Guidelines: Management of Diaphragmatic Injury
Objective: To define diagnostic approaches and the management of diaphragmatic injuries
Organ Injury Scale (Diaphragm)
Grade Injury Description AIS-90
I Contusion 2
II Laceration <2 cm 3
III Laceration 2-10 cm 3
IV Laceration > 10 cm 3
V Laceration with tissue loss > 25 sq cm 3
(Advance one grade for bilateral injuries)
History:
Diaphragmatic injuries can be due to penetrating and blunt trauma. Blunt trauma causes large defects, and ten percent of pelvic fractures are associated with diaphragmatic rupture. In blunt trauma, sudden increase in intra-abdominal pressure may cause a 'blow out' or tear at the weakest point in the diaphragm, most commonly the left posterolateral diaphragm (over 80%). The stronger right side is 'protected' by the larger liver. Intra-abdominal contents, commonly colon, stomach and spleen may herniate into the chest, often not detected in multiply injured and ventilated patients. Difficulty passing a nasogastric tube or the intra-thoracic positioning of a successfully placed nasogastric tube may assist in the diagnosis of a ruptured diaphragm with the stomach in the chest. Diaphragmatic ruptures without herniation are difficult to demonstrate on computerized tomography scan, and diagnosis is often accidental, such as the appearance of abdominal lavage fluid or gastric content from a perforated stomach in a chest tube container after chest tube insertion, or the appearance of a pneumoperitoneum on plain x-ray with coexisting thoracic trauma.
Diaphragmatic defects do not spontaneously close, regardless of the size, because of the pleuroperitoneal pressure gradient caused by respirations. If undetected in the early period, non-specific abdominal complaints due to intermittent herniation of abdominal visceral contents may be the subsequent presenting symptom even well after discharge. Bowel obstruction and incarceration may also occur. Finally, bowel ischemia and subsequent bowel necrosis may result. When such patients are intubated and sedated for other injuries, the possibility of such a missed injury or delay in diagnosis may result in serious life threatening injury to the patient.
Operative closure and relocation of abdominal contents is mandatory. The diaphragm may be approached from either the chest or the abdomen, and recent reports have demonstrated the ability to repair the diaphragm laparoscopically in a stable patient.
Guidelines:
1) The diaphragm separates the chest and the abdominal cavities. Injury to this large muscle of respiration may be challenging.
2) A tear in the diaphragm allows abdominal viscera to enter the chest. Such an event can lead to difficulty in breathing and respiratory distress. The process is more rapid with spontaneous or unsupported respirations. It may also lead to bowel/visceral strangulation.
3) Prompt identification is mandatory to avoid ischemia to the viscera or respiratory failure.
4) Initiate the ATLS protocol with each trauma patient entering the MIHS system.
5) Intubate the patient if the patient is in respiratory distress.
6) Obtain necessary adjuncts such as a chest radiograph, however, a chest radiograph may be non-diagnostic.
7) If the patient has sustained a blunt abdominal injury with a tear in the diaphragm on the left or a penetrating injury to the left diaphragm, a chest radiograph may display viscera in the left chest cavity.
8) If the chest radiograph is suspicious, a nasogastric tube may be inserted into the patient’s stomach. If a repeat chest radiograph is obtained, examine the radiograph for evidence that the nasogastric tube placement into the chest.
9) Commonly obtained a thoracic computed tomography scan will most likely be non-diagnostic for a diaphragmatic injury.
10) If necessary, a contrasted upper gastrointestinal swallow may be obtained to assess the location of the stomach. In addition, contrast may be used in the nasogastric tube to help identify gastric herniation into the chest.
11) If the injury is to the right diaphragm, assess the chest radiograph for an abnormal “hump” in the lateral diaphragm which is suggestive of a large laceration of the diaphragm with protrusion of the liver.
12) Confirmation of diaphragmatic injuries by computed tomography of the chest or by thorascopic or laparoscopic evaluation of the right chest.
13) While laparoscopy may be challenging to assess the entire diaphragm, it may be useful, especially when examining the abdomen for other concomitant injuries.
14) Once identified, diaphragmatic injuries must be repaired promptly with reduction of abdominal viscera back into the abdomen, inspection of those abdominal viscera, and debridement of necrotic diaphragmatic muscle if necessary.
15) Repair all left-sided injuries even if it is small while small injuries on the right side may not require repair (intra-operative determination for repair is recommended.)
16) For those diaphragmatic injuries that are early on in the patent’s clinical course, consider an open abdominal approach, however, laparoscopic repair has been described for such injuries.
17) Diagnostic laparoscopy provides a vital tool for detecting occult diaphragmatic injury among patients who have no other indications for formal laparotomy.
18) For those diaphragmatic injuries that are late in the patient’s clinical course, consider a trans-thoracic approach. The patient may require both abdominal and thoracic approaches if the dissection is difficult, yet could be facilitated with a dual cavity exploration.
19) Mesh replacement is rarely needed but several options are available, including both synthetic and non-synthetic substitutes.
20) Close all injuries using a non-absorbable suture in an interrupted or running fashion.
21) Place a 32 or 36 French chest tube into the thoracic cavity on the side of injury prior to repairing the diaphragm. This chest tube may be removed if there is no injury to the lung parenchyma and no pneumothorax where a chest tube would therefore not be warranted.
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