Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

The edemiological state of blunt diaphragmatic injury: An analysis of a nationwide trauma registry in Japan

BackgroundLittle is known about blunt traumatic diaphragmatic injury (BTDI). This study aimed to investigate the epidemiological state of BTDI, using a nationwide trauma registry in Japan.MethodsData of patients aged ≥18 years who experienced blunt injury between January 2004 and May 2019 were extracted from the Japan Trauma Data Bank. Demographics, cause of trauma, mechanism of injury, physiological parameters, organ injuries, and bone fractures were compared between patients with and those without BTDI. Multivariable logistic regression analysis was performed to identify factors associated with BTDI.ResultsA total of 305,141 patients from 244 hospitals were analyzed. The median patient age (interquartile range) was 65 (44–79) years, and 185,750 (60.9%) were men. BTDI was diagnosed in 868 patients (0.3%). The prevalence of BTDI was stable, between 0.2 and 0.6%, over the study period. Among the 868 patients with BTDI, 408 (47.0%) fatalities were recorded. Mortality rates in each year were 42.5–68.2%, with no significant trend toward an improved outcome (P = 0.925). Our multivariable logistic regression analysis found that mechanism of injury, Glasgow Coma Scale score (9–12 or 3–8) on hospital arrival, hypotension (systolic blood pressure <90 mmHg) on hospital arrival, organ injuries (lung, heart, spleen, bladder, kidney, pancreas, stomach, and liver), and bone fractures (rib, pelvis, lumbar spine, and upper extremities) were independently associated with BTDI.ConclusionUsing a nationwide trauma registry, this study revealed the epidemiological state of BTDI in Japan. BTDI was found to be a very rare but devastating injury, with high in-hospital mortality. Some clinical factors, such as mechanism of injury, Glasgow Coma Scale score, organ injuries, and bone fractures, were independently associated with BTDI.     

Traumatic diaphragmatic hernia. Occult marker of serious injury.

OBJECTIVE: Recent experience with traumatic diaphragmatic hernias at the Massachusetts General Hospital was reviewed to identify pitfalls in the diagnosis and treatment of this injury. SUMMARY BACKGROUND DATA: Traumatic diaphragmatic disruption is a common injury and a marker of severe trauma. It occurs in 5% of hospitalized automobile accident victims and 10% of victims of penetrating chest trauma. Numerous reports describe splenic rupture in 25% of patients with blunt diaphragmatic rupture, liver lacerations in 25%, pelvic fracture in 40%, and thoracic aortic tears in 5%. Diaphragmatic rupture is a predictor of serious associated injuries which, unfortunately, is itself often occult. METHODS: A chart review of all patients admitted to the Trauma Service with traumatic diaphragmatic hernias was undertaken for the period of January 1982 to June 1992. RESULTS: Data on 68 patients sustaining blunt (n = 25) and penetrating (n = 43) diaphragmatic rupture or laceration were presented. The diagnosis was made preoperatively in only 21 (31%). Associated injuries were frequent in those injured by either blunt or penetrating trauma. Sixty-six patients underwent repair, 54 (82%) through a laparotomy alone and 12 (18%) with the addition of a thoracotomy. There were five (7.4%) deaths that were caused by coagulopathy, hemorrhagic shock, multisystem organ failure, and pulmonary embolism. Complications were twice as frequent in the blunt-trauma group and included abscess, pneumonia, and the sequelae of closed head injuries. CONCLUSIONS: The recognition of diaphragmatic rupture is important because of the frequency and severity of associated injuries. The difficulties in reaching the diagnosis require an aggressive search in patients at risk.     

Factors affecting morbidity and mortality in pancreatic injuries

Purpose

Difficulties in the detection of pancreatic damage result in morbidity and mortality in cases of pancreatic trauma. This study was performed to determine factors affecting morbidity and mortality in pancreatic trauma.

Methods

The records of 33 patients who underwent surgery for pancreatic trauma between January 2004 and December 2013 were analyzed retrospectively.

Results

The types of injury were penetrating injury and blunt abdominal trauma in 75.8 and 24.2 % of all cases, respectively. Injuries were classified as stage 1 in 6 cases (18.2 %), stage 2 in 18 cases (54.5 %), stage 3 in 5 cases (15.2 %), and stage 4 in 4 cases (12.1 %). The average injury severity scale (ISS) value was 25.70 ± 9:33. Six patients (18.2 %) had isolated pancreatic injury, 27 (81.2 %) had additional intraabdominal organ injuries and 10 patients (30.3 %) had extraabdominal organ injuries. The mean length of hospital stay was 13.24 ± 9 days. Various complications were observed in eight patients (24.2 %) and mortality occurred in three (9.1 %). Complications were more frequent in patients with high pancreatic damage scores (p = 0.024), additional organ injuries (p = 0.05), and blunt trauma (p = 0.026). Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

Conclusions

Complications were significantly more common in injuries with higher pancreatic damage scores, additional organ injuries, and blunt abdominal trauma. Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

     

