Emergency Medicine Book

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Diaphragmatic Injury

Aka: Diaphragmatic Injury, Diaphragmatic Rupture, Rupture of Diaphragm
  1. Causes
    1. Blunt Trauma to anterior Abdomen (MVA, fall from height)
      1. Increased abdominal pressure disrupts diaphragm
      2. High risk of pre-hospital mortality
      3. Associated injuries
        1. Large vessel injury (inferior vena cava, hepatic vein, aorta)
        2. Hemo-Pneumothorax (90% of cases), liver and Spleen injuries (25%)
        3. Pelvic Fracture (40%), long bone Fracture (75%) and multiple Rib Fractures
        4. Closed Head Injury (42%)
    2. Penetrating Trauma (Gunshot Wound, Stab Wound)
      1. May occur from either Thoracic Injury or Abdominal Injury
      2. Typically small (<2 cm) and linear (and often occult)
      3. Smaller, more occult diaphragm injuries at risk for Incarcerated Hernias
    3. Surgical complication
  2. Symptoms
    1. Shoulder Pain
    2. Epigastric Pain
    3. Respiratory distress
  3. Imaging: Chest XRay
    1. First-line study
    2. Findings
      1. Stomach or bowel appears in the left chest
      2. Nasogastric Tube curled in the left chest
    3. Misdiagnoses (Diaphragmatic Rupture look-alikes)
      1. Elevated left hemidiaphragm
      2. Left loculated Pneumothorax
      3. Left subpulmonary hematoma
  4. Imaging: CT Chest
    1. Left sided Diaphragmatic Injury is most common
      1. Right side is shielded by the liver
      2. Bilateral injury is uncommon
    2. Efficacy (insufficient to completely exclude diaphragmatic perforation)
      1. Test Sensitivity: 82%
      2. Test Specificity: 88%
      3. Yucel (2015) Injury 46(9): 1734-7 +PMID:26105131 [PubMed]
  5. Management
    1. Emergent Trauma surgical Consultation and evaluation (Laparoscopy, thoracoscopy)
      1. Negative imaging (including CT) does not exclude Diaphragmatic Injury
      2. Laparoscopy and thoracoscopy are indicated in high suspicion cases (despite negative imaging)
      3. Missed Diaphragmatic Injury may result in serious complications
  6. Complications
    1. Herniation of Stomach, bowel, liver of Spleen
    2. Delayed diagnosis and repair
      1. Difficult repair outside the acute phase
      2. High morbidity and mortality from missed Diaphragmatic Rupture
  7. Prognosis
    1. Overall mortality
      1. Penetrating Diaphragmatic Injury: 4.3%
      2. Blunt Diaphragmatic Injury: 37%
  8. References
    1. Cowling and Mullins (2017) Crit Dec Emerg Med 31(10): 3-10
    2. Dwivedi (2010) J Emerg Trauma Shock 3(2): 173–6 +PMID:20606795 [PubMed]

Rupture of diaphragm (C0238088)

Concepts Injury or Poisoning (T037)
SnomedCT 83336007
Italian Rottura del diaframma
Japanese 横隔膜破裂, オウカクマクハレツ
English diaphragmatic rupture (diagnosis), diaphragmatic rupture, diaphragm rupture, rupture of diaphragm, Diaphragmatic rupture, Rupture of diaphragm, Rupture of the diaphragm, Rupture of diaphragm (disorder), diaphragm; rupture, rupture; diaphragm
Czech Ruptura bránice
Hungarian Rekesz ruptura
Dutch diafragma; ruptuur, ruptuur; diafragma, diafragmatische ruptuur
Spanish ruptura del diafragma (trastorno), ruptura del diafragma, ruptura diafragmática, Rotura diafragmática
Portuguese Ruptura diafragmática
French Rupture diaphragmatique
German Diaphragmaruptur
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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