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