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.

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.

Guidelines

Mahamid A, Peleg K, Givon A, Alfici R, Olsha O, Israeli Trauma Group., et al. Blunt traumatic diaphragmatic injury: A diagnostic enigma with potential surgical pitfalls. Am J Emerg Med. 2017 Feb. 35 (2):214-217. [QxMD MEDLINE Link].
Abdellatif W, Chow B, Hamid S, Khorshed D, Khosa F, Nicolaou S, et al. Unravelling the Mysteries of Traumatic Diaphragmatic Injury: An Up-to-Date Review. Can Assoc Radiol J. 2020 Mar 11. 846537120905133. [QxMD MEDLINE Link].
Thiam O, Konate I, Gueye ML, Toure AO, Seck M, Cisse M, et al. Traumatic diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects. Springerplus. 2016. 5 (1):1614. [QxMD MEDLINE Link].
Iadicola D, Branca M, Lupo M, Grutta EM, Mandalà S, Cocorullo G, et al. Double traumatic diaphragmatic injury: A case report. Int J Surg Case Rep. 2019. 61:82-85. [QxMD MEDLINE Link].
Al-Thani H, Jabbour G, El-Menyar A, Abdelrahman H, Peralta R, Zarour A. Descriptive Analysis of Right and Left-sided Traumatic Diaphragmatic Injuries; Case Series from a Single Institution. Bull Emerg Trauma. 2018 Jan. 6 (1):16-25. [QxMD MEDLINE Link].
Mancini A, Duramé A, Barbois S, Abba J, Ageron FX, Arvieux C. Relevance of early CT scan diagnosis of blunt diaphragmatic injury: A retrospective analysis from the Northern French Alps Emergency Network. J Visc Surg. 2019 Feb. 156 (1):3-9. [QxMD MEDLINE Link].
McDonald AA, Robinson BRH, Alarcon L,et al. Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018 Jul. 85 (1):198-207. [QxMD MEDLINE Link].
Carter BN, Giuseffi J, Felson B. Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther Nucl Med. 1951 Jan. 65(1):56-72. [QxMD MEDLINE Link].
Baloyiannis I, Kouritas VK, Karagiannis K, Spyridakis M, Efthimiou M. Isolated right diaphragmatic rupture following blunt trauma. Gen Thorac Cardiovasc Surg. 2011 Nov. 59(11):760-2. [QxMD MEDLINE Link].
Melo EL, de Menezes MR, Cerri GG. Abdominal gunshot wounds: multi-detector-row CT findings compared with laparotomy-a prospective study. Emerg Radiol. 2011 Dec 2. [QxMD MEDLINE Link].
Berardoni NE, Kopelman TR, O'Neill PJ, August DL, Vail SJ, Pieri PG, et al. Use of computed tomography in the initial evaluation of anterior abdominal stab wounds. Am J Surg. 2011 Oct 27. [QxMD MEDLINE Link].
Iadicola D, Branca M, Lupo M, Grutta EM, Mandalà S, Cocorullo G, et al. Double traumatic diaphragmatic injury: A case report. Int J Surg Case Rep. 2019. 61:82-85. [QxMD MEDLINE Link]. [Full Text].
Rizoli SB, Brenneman FD, Boulanger BR, Maggisano R. Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex. Ann Thorac Surg. 1994 Nov. 58(5):1404-8. [QxMD MEDLINE Link].
Lim BL, Teo LT, Chiu MT, Asinas-Tan ML, Seow E. Traumatic diaphragmatic injuries: a retrospective review of a 12-year experience at a tertiary trauma centre. Singapore Med J. 2017 Oct. 58 (10):595-600. [QxMD MEDLINE Link]. [Full Text].
Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg. 1974 Aug. 128(2):175-81. [QxMD MEDLINE Link].
[Guideline] American College of Radiology Expert Panel on Major Trauma Imaging: Shyu JY, Khurana B, Soto JA, et al. ACR Appropriateness Criteria® Major Blunt Trauma. ACR.org. Available at https://acsearch.acr.org/docs/3102405/Narrative/. 2019; Accessed: December 15, 2019.
Dreizin D, Bergquist PJ, Taner AT, Bodanapally UK, Tirada N, Munera F. Evolving concepts in MDCT diagnosis of penetrating diaphragmatic injury. Emerg Radiol. 2015 Apr. 22 (2):149-56. [QxMD MEDLINE Link].
Patlas MN, Leung VA, Romano L, Gagliardi N, Ponticiello G, Scaglione M. Diaphragmatic injuries: why do we struggle to detect them?. Radiol Med. 2015 Jan. 120 (1):12-20. [QxMD MEDLINE Link].
Turmak M, Deniz MA, Özmen CA, Aslan A. Evaluation of the multi-slice computed tomography outcomes in diaphragmatic injuries related to penetrating and blunt trauma. Clin Imaging. 2018 Jan - Feb. 47:65-73. [QxMD MEDLINE Link].
Lee JY, Sul YH, Ye JB, Ko SJ, Choi JH, Kim JS. Right-sided diaphragmatic rupture in a poly traumatized patient. Ann Surg Treat Res. 2018 Jun. 94 (6):342-345. [QxMD MEDLINE Link]. [Full Text].
Leung VA, Patlas MN, Reid S, Coates A, Nicolaou S. Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre. Can Assoc Radiol J. 2015 Jun 19. [QxMD MEDLINE Link].
