Rosen & Barkin's 5-Minute Emergency Medicine Consult (210 page)

Uncommon; <1% of all traumatic injuries

• Lateral torso impact is 3 times more likely to result in ipsilateral diaphragmatic rupture than frontal impact.
  
• Suspect diaphragmatic injury:
  
  • Penetrating trauma to thoracoabdominal area
    
  • Injuries that cross plane of the diaphragm
    

DIAGNOSIS

• Vary depending on whether phase is acute, latent, or obstructive:
  
  • Acute:
    
    • Tachypnea
      
    • Hypotension
      
    • Absent or diminished breath sounds
      
    • Abdominal distention
      
    • Bowel sounds in chest
      
  • Latent:
    
    • Abdominal discomfort from intermittent herniation of abdominal contents into thorax
      
    • Abdominal pain that is worse postprandially
      
    • Exacerbated by lying supine
      
    • Pain radiating to left shoulder
      
    • Nausea, vomiting, or belching
      
  • Obstructive:
    
    • Severe abdominal pain
      
    • Obstipation
      
    • Nausea, vomiting
      
    • Abdominal distention
      
• Strangulated abdominal organs may perforate and spill abdominal contents into chest
  
• Respiratory compromise, sepsis, and death
  
• Obstructive injuries may present in delayed fashion
  

CXR may reveal herniated loops of bowel or other abdominal viscera in thorax:

• Pathognomonic finding is presence of nasogastric tube above diaphragm.
  
• Findings are often nonspecific:
  
  • Elevated hemidiaphragm
    
  • Irregular diaphragmatic contour
    
  • Mediastinal shift away from affected side
    
  • Unilateral pleural thickening or pleural effusion
    
  • Areas of atelectasis or consolidation at bases
    
  • Small hemothorax or pneumothorax
    
• 50% of initial CXRs may be normal.
  
• Diagnosis may be difficult in latent phase because of intermittent nature of herniation.
  
• Contrast studies of GI tract may be helpful.
  

• If diagnostic peritoneal lavage (DPL) is performed:
  
  • Red blood cell count of 1,000 RBC/mm
    ³
    is considered positive for diaphragmatic injury after penetrating trauma.
    
  • May provide false-negative result in up to 40% of patients with isolated diaphragmatic injury
    
• No lab studies confirm or rule out presence of diaphragmatic injury.
  

• CXR is diagnostic in 90% of cases in which herniation is present, but sensitivity is limited in absence of acute hernia.
  
• GI contrast studies are the most useful in diagnosing chronic herniation of abdominal contents through diaphragm.
  
• US may be used, particularly on right side with accompanying hepatic herniation.
  
• Conventional CT is rarely diagnostic and has poor sensitivity.
  
• New helical and multidetector CT (MDCT) modalities have much more success in diagnosing subtle diaphragmatic injuries.
  
• MRI is useful in its ability to visualize the diaphragm as a discrete structure, but is not practical in acute settings.
  

• Diagnostic pneumoperitoneography:
  
  • Air is injected through DPL catheter.
    
  • Pneumothorax on subsequent CXR is diagnostic of diaphragmatic injury.
    
  • Poorly tolerated by unstable patients and may require chest tube placement.
    
• Thoracoscopic and laparoscopic exploration may be indicated
  
  • Especially when suspicion is high despite negative imaging results
    
  • Facilitates minimally invasive repair
    

• Atelectasis
  
• Hemothorax
  
• Pneumothorax
  
• Pulmonary contusion
  
• Gastric dilation, intra-abdominal fluid
  
• Traumatic pneumatocele
  
• Subdiaphragmatic abscess
  
• Intrathoracic cyst
  
• Empyema
  
• Congenital eventration of the diaphragm
  

TREATMENT

• Follow advanced trauma life support (ATLS) protocols.
  
• If respiratory distress is present, immediate placement of a nasogastric tube may decompress herniated abdominal contents.
  

• Palpate within the chest cavity for visceral organs before inserting a chest tube.
  
• Patients with visceral perforations are septic and need aggressive resuscitation and antibiotic therapy.
  
• Empiric broad-spectrum antibiotics are indicated in the case of perforated viscera.
  
• Early surgical intervention is paramount.
  
• Minimally invasive repair may be possible in selected circumstances
  

• Gram-negative aerobes:
  
  • Gentamicin: Adults/peds: 2–5 mg/kg IV initial dose
    
• Gram-negative anaerobes:
  
  • Clindamycin: 900 mg (peds: 20–40 mg/kg/24h) IV q8h
    
  • Metronidazole: 1 g (peds: 15 mg/kg) IV load, then 500 mg (peds: 7.5 mg/kg) IV q6h
    
• Both aerobic and anaerobic:
  
  • Ampicillin/sulbactam: 1.5–3 g (peds: 100–400 mg/kg/24h) IV q6h
    
  • Cefotetan: 2 g (peds: 40–80 mg/kg/24h) IV q12h
    
  • Cefoxitin: 2 g (peds: 80–160 mg/kg/24h) IV q12h
    
  • Ticarcillin/clavulanate: 3.1 g (peds: 50 mg/kg/dose) IV q6h
    

FOLLOW-UP

• Patients with suspicion for diaphragmatic injury must be admitted to trauma surgery.
  
• Patients should be admitted to the monitored or ICU setting.
  

Patients with diaphragmatic injury or any significant suspicion for it must not be discharged from ED.

Patients with diaphragmatic injuries s/p repair must be followed by trauma surgeon to monitor for recurrence.

• Pediatric anatomic differences predispose to diaphragmatic injury via less severe mechanisms:
  
  • Thinner abdominal wall
    
  • More horizontal orientation of diaphragm
    
  • Greater cartilaginous rib component
    
• Incidence of right- and left-sided injury is equal.
  
• More likely to be isolated injury
  

• Overall mortality is 18–40% depending on mechanism.
  
• Highly associated with concomitant severe injuries to spleen and liver, hemothorax, pneumothorax, and pelvic fractures.
  
• Must have high suspicion for diaphragmatic injury with left-sided upper abdominal and lower thoracic penetrating trauma.
  
• Delayed diagnosis is associated with increased risk for herniation and strangulation of abdominal organs.
  
• Always obtain chest imaging.
  

• Al-Salem AH. Traumatic diaphragmatic hernia in children.
  Pediatr Surg Int
  . 2012;28:687–691.
  
• Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma.
  Am J Emerg Med
  . 2004;22(7):601–604.
  
• Desir A, Ghaye B. CT of blunt diaphragmatic rupture.
  Radiographics
  . 2012;32:477–498.
  
• Hanna WC, Ferri LE. Acute traumatic diaphragmatic injury.
  Thorac Surg Clin
  . 2009;19:485–489.
  
• Lewis JD, Starnes SL, Pandalai PK, et al. Traumatic diaphragmatic injury: Experience from a level I trauma center.
  Surgery
  . 2009;146(4):578–583.
  

CODES

• 862.0 Injury to diaphragm, without mention of open wound into cavity
  
• 862.1 Injury to diaphragm, with open wound into cavity
  

BASICS