two months after abdominoplasty. In our review of the literature, we were unable to find any reports of delayed presentation of a traumatic right-sided diaphragmatic hernia occurring acutely following abdominoplasty.

Does prehospital prolonged extrication (entrapment) place trauma patients at higher risk for venous thromboembolism?

BACKGROUND: The aim of this study was to determine if prolonged immobility and tissue injury from a prehospital entrapment would place patients at higher risk for in-hospital venous thromboembolism (VTE) complications. It was hypothesized that entrapment would increase in-hospital VTE. METHODS: All consecutive trauma admissions over a 10-year period were retrospectively reviewed. Patients were divided into those who were entrapped according to defined prehospital criteria for entrapment and those who were not entrapped. The complications of deep vein thrombosis and pulmonary embolism were noted. RESULTS: There were 15,159 patients admitted between 1999 and 2008. Of these, 1,176 met the criteria for prehospital entrapment. Those patients who met the criteria for entrapment had a significant risk for developing both deep vein thrombosis (P < .001, χ(2) test) and pulmonary embolism (P = .005, Fisher's exact test). Multiple logistic regression analysis revealed entrapment to be a significant contributing risk factor to the development of VTE (odds ratio, 1.54; P = .04). CONCLUSIONS: Patients with prehospital entrapment are at higher risk for VTE. These results mandate aggressive VTE prophylaxis in patients with histories of prehospital entrapment.

In a mature trauma system, there is no difference in outcome (survival) between Level I and Level II trauma centers.

BACKGROUND: The state of Pennsylvania (PA) has one of the oldest, most well-established trauma systems in the country. The requirements for verification for Level I versus Level II trauma centers within PA differ minimally (only in the requirement for patient volume, residency, and research). We hypothesized that there would be no difference in outcome at Level I versus Level II trauma centers. METHODS: Odds of mortality for 16 Level I and 11 Level II hospitals in PA over a 5-year period (2004-2008) was computed using a random effects logistic regression model. Overall adjusted mortality rates at Level I versus Level II hospitals were compared using the nonparametric Wilcoxon's rank sum test. The crude mortality rates for 140,691 patients over the 5-year period were similar (5.07% Level II vs. 5.48% Level I), but statistically significant (odds ratio mortality at Level I = 1.084, p = 0.002 Fisher's exact test). RESULTS: Although Level I centers had on average crude mortality rates that were higher than those of Level II centers, median adjusted mortality rates were not different for the two types of centers (Wilcoxon's rank sum test). Performance of Level I versus Level II shows considerable variability among centers (basic random effects model, age, blunt/penetrating, and Injury Severity Score [ISS]). However, Level II centers seem no different from Level I. CONCLUSION: As trauma systems mature, the distinction between Level I and Level II trauma centers blurs. The hierarchal descriptors "Level I" or "Level II" in a mature trauma system is pejorative and implies in those hospitals labeled "Level II" as inferior, and as such should be replaced with nonhierarchal descriptors.