Guidelines Summary

The Eastern Association for the Surgery of Trauma published the following guidelines for traumatic diaphragmatic injuries^[7]:

In left thoracoabdominal stab wound patients who are stable and do not have peritonitis, laparoscopy is recommended over CT to decrease the incidence of missed diaphragmatic injury.
In penetrating thoracoabdominal trauma patients who are stable without peritonitis in whom a right diaphragmatic injury is confirmed or suspected, nonoperative over operative management is recommended in weighing the risks of delayed herniation, missed thoracoabdominal organ injury, and surgical morbidity.
In stable patients with acute diaphragmatic injuries, abdominal rather than thoracic approach is recommended to decrease mortality, delayed herniation, missed thoracoabdominal organ injury, and surgical approach-associated morbidity.

The American College of Radiology ACR Appropriateness Criteria for major blunt trauma includes the following key recommendations for initial imaging based on suspected injury and/or hemodynamic stability.^[16]

Major blunt trauma-hemodynamically unstable

Radiography trauma series and focused assessment with sonography in trauma (FAST) scan of the chest, abdomen, and pelvis are usually appropriate. These procedures are complementary, and more than one procedure is ordered as a set or simultaneously, where each procedure provides unique clinical information to effectively manage the patient’s care.

Major blunt trauma-hemodynamically stable

CT whole body with IV contrast, radiography trauma series, and focused assessment with sonography in trauma (FAST) scan of the chest, abdomen, and pelvis are usually appropriate. These procedures are complementary.

Suspected chest trauma-hemodynamically stable

Chest CT with IV contrast, whole body CT with IV contrast, chest CTA with IV contrast, or radiography trauma series is usually appropriate. These procedures are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care).

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Author

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

Michelle Welsford, MD, FACEP, CCPE, FRCPC 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, 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.