Diaphragmatic Injury Management in the Emergency Department Guidelines

Updated: May 01, 2020
  • Author: Michelle Welsford, MD, FACEP, CCPE, FRCPC; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines

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).