Experiences that matter in bipolar disorder: a qualitative study using the capability, comfort and calm framework.

BACKGROUND: When assessing the value of an intervention in bipolar disorder, researchers and clinicians often focus on metrics that quantify improvements to core diagnostic symptoms (e.g., mania). Providers often overlook or misunderstand the impact of treatment on life quality and function. We wanted to better characterize the shared experiences and obstacles of bipolar disorder within the United States from the patient's perspective. METHODS: We recruited 24 individuals diagnosed with bipolar disorder and six caretakers supporting someone with the condition. Participants were involved in treatment or support services for bipolar disorder in central Texas. As part of this qualitative study, participants discussed their everyday successes and obstacles related to living with bipolar disorder during personalized, open-ended interviews. Audio files were transcribed, and Nvivo software processed an initial thematic analysis. We then categorized themes into bipolar disorder-related obstacles that limit the patient's capability (i.e., function), comfort (i.e., relief from suffering) and calm (i.e., life disruption) (Liu et al., FebClin Orthop 475:315-317, 2017; Teisberg et al., MayAcad Med 95:682-685, 2020). We then discuss themes and suggest practical strategies that might improve the value of care for patients and their families. RESULTS: Issues regarding capability included the struggle to maintain identity, disruptions to meaningful employment, relationship loss and the unpredictable nature of bipolar disorder. Comfort related themes included the personal perception of diagnosis, social stigma and medication issues. Calm themes included managing dismissive doctors, finding the right psychotherapist and navigating financial burdens. CONCLUSIONS: Qualitative data from patients with bipolar disorder helps identify gaps in care or practical limitations to treatment. When we listen to these individuals, it is clear that treatments must also address the unmet psychosocial impacts of the condition to improve patient care, capability and calm.

Facing Trauma and Surgical Emergency in Space: Hemorrhagic Shock.

Although the risk of trauma in space is low, unpredictable events can occur that may require surgical treatment. Hemorrhage can be a life-threatening condition while traveling to another planet and after landing on it. These exploration missions call for a different approach than rapid return to Earth, which is the policy currently adopted on the International Space Station (ISS) in low Earth orbit (LEO). Consequences are difficult to predict, given the still scarce knowledge of human physiology in such environments. Blood loss in space can deplete the affected astronaut's physiological reserves and all stored crew supplies. In this review, we will describe different aspects of hemorrhage in space, and by comparison with terrestrial conditions, the possible solutions to be adopted, and the current state of the art.

Impact of trauma centre capacity and volume on the mortality risk of incoming new admissions.

INTRODUCTION: Trauma centre capacity and surge volume may affect decisions on where to transport a critically injured patient and whether to bypass the closest facility. Our hypothesis was that overcrowding and high patient acuity would contribute to increase the mortality risk for incoming admissions. METHODS: For a 6-year period, we merged and cross-correlated our institutional trauma registry with a database on Trauma Resuscitation Unit (TRU) patient admissions, movement and discharges, with average capacity of 12 trauma bays. The outcomes of overall hospital and 24 hours mortality for new trauma admissions (NEW) were assessed by multivariate logistic regression. RESULTS: There were 42 003 (mean=7000/year) admissions having complete data sets, with 36 354 (87%) patients who were primary trauma admissions, age ≥18 and survival ≥15 min. In the logistic regression model for the entire cohort, NEW admission hospital mortality was only associated with NEW admission age and prehospital Glasgow Coma Scale (GCS) and Shock Index (SI) (all p<0.05). When TRU occupancy reached ≥16 patients, the factors associated with increased NEW admission hospital mortality were existing patients (TRU >1 hour) with SI ≥0.9, recent admissions (TRU ≤1 hour) with age ≥65, NEW admission age and prehospital GCS and SI (all p<0.05). CONCLUSION: The mortality of incoming patients is not impacted by routine trauma centre overcapacity. In conditions of severe overcrowding, the number of admitted patients with shock physiology and a recent surge of elderly/debilitated patients may influence the mortality risk of a new trauma admission.

Validity and severity thresholds for the depression subscale of the affective self rating scale: An equipercentile equating study using classical test theory.

