Diaphragmatic Injury Management in the Emergency Department Treatment & Management

Updated: May 01, 2020
  • Author: Michelle Welsford, MD, FACEP, FRCPC(Canada); Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

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 to 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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Surgical Care

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. [22, 23]

Guidelines

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.
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