Updated: 8/5/2019

Traumatic Diaphragmatic Injury

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Snapshot
  • A 20-year-old man presents to the emergency room after a high-speed motorcycle accident. He reports chest and shoulder pain and difficulty breathing. His blood pressure is 85/53 mmHg, pulse is 110/min, and respirations are 22/min. On physical exam, he is in significant distress. On chest exam, there is decreased breath sounds and bowel sounds on the left side. A focused assessment with sonography for trauma exam is performed, revealing displacement of abdominal organs into the thorax.
Introduction
  • Clinical definition
    • injury to diaphragm from blunt or penetrating trauma
  • Epidemiology
    • location
      • diaphragm creates a partition between the thorax and abdomen
        • three openings for
          • inferior vena cava
          • esophagus and vagus nerves
          • aorta, thoracic duct, and azygos vein
          • innervated by C3-C5 phrenic nerve
    • risk factors
      • motorcycle driving
  • Etiology
    • blunt trauma
      • more likely to affect aorta, lungs, bladder, and spleen
    • penetrating trauma
      • more likely to affect liver
  • Pathogenesis
    • pressure from high kinetic blunt trauma damages internal organs
    • penetrating trauma directly injures internal organs
Presentation
  • Symptoms 
    • depends on location and type of injury
    • chest pain
    • shoulder pain
    • shortness of breath
    • abdominal pain
    • nausea and vomiting
    • lightheadedness
  • Physical exam
    • depends on location and type of injury
    • abnormal thoracic findings
      • from abdominal organs displaced into thorax
      • bowel sounds on chest auscultation
      • decreased breath sounds
      • dullness to percussion
      • tachypnea
    • abnormal abdominal findings
      • from displaced abdominal contents
      • distended abdomen
      • tenderness to palpation
Imaging
  • Focused assessment with sonography for trauma (FAST) exam
    • indication
      • for all patients
    • findings
      • nonvisualization of abdominal organs that are displaced into the thorax
      • poor movement of diaphragm
  • Chest radiography
    • indication
      • for all patients
    • findings
      • rib fractures
      • pneumoperitoneum
      • diaphragmatic hernia
      • abdominal contents in thorax
  • Computed tomography (CT)
    • indication
      • often ordered for further evaluation of diaphragmatic injury
    • findings
      • diaphragmatic hernia
      • abdominal contents in thorax
Studies
  • Labs
    • trauma panel
  • Making the diagnosis
    • based on clinical presentation and imaging
Treatment
  • Management approach
    • treat with Advanced Trauma Life Support protocol
  • Medical
    • intravenous fluid resuscitation
      • indication
        • for all patients with hypotension
    • intravenous pain medication
      • indication
        • for all patients
  • Operative
    • exploratory laparoscopy or thoracoscopy and repair of diaphragm
      • indications
        • for all patients with penetrating trauma
        • for patients with blunt trauma is there is suspicion for diaphragmatic injury and need for repair
        • to prevent strangulation of abdominal contents
Complications
  • Cardiopulmonary arrest
  • Strangulation of abdominal organs
  • Death
 
 

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