Diaphragmatic Trauma

Diaphragmatic Trauma is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Penetrating injury:
    • 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)
  • Blunt injury:
    • Increased intra-abdominal or intrathoracic pressure is transmitted to diaphragm, causing rupture
    • 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 5–15 cm in length)
  • Diaphragmatic defects do not heal spontaneously because of pleuroperitoneal pressure gradient:
    • May exceed 100 cm H2O during maximal respiratory effort
    • Promotes herniation of abdominal contents through tear in diaphragm

Epidemiology

Incidence
Uncommon; <1% of all traumatic injuries

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 area
    • Injuries that cross plane of the diaphragm, which can extend up to the fourth rib

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Basics

Description

  • Penetrating injury:
    • 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)
  • Blunt injury:
    • Increased intra-abdominal or intrathoracic pressure is transmitted to diaphragm, causing rupture
    • 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 5–15 cm in length)
  • Diaphragmatic defects do not heal spontaneously because of pleuroperitoneal pressure gradient:
    • May exceed 100 cm H2O during maximal respiratory effort
    • Promotes herniation of abdominal contents through tear in diaphragm

Epidemiology

Incidence
Uncommon; <1% of all traumatic injuries

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 area
    • Injuries that cross plane of the diaphragm, which can extend up to the fourth rib

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