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Diaphragmatic Injury
Aka: Diaphragmatic Injury, Diaphragmatic Rupture, Rupture of Diaphragm
- Causes
- Blunt Trauma to anterior Abdomen (MVA, fall from height, Contact Sports)
- Increased abdominal pressure disrupts diaphragm
- High risk of pre-hospital mortality
- Associated injuries
- Large vessel injury (inferior vena cava, hepatic vein, aorta)
- Hemo-Pneumothorax (90% of cases), liver and Spleen injuries (25%)
- Pelvic Fracture (40%), long bone Fracture (75%) and multiple Rib Fractures
- Closed Head Injury (42%)
- Penetrating Trauma (Gunshot Wound, Stab Wound)
- May occur from either Thoracic Injury or Abdominal Injury
- Typically small (<2 cm) and linear (and often occult)
- Smaller, more occult diaphragm injuries at risk for Incarcerated Hernias
- Surgical complication
- Symptoms
- Shoulder Pain
- Epigastric Pain
- Shortness of Breath
- Chest Pain
- Signs
- Respiratory distress
- ScaphoidAbdomen
- Bowel sounds in chest
- Imaging: Chest XRay
- First-line study
- Findings
- Stomach or bowel appears in the left chest
- Nasogastric Tube curled in the left chest
- Misdiagnoses (Diaphragmatic Rupture look-alikes)
- Elevated left hemidiaphragm
- Left loculated Pneumothorax
- Left subpulmonary hematoma
- Imaging: CT Chest (or CT Chest, Abdomen and Pelvis)
- Left sided Diaphragmatic Injury is most common
- Right side is shielded by the liver
- Bilateral injury is uncommon
- Efficacy (insufficient to completely exclude diaphragmatic perforation)
- Test Sensitivity: 82%
- Test Specificity: 88%
- Yucel (2015) Injury 46(9): 1734-7 +PMID:26105131 [PubMed]
- Management
- Emergent Trauma surgical Consultation and evaluation (Laparoscopy, thoracoscopy)
- Negative imaging (including CT) does not exclude Diaphragmatic Injury
- Laparoscopy and thoracoscopy are indicated in high suspicion cases (despite negative imaging)
- Missed Diaphragmatic Injury may result in serious complications
- Complications
- Herniation of Stomach, bowel, liver of Spleen
- Delayed diagnosis and repair
- Difficult repair outside the acute phase
- High morbidity and mortality from missed Diaphragmatic Rupture
- Prognosis
- Overall mortality
- Penetrating Diaphragmatic Injury: 4.3%
- Blunt Diaphragmatic Injury: 37%
- References
- Cowling and Mullins (2017) Crit Dec Emerg Med 31(10): 3-10
- Dwivedi (2010) J Emerg Trauma Shock 3(2): 173–6 +PMID:20606795 [PubMed]