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Diaphragmatic Trauma, Emergency Medicine

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Diaphragmatic Trauma, Emergency Medicine

Basics

Description

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

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.

  • Penetrating injury:Violation of the diaphragm by penetrating object (most commonly stab and gunshot wounds)May involve any portion of diaphragmSmaller defect compared with blunt injuries (more likely to be missed)
  • Blunt injury:Increased intra-abdominal or intrathoracic pressure is transmitted to diaphragm, causing rupture.Usually due to motor vehicle crashesInjuries are more commonly left-sided:Left hemidiaphragm has posterolateral embryologic point of weakness.Right hemidiaphragm is protected by liver.Injuries are larger than with penetrating injury (frequently between 5 and 15 cm in length).
  • Diaphragmatic defects do not heal spontaneously because of pleuroperitoneal pressure gradient:May exceed 100 cm H2O during maximal respiratory effortPromotes herniation of abdominal contents through rent in diaphragm and into chest
  • Violation of the diaphragm by penetrating object (most commonly stab and gunshot wounds)
  • May involve any portion of diaphragm
  • Smaller defect compared with blunt injuries (more likely to be missed)
  • Increased intra-abdominal or intrathoracic pressure is transmitted to diaphragm, causing rupture.
  • Usually due to motor vehicle crashes
  • Injuries are more commonly left-sided:Left hemidiaphragm has posterolateral embryologic point of weakness.Right hemidiaphragm is protected by liver.Injuries are larger than with penetrating injury (frequently between 5 and 15 cm in length).
  • Left hemidiaphragm has posterolateral embryologic point of weakness.
  • Right hemidiaphragm is protected by liver.
  • Injuries are larger than with penetrating injury (frequently between 5 and 15 cm in length).
  • May exceed 100 cm H2O during maximal respiratory effort
  • Promotes herniation of abdominal contents through rent in diaphragm and into chest

Epidemiology

Etiology

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

Diagnosis

  • This injury may even be missed on initial laparotomy or laparoscopy.

Signs and Symptoms

  • Vary depending on whether phase is acute, latent, or obstructive:Acute:TachypneaHypotensionAbsent or diminished breath soundsAbdominal distentionBowel sounds in chestLatent:Abdominal discomfort from intermittent herniation of abdominal contents into thoraxAbdominal pain that is worse postprandiallyExacerbated by lying supinePain radiating to left shoulderNausea, vomiting, or belchingObstructive:Severe abdominal painObstipationNausea, vomitingAbdominal distention
  • Strangulated abdominal organs may perforate and spill abdominal contents into chest
  • Respiratory compromise, sepsis, and death
  • Obstructive injuries may present in delayed fashion
  • Acute:TachypneaHypotensionAbsent or diminished breath soundsAbdominal distentionBowel sounds in chest
  • Latent:Abdominal discomfort from intermittent herniation of abdominal contents into thoraxAbdominal pain that is worse postprandiallyExacerbated by lying supinePain radiating to left shoulderNausea, vomiting, or belching
  • Obstructive:Severe abdominal painObstipationNausea, vomitingAbdominal distention
  • Tachypnea
  • Hypotension
  • Absent or diminished breath sounds
  • Abdominal distention
  • Bowel sounds in chest
  • 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
  • Severe abdominal pain
  • Obstipation
  • Nausea, vomiting
  • Abdominal distention

Essential Workup

  • Pathognomonic finding is presence of nasogastric tube above diaphragm.
  • Findings are often nonspecific:Elevated hemidiaphragmIrregular diaphragmatic contourMediastinal shift away from affected sideUnilateral pleural thickening or pleural effusionAreas of atelectasis or consolidation at basesSmall 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.
  • 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

Diagnosis Tests & Interpretation

  • If diagnostic peritoneal lavage (DPL) is performed:Red blood cell count of 1,000 RBC/mm3 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.
  • Red blood cell count of 1,000 RBC/mm3 is considered positive for diaphragmatic injury after penetrating trauma.
  • May provide false-negative result in up to 40% of patients with isolated 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 indicatedEspecially when suspicion is high despite negative imaging resultsFacilitates minimally invasive repair
  • 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.
  • Especially when suspicion is high despite negative imaging results
  • Facilitates minimally invasive repair

Differential Diagnosis

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

Treatment

  • Herniation of abdominal contents into chest wall may mimic hemothorax or tension pneumothorax
  • Bowel sounds in chest may help distinguish
  • Be suspicious of diaphragmatic injury with lateral compression of chest:Be cautious in placement of needle or tube thoracostomies.
  • Fecal thorax has been reported with bowel rupture.
  • Be cautious in placement of needle or tube thoracostomies.

Initial Stabilization/Therapy

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

Ed Treatment/Procedures

  • 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

Medication

  • 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 q8hMetronidazole: 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 q6hCefotetan: 2 g (peds: 40-80 mg/kg/24h) IV q12hCefoxitin: 2 g (peds: 80-160 mg/kg/24h) IV q12hTicarcillin/clavulanate: 3.1 g (peds: 50 mg/kg/dose) IV q6h
  • Gentamicin: Adults/peds: 2-5 mg/kg IV initial dose
  • 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
  • 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

Disposition

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

Followup Recommendations

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

Pearls and Pitfalls

  • 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.

Additional Reading

  • 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

ICD9

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

ICD10

  • S27.802A Contusion of diaphragm, initial encounter
  • S27.803A Laceration of diaphragm, initial encounter
  • S27.809A Unspecified injury of diaphragm, initial encounter
  • S27.808A Other injury of diaphragm, initial encounter

SNOMED

  • 262787008 Injury of diaphragm (disorder)
  • 76877000 Injury of diaphragm with open wound into cavity (disorder)
  • 210084003 Open injury of diaphragm (disorder)
  • 210083009 Closed injury of diaphragm (disorder)
  • 233746005 Traumatic rupture of diaphragm (disorder)