eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Diaphragmatic Injuries: Treatment & Medication

Author: Michelle Welsford, MD, FRCP(C), FACEP, Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University; Staff Emergency Physician, Emergency and Prehospital Services, Medical Director, Paramedic Base Hospital Program, Hamilton, Ontario Health Sciences
Contributor Information and Disclosures

Updated: Oct 21, 2008

Treatment

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.

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.

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.

More on Diaphragmatic Injuries

Overview: Diaphragmatic Injuries
Differential Diagnoses & Workup: Diaphragmatic Injuries
Treatment & Medication: Diaphragmatic Injuries
Follow-up: Diaphragmatic Injuries
References
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References

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Further Reading

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Keywords

diaphragmatic injuries, diaphragmatic injury, diaphragmatic rupture, diaphragmatic tear, diaphragm, abdominal injuries, diagnostic peritoneal lavage, blunt diaphragmatic ruptures, blunt trauma, penetrating trauma, knife wounds, gunshot wounds, motor vehicle crash, blunt traumatic injuries, penetrating traumatic injuries

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Contributor Information and Disclosures

Author

Michelle Welsford, MD, FRCP(C), FACEP, Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University; Staff Emergency Physician, Emergency and Prehospital Services, Medical Director, Paramedic Base Hospital Program, Hamilton, Ontario Health Sciences
Michelle Welsford, MD, FRCP(C), FACEP is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Canadian Association of Emergency Physicians, Canadian Medical Association, National Association of EMS Physicians, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

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, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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