Diaphragmatic Injury

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