Powell L, Chai J, Shaikh A, Shaikh A. Experience with acute diaphragmatic trauma and multiple rib fractures using routine thoracoscopy. J Thorac Dis. 2019 May. 11 (Suppl 8):S1024-S1028. [QxMD MEDLINE Link].
Tserng TL, Gatmaitan MB. Laparoscopic approach to the management of penetrating traumatic diaphragmatic injury. Trauma Case Rep. 2017 Aug. 10:4-11. [QxMD MEDLINE Link].
Athanassiadi K, Kalavrouziotis G, Athanassiou M, et al. Blunt diaphragmatic rupture. Eur J Cardiothorac Surg. 1999 Apr. 15(4):469-74. [QxMD MEDLINE Link].
Barbiera F, Nicastro N, Finazzo M, et al. The role of MRI in traumatic rupture of the diaphragm. Our experience in three cases and review of the literature. Radiol Med (Torino). 2003 Mar. 105(3):188-94. [QxMD MEDLINE Link].
Barsness KA, Bensard DD, Ciesla D, et al. Blunt diaphragmatic rupture in children. J Trauma. 2004 Jan. 56(1):80-2. [QxMD MEDLINE Link].
Bergqvist D, Dahlgren S, Hedelin H. Rupture of the diaphragm in patients wearing seatbelts. J Trauma. 1978 Nov. 18(11):781-3. [QxMD MEDLINE Link].
Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging. Emerg Radiol. 2012 Jun. 19(3):225-35. [QxMD MEDLINE Link].
Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma. 1993 Aug. 35(2):255-60. [QxMD MEDLINE Link].
Boulanger BR, Mirvis SE, Rodriguez A. Magnetic resonance imaging in traumatic diaphragmatic rupture: case reports. J Trauma. 1992 Jan. 32(1):89-93. [QxMD MEDLINE Link].
Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg. 1995 Jul. 170(1):5-9. [QxMD MEDLINE Link].
Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008 Mar. 85(3):1044-8. [QxMD MEDLINE Link].
Jarrett F, Bernhardt LC. Right-sided diaphragmatic injury: rarity or overlooked diagnosis?. Arch Surg. 1978 Jun. 113(6):737-9. [QxMD MEDLINE Link].
Leaman PL. Rupture of the right hemidiaphragm due to blunt trauma. Ann Emerg Med. 1983 Jun. 12(6):351-7. [QxMD MEDLINE Link].
Leppaniemi A, Haapiainen R. Occult diaphragmatic injuries caused by stab wounds. J Trauma. 2003 Oct. 55(4):646-50. [QxMD MEDLINE Link].
Matsevych OY. Blunt diaphragmatic rupture: four year's experience. Hernia. 2008 Feb. 12(1):73-8. [QxMD MEDLINE Link].
Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury. 2003 Mar. 34(3):169-72. [QxMD MEDLINE Link].
Nau T, Seitz H, Mousavi M, Vecsei V. The diagnostic dilemma of traumatic rupture of the diaphragm. Surg Endosc. 2001 Sep. 15(9):992-6. [QxMD MEDLINE Link].
Patselas TN, Gallagher EG. The diagnostic dilemma of diaphragm injury. Am Surg. 2002 Jul. 68(7):633-9. [QxMD MEDLINE Link].
Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA, Fischer PE, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May. 39(5):530-4. [QxMD MEDLINE Link].
Ramos CT, Koplewitz BZ, Babyn PS, et al. What have we learned about traumatic diaphragmatic hernias in children?. J Pediatr Surg. 2000 Apr. 35(4):601-4. [QxMD MEDLINE Link].
Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma. 1986 May. 26(5):438-44. [QxMD MEDLINE Link].
Sangster G, Ventura VP, Carbo A, et al. Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients. Emerg Radiol. 2006 Nov 29. [QxMD MEDLINE Link].
Schneider CF. Traumatic diaphragmatic hernia. Am J Surg. 1956 Feb. 91(2):290-7. [QxMD MEDLINE Link].
Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: spectrum of radiographic findings. Radiographics. 1998 Jan-Feb. 18(1):49-59. [QxMD MEDLINE Link].
Shatney CH, Sensaki K, Morgan L. The natural history of stab wounds of the diaphragm: implications for a new management scheme for patients with penetrating thoracoabdominal trauma. Am Surg. 2003 Jun. 69(6):508-13. [QxMD MEDLINE Link].
Shehata SM, Shabaan BS. Diaphragmatic injuries in children after blunt abdominal trauma. J Pediatr Surg. 2006 Oct. 41(10):1727-31. [QxMD MEDLINE Link].
Sukul DM, Kats E, Johannes EJ. Sixty-three cases of traumatic injury of the diaphragm. Injury. 1991 Jul. 22(4):303-6. [QxMD MEDLINE Link].
Tansley P, Treasure T. Trauma care and the pitfalls of diaphragmatic rupture. J R Soc Med. 1999 Mar. 92(3):134-5. [QxMD MEDLINE Link].
Voeller GR, Reisser JR, Fabian TC, et al. Blunt diaphragm injuries. A five-year experience. Am Surg. 1990 Jan. 56(1):28-31. [QxMD MEDLINE Link].
Zarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC. Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg. 2013 Jun. 74(6):1392-8; quiz 1611. [QxMD MEDLINE Link].

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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.