BACKGROUND: The Affective Symptoms Scale (ASRS) is a unique instrument designed to separately measure depressive and manic symptoms in mood disorders. We validated the ASRS against the Patient Health Questionnaire (PHQ-9) and the Quick Inventory of Depressive Symptomatology (QIDS-16). METHODS: A retrospective study of 258 patients who completed the PHQ-9, QIDS-16 and ASRS as part of routine clinical care. To establish meaningful clinical thresholds for the depression subscale of the ASRS, it was equated with the QIDS and the PHQ-9. RESULTS: The depression subscale of the ASRS had significant positive correlations with the QIDS-16 and the PHQ-9 (respectively, r= 0.8, t[253] = 19.8, p < 0.001, and r= 0.8, t[245] = 28.2, p < 0.001). The equipercentile equating method with the PHQ-9 indicated that the thresholds corresponded to ASRS depression subscale scores of 5.4, 10.6, 16.1, and 23. Equating with the QIDS indicated that thresholds corresponded to ASRS depression subscale scores of 5.1, 11, 18.4, and 27.5. LIMITATIONS: Limitations include a small sample size that did not allow more detailed statistical analysis, such as Item Response Theory. The population is a heterogenous population at a university outpatient setting. CONCLUSIONS: The ASRS depression subscale significantly correlated with the PHQ-9 and QIDS-16. Our proposed threshold scores for the ASRS are 5, 11, 16 and 23 to indicated mild, moderate, severe and very severe depression respectively.

Incidence of healthcare-associated infections in patients with fever during the first 48 hours after decannulation from veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: Fevers following decannulation from veno-venous extracorporeal membrane oxygenation often trigger an infectious workup; however, the yield of this workup is unknown. We investigated the incidence of post-veno-venous extracorporeal membrane oxygenation decannulation fever as well as the incidence and nature of healthcare-associated infections in this population within 48 hours of decannulation. METHODS: All patients treated with veno-venous extracorporeal membrane oxygenation for acute respiratory failure who survived to decannulation between August 2014 and November 2018 were retrospectively reviewed. Trauma patients and bridge to lung transplant patients were excluded. The highest temperature and maximum white blood cell count in the 24 hours preceding and the 48 hours following decannulation were obtained. All culture data obtained in the 48 hours following decannulation were reviewed. Healthcare-associated infections included blood stream infections, ventilator-associated pneumonia, and urinary tract infections. RESULTS: A total of 143 patients survived to decannulation from veno-venous extracorporeal membrane oxygenation and were included in the study. In total, 73 patients (51%) were febrile in the 48 hours following decannulation. Among this cohort, seven healthcare-associated infections were found, including five urinary tract infections, one blood stream infection, and one ventilator-associated pneumonia. In the afebrile cohort (70 patients), four healthcare-associated infections were found, including one catheter-associated urinary tract infection, two blood stream infections, and one ventilator-associated pneumonia. In all decannulated patients, the majority of healthcare-associated infections were urinary tract infections (55%). No central line-associated blood stream infections were identified in either cohort. When comparing febrile to non-febrile cohorts, there was a significant difference between pre- and post-decannulation highest temperature (p < 0.001) but not maximum white blood cell count (p = 0.66 and p = 0.714) between the two groups. Among all positive culture data, the most commonly isolated organism was Klebsiella pneumoniae (41.7%) followed by Escherichia coli (33%). Median hospital length of stay and time on extracorporeal membrane oxygenation were shorter in the afebrile group compared to the febrile group; however, this did not reach a statistical difference. CONCLUSION: Fever is common in the 48 hours following decannulation from veno-venous extracorporeal membrane oxygenation. Differentiating infection from non-infectious fever in the post-decannulation veno-venous extracorporeal membrane oxygenation population remains challenging. In our febrile post-decannulation cohort, the incidence of healthcare-associated infections was low. The majority were diagnosed with a urinary tract infection. We believe obtaining cultures in febrile patients in the immediate decannulation period from veno-venous extracorporeal membrane oxygenation has utility, and even in the absence of other clinical suspicion, should be considered. However, based on our data, a urinalysis and urine culture may be sufficient as an initial work up to identify the source of infection.

Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure From Heatstroke.

