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Diaphragmatic Injuries Treatment & Management

  • Author: Michelle Welsford, MD, FACEP, FRCPC(Canada); Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 08, 2015
 

Prehospital Care

Meticulous attention to management of the ABCs, as with all patients, is the cornerstone for prehospital management of diaphragmatic injuries. The diagnosis rarely is made in the field, and no specific prehospital treatment is required. Treat the associated injuries and ensure adequate airway control and ventilation if signs of respiratory distress are present.

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Emergency Department Care

Focus on resuscitating the patient. As in all trauma patients, the ABCs are most important. Ensure a patent airway, assist ventilation if required, and begin fluid resuscitation if necessary.

Place an NG tube when possible, as this will help in diagnosis if the NG tube appears in the chest on chest radiograph. Aspiration of gastric contents also helps to decompress any abdominal herniation and lessen the abdominoperitoneal gradient that favors herniation into the chest.

Consider placing a chest tube to drain any associated hemothorax or pneumothorax. Perform this with caution to prevent injury to herniated abdominal contents within the pleural cavity.

Most surgeons recommend chest tube placement prior to transfer to another facility. If this is not required immediately in the definitive care institution, it may be delayed and completed in the operating room.

Performing chest radiography before intubation may yield a better result (because it is more likely to show associated herniation). A repeated chest radiograph may also add to the sensitivity of diagnosis.

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Consultations

Surgical repair is necessary, even for small tears, because the defect will not heal spontaneously. The parietoperitoneal pressure gradients favor enlargement of the defect with herniation of abdominal contents.

Surgical management usually employs the transabdominal approach to allow a complete trauma laparotomy to search for other injuries. A thoracotomy may be necessary for repair, especially in right-sided injuries or when significant herniation has occurred. In a few situations of isolated penetrating injury where abdominal injury is thought to be unlikely, the repair can be accomplished by thoracotomy or thoracoscopy.

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Contributor Information and Disclosures
Author

Michelle Welsford, MD, FACEP, FRCPC(Canada) Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University School of Medicine; Staff Emergency Physician, Hamilton Health Sciences; Medical Director, Centre for Paramedic Education and Research

Michelle Welsford, MD, FACEP, FRCPC(Canada) is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Ontario Medical Association, Canadian Association of Emergency Physicians, Canadian Medical Association, National Association of EMS Physicians, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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