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Updated: Dec 8 2021

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
  • DIAGNOSIS
    • 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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