BACKGROUND: Exertional heatstroke is an extremely rare cause of fulminant hepatic failure. Maximal supportive care has failed to provide adequate survival in earlier studies. This is particularly true in cases accompanied by multiorgan failure. METHODS AND MATERIALS: Our prospectively collected transplant database was retrospectively reviewed to identify patients undergoing liver transplantation for heatstroke between January 1, 2012, and December 31, 2016. We report 3 consecutive cases of male patients with fulminant hepatic failure from exertional heatstroke. RESULTS: All patients developed multiorgan failure and required intubation, vasopressor support, and renal replacement therapy. All patients were listed urgently for liver transplantation and were supported with the molecular adsorbent recirculating system while awaiting transplantation. All patients underwent liver transplantation alone and are alive and well, with recovered renal function, normal liver allograft function, and no chronic sequelae of their multiorgan failure at more than one year. CONCLUSION: Extreme heatstroke leading to whole-body organ dysfunction and fulminant liver failure is a complex entity that may benefit from therapy using the Molecular Adsorbent Recirculating System while waiting for liver transplantation as a component of a multidisciplinary, multiorgan system approach.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Pharmacologic Treatment Reduces Pressure Times Time Dose and Relative Duration of Intracranial Hypertension.

INTRODUCTION: Past work has shown the importance of the "pressure times time dose" (PTD) of intracranial hypertension (intracranial pressure [ICP] > 19 mm Hg) in predicting outcome after severe traumatic brain injury. We used automated data collection to measure the effect of common medications on the duration and dose of intracranial hypertension. METHODS: Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a single, large urban tertiary care facility, were retrospectively enrolled. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. The ICP data were collected automatically at 6-second intervals and averaged over 5 minutes. The percentage of time of intracranial hypertension (PTI) and PTD (mm Hg h) were calculated. RESULTS: A total of 98 patients with 664 treatment instances were identified. Baseline PTD ranged from 27 (before administration of propofol and fentanyl) to 150 mm Hg h (before mannitol). A "small" dose of hypertonic saline (HTS; ≤250 mL 3%) reduced PTD by 38% in the first hour and 37% in the second hour and reduced the time with ICP >19 by 38% and 39% after 1 and 2 hours, respectively. A "large" dose of HTS reduced PTD by 40% in the first hour and 63% in the second (PTI reduction of 36% and 50%, respectively). An increased dose of propofol or fentanyl infusion failed to decrease PTD but reduced PTI between 14% (propofol alone) and 30% (combined increase in propofol and fentanyl, after 2 hours). Barbiturates failed to decrease PTD but decreased PTI by 30% up to 2 hours after administration. All reductions reported are significantly changed from baseline, P < .05. CONCLUSION: Baseline PTD values before drug administration reflects varied patient criticality, with much higher values seen before the use of mannitol or barbiturates. Treatment with HTS reduced PTD and PTI burden significantly more than escalation of sedation or pain management, and this effect remained significant at 2 hours after administration.

Loop versus end colostomy reversal: has anything changed?

PURPOSE: Though primary repair of colon injuries is preferred, certain injury patterns require colostomy creation. Colostomy reversal is associated with significant morbidity and healthcare cost. Complication rates may be influenced by technique of diversion (loop vs. end colostomy), though this remains ill-defined. We hypothesized that reversal of loop colostomies is associated with fewer complications than end colostomies. METHODS: This is a retrospective, multi-institutional study (four, level-1 trauma centers) of patients undergoing colostomy takedown for trauma during the time period 1/2006-12/2012. Data were collected from index trauma admission and subsequent admission for reversal and included demographics and complications of reversal. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests. RESULTS: Over the 6-year study period, 218 patients underwent colostomy takedown after trauma with a mean age of 30; 190 (87%) were male, 162 (74%) had penetrating injury as their indication for colostomy, and 98 (45%) experienced at least one complication. Patients in the end colostomy group (n = 160) were more likely to require midline laparotomy (145 vs. 18, p < 0.001), had greater intra-operative blood loss (260.7 vs. 99.4 mL, p < 0.001), had greater hospital length of stay (8.4 vs. 5.5 days, p < 0.001), and had more overall complications (81 vs. 17, p = 0.005) than patients managed with loop colostomy (n = 58). CONCLUSIONS: Local takedown of a loop colostomy is safe and leads to shorter hospital stays, less intra-operative blood loss, and fewer complications when compared to end colostomy.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.(AU)

Responsiveness to therapy for increased intracranial pressure in traumatic brain injury is associated with neurological outcome.

In patients with severe traumatic brain injury, increased intracranial pressure (ICP) is associated with poor functional outcome or death. Hypertonic saline (HTS) is a hyperosmolar therapy commonly used to treat increased ICP; this study aimed to measure initial patient response to HTS and look for association with patient outcome. Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a large urban tertiary care facility were retrospectively enrolled. The first dose of hypertonic saline administered after admission for ICP >19mmHg was recorded and correlated with vital signs recorded at the bedside. The absolute and relative change in ICP at 1 and 2h after HTS administration was calculated. Patients were stratified by mortality and long-term (≥6 months) functional neurological outcome. We identified 46 patients who received at least 1 dose of HTS for ICP>19, of whom 80% were male, mean age 34.4, with a median post-resuscitation GCS score of 6. All patients showed a significant decrease in ICP 1h after HTS administration. Two hours post-administration, survivors showed a further decrease in ICP (43% reduction from baseline), while ICP began to rebound in non-survivors (17% reduction from baseline). When patients were stratified for long-term neurological outcome, results were similar, with a significant difference in groups by 2h after HTS administration. In patients treated with HTS for intracranial hypertension, those who survived or had good neurological outcome, when compared to those who died or had poor outcomes, showed a significantly larger sustained decrease in ICP 2h after administration. This suggests that even early in a patient's treatment, treatment responsiveness is associated with mortality or poor functional outcome. While this work is preliminary, it suggests that early failure to obtain a sustainable response to hyperosmolar therapy may warrant greater treatment intensity or therapy escalation.

Longitudinal associations between depression and functioning in midlife women.

Associations between depression and impaired functioning are well known and have been documented in numerous clinical, primary care and epidemiological studies. Reviews of this research have focused on the elderly. Recent studies suggest that women become increasingly vulnerable during the menopausal transition to declines in physical and role function and increases in depressive symptoms. The purpose of the current research is to review the literature since 1966 for studies examining the association between depression and physical and psychosocial impairment in midlife women. We selected only longitudinal studies that had the potential to elucidate the nature of the complex relationship between depression and functioning. Results of the review indicate evidence for bi-directional associations between depression and functioning in middle-aged women. However, the studies are only broadly informative. Most adjusted for only a limited group of factors that could be associated with both depression and functioning. None of them directly examined potential moderators or mediators of the relationship between depression and impaired functioning.

Penetrating cardiac injury.

It is understood that penetrating cardiac trauma is a highly lethal injury and those surviving to hospital have an overall mortality approaching 80%. Reported mortality figures vary widely and are extremely dependent on mechanism of wounding, cardiac chambers involved and possibly the presence of cardiac tamponade. Despite significant advances in prehospital care, operative techniques, and intensive care management, the mortality has not changed over several decades. This article will review the anatomic regions of concern for a cardiac injury, clinical presentation, and physical findings. The need for an expeditious evaluation and modalities available including, plain radiographs, sub-xiphoid window, and echocardiography will be considered. Options for surgical exposure, technical details of repairing cardiac injuries, and special circumstances such as injury adjacent to a coronary artery and intra-cardiac shunts are discussed in detail. Outcome data and future directions in managing this challenging injury are also examined.

Multidisciplinary approach for patients with pelvic fractures and hemodynamic instability.

The hemodynamically unstable patient with a pelvic fracture presents a diagnostic and therapeutic challenge. The care of these patients requires a unique multidisciplinary approach with input and expertise from many different specialists. An understanding of pelvic anatomy and fracture patterns can help guide the diagnostic evaluation and treatment plan. The initial management of these patients must focus on rapid airway and hemorrhage control while preparing for ongoing blood loss. Rapid temporary fracture stabilization with simple bedside modalities is crucial in limiting additional blood loss. An exhaustive search must also be performed to evaluate for concomitant injuries that commonly accompany major pelvic fractures and the treatment of these other injuries must be appropriately prioritized. For patients who are unresponsive to standard resuscitation and bedside attempts at limiting hemorrhage, angiographic embolization is often utilized as the next step to attain hemodynamic stability. The key to successful management of these patients lies in the careful coordination of different specialists and the expertise that each brings to the clinical care of the patient.

Pattern of injury from personal watercraft.

Injury from personal watercraft has continued to increase. Prior attempts to delineate patterns of injury and relative frequencies have yielded varied results. We retrospectively reviewed Trauma Registry data and charts of all patients who suffered personal watercraft injury treated at the R. Adams Cowley Shock Trauma Center between August 1996 and January 2001. Patient demographics included mechanism of injury, injuries sustained, and outcomes. Attempts were made to correlate events around the injury and injury pattern. During the study period 24 patients were treated. Mechanisms consisted of direct collision, fails from the watercraft, handlebar straddle injuries, axial loading, and hydrostatic jet injury. Traumatic brain injury was most common occurring in 54 per cent of patients. Spinal injury was also common occurring in 29 per cent of patients. Axial loading from falls while wave jumping seemed to correlate with skeletal injury. Thoracolumbar spine injury were often skeletally unstable requiring either brace or operative fixation. Inexperience and reckless behavior were found to be the greatest contributing factors. Substance abuse did not influence injury.

Group A Streptococcus (GAS) soft-tissue infections: a lethal organism on the rise.

Several reports over the past decade have suggested that there has been an increase in the number of invasive streptococcal infections with young children and the elderly being at the highest risk. We evaluated the incidence of group A Streptococcus (GAS) and compared it with historic data collected at our institution. Prospective data were collected on patients diagnosed with GAS (with and without shock) admitted to a tertiary-care center from July 1995 to July 2000. Each patient was followed by an infectious disease specialist throughout the hospital stay. Definitions of streptococcal toxic shock syndrome (STSS) developed by the Centers for Disease Control and Prevention were used. Thirty-eight patients (mean age of 39+/-12) presenting with GAS soft-tissue infections were admitted to our institution over a 5-year period (7.6 patients per year). Fourteen (37%) were diagnosed with STSS. This represents a greater than fourfold increase in the average number of cases per year of patients diagnosed with GAS and a nearly 4.5 times greater increase in the annual number of patients diagnosed with STSS. The overall mortality of patients diagnosed with GAS was 13 per cent, which increased to 36 per cent in patients diagnosed with STSS. We conclude that there has been a significant increase in the incidence of GAS soft-tissue infections over the past 5 years at our institution. This may represent a new virulent strain, as the majority of these infections did not occur in typical high-risk patients at the extremes of their lives. Further epidemiologic population-based studies are needed to further delineate the severe nature of this problem.

Admission angiography for blunt splenic injury: advantages and pitfalls.

BACKGROUND: To analyze the use of admission angiography as a nonoperative adjunct for management of blunt splenic injury. METHODS: Retrospective chart review of all blunt splenic injuries to a Level I trauma center from March 1997 through July 1999. RESULTS: One hundred twenty-six patients underwent angiography for splenic injury. Eighty-six patients (68%) had a negative angiogram and were treated expectantly. Of these, seven patients (8%) required laparotomy, with a splenic salvage rate of 92%. Embolization was performed on 40 patients (32%) for evidence of vascular injury. Of these, three patients (8%) required laparotomy, for a total salvage of 92%. Repeat angiography was performed for suspicion of bleeding in 12 patients (10%), with 50% requiring embolization. Outcome based on CT grade demonstrated an average grade of 2.9, with a salvage rate of greater than 70% for grade IV and V injuries. CONCLUSION: Vascular injury increases with splenic injury grade. Embolization improves nonoperative salvage rates to 92%, even with high-grade injuries. Ten percent of patients require additional therapy including "second-look" angiography. A significant portion of patients with negative screening angiograms (10%) required either embolization or laparotomy to control delayed hemorrhage.

Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography.

BACKGROUND: The nontherapeutic laparotomy rate in penetrating abdominal trauma remains high and the morbidity rate in these cases is approximately 40%. Selective management, rather than mandatory laparotomy, has become a popular approach in both stab wounds and gunshot wounds. The advent of spiral technology has stimulated a reassessment of the role of computed tomography (CT) in many aspects of trauma care. We prospectively investigated the current utility of triple-contrast CT as a diagnostic tool to facilitate initial therapeutic management decisions in penetrating torso trauma. METHODS: We studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without definite indication for laparotomy, admitted to our trauma center during the 1-year period from 7/99 through 6/00. Patients underwent triple-contrast enhanced spiral CT as the initial study. A positive CT scan was defined as any evidence of peritoneal violation (free air or fluid, contrast leak, or visceral injury). Patients with positive CT, except those with isolated solid viscus injury, underwent laparotomy. Patients with negative CT were observed. RESULTS: There were 75 consecutive patients studied: mean age 30 years (range 15-85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound, 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (range 95-194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 nontherapeutic, and 1 negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization and two had thoracoscopic diaphragm repair. In patients with negative CT, 47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients. CONCLUSION: In penetrating torso trauma, triple-contrast abdominopelvic CT can accurately predict need for laparotomy, exclude peritoneal violation, and facilitate nonoperative management of hepatic injury. Adjunctive angiography and investigation for diaphragm injury may be prudent.