Blunt diaphragmatic rupture: four year’s experience

Background Blunt diaphragmatic rupture (DR) is a rare condition usually masked by multiple associated injuries, which are the main cause of morbidity and mortality. The overall incidence of diaphragmatic injury is 0.8–5.8% in blunt trauma—2.5–5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. A correct diagnosis remains difficult and is usually made late. Methods Over four years 12 patients with blunt DR were treated in our hospital. Their charts and X-rays were analyzed. All the surgeons involved were interviewed. Diagnostic and treatment modalities were analyzed and discussed. Results Acute diaphragmatic rupture (ADR) was diagnosed in nine patients within seven days. Three patients presented with bowel obstruction and post-traumatic diaphragmatic hernia was diagnosed intraoperatively. Nine patients had rupture of the left hemidiaphragm, two had rupture of the right hemidiaphragm, and one had bilateral DR. Diagnosis of DR was made in all patients in the ADR group before surgery. The correct diagnosis was made within 12 h by junior medical officers in 66.6% of cases. Two patients were diagnosed on a second chest X-ray in response to progressive respiratory distress. The diaphragmatic defect was repaired in all patients via laparotomy; only one patient required additional thoracotomy. Mortality was 25%. Conclusions Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases of DR. Respiratory distress should be treated with intubation as intercostal drainage (ICD) may not improve the situation and is associated with a high risk of iatrogenic injuries. Surgical repair is mandatory and laparotomy should be the preferred approach in unstable patients. To avoid missed injury thorough inspection of both hemidiaphragms should be done routinely on every trauma patient undergoing laparotomy. It is widely recommended to use non-absorbable suturing for diaphragm repair but slowly absorbable material seems reliable also.     

Early diagnosis and treatment of blunt diaphragmatic injury

Diaphragmatic rupture following blunt torso trauma is an infrequent injury often posing a considerable diagnostic challenge. Between June 1984 and July 1986, nine patients sustaining rupture of the diaphragm due to blunt trauma were treated. All were injured in high-speed motor-vehicle accidents. Six patients arrived in shock (SBP less than or equal to 95 mm Hg). All patients had multiple associated injuries; mean ISS = 41.5. Eight patients (89%) had associated intra-abdominal injuries, the spleen being injured most frequently (63%). Associated thoracic injuries occurred in six patients (67%). The admission CXR was abnormal in eight patients (89%) but diagnostic of diaphragmatic rupture in only four. DPL was positive in four of five patients (80%) and falsely negative in one. Seven ruptures were left-sided, one right-sided and one involved the central tendon. All injuries were diagnosed shortly after admission and successfully repaired via a transabdominal approach. One patient died as a result of a massive subdural hematoma. Blunt diaphragmatic rupture is an indication of a high-energy insult and is usually associated with other major organ system injuries. An aggressive approach to the management of the multiply injured patient can result in early recognition and successful treatment of this injury.     

Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation: A case report

BackgroundMassive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation is quite an uncommon life-threatening condition usually associated with blunt thoracoabdominal trauma. Mortality is generally associated with coexistent vascular and visceral injuries that could be rapidly fatal. Timely, and proper diagnosis is mandatory as survival depends on prompt diagnosis and treatment.Presentation of caseWe describe a case of massive left hemothorax secondary to blunt thoracoabdominal injury with left diaphragmatic and splenic rupture, gastric, greater omentum and splenic herniation into the left thoracic cavity in a 32 years old male car driver after sustaining a road traffic accident and presented with shortness of breath of 4 h’ duration. He also had zone 3 retroperitoneal hematoma and left acetabular fracture. He was treated surgically and discharged home improved.DiscussionDiaphragmatic ruptures following blunt injuries are larger leading to herniation of visceral organs into the thoracic cavity and the most common organ to herniate on the left side is the stomach followed by omentum and small intestine. Splenic rupture is a very rare cause of hemothorax and is often missed in the differential diagnosis.ConclusionMassive hemothorax following splenic and diaphragmatic rupture with visceral herniation following either blunt or penetrating trauma is rare. Delayed or missed diagnosis is associated with higher morbidity and mortality. A high index of suspicion and proper use of diagnostic studies are crucial for early and correct diagnosis.     

Laparoscopic management of a late-diagnosed major diaphragmatic rupture

A 20-year-old male patient was admitted to our emergency ward because of acute respiratory insufficiency following gastroscopy 2 years after a car accident. The chest radiograph showed migration of the stomach into the left hemithorax. A large diaphragmatic hernia was diagnosed and repaired laparoscopically using slowly resorbable sutures and patches. Diaphragmatic rupture secondary to blunt thoracic or abdominal trauma is a rare injury, whose diagnosis may be delayed. The majority of these defects are diagnosed during laparotomy performed for other major abdominal lesions. If diaphragmatic rupture is suspected, and no lesion of a parenchymatous organ has been diagnosed, there is a role for diagnostic laparoscopy. In the absence of other abdominal injuries, diaphragmatic rupture can be repaired by minimal-access surgery.     

Right-sided diaphragmatic rupture after blunt trauma. An unusual entity

Traumatic injuries of the diaphragm remain an entity of difficult diagnosis despite having been recognised early in the history of surgery, especially when it comes to blunt trauma and injuries of the right diaphragm. We report the case of a patient with blunt trauma with right diaphragmatic rupture that required urgent surgical treatment for hepatothorax and iatrogenic severe liver injury. Blunt trauma can cause substantial diaphragmatic rupture. It must have a high index of suspicion for diaphragmatic injury in patients, victims of vehicle collisions, mainly if they have suffered frontal impacts and/or side precipitates in patients with severe thoracoabdominal trauma. The diagnosis can be performed clinically and confirmation should be radiological. The general measures for the management of multiple trauma patients must be applied. Surgery at the time of diagnosis should restore continuity.     

Blunt diaphragmatic rupture

Diaphragmatic injury is often a missed diagnosis in patients with multiple trauma. For this reason, mortality can be high. From 1970 to 1981, 32 patients with diaphragmatic injuries were seen at Maisonneuve-Rosemont Hospital. Twenty-four of the patients (22 men and 2 women aged 18 to 79 years) had blunt abdominal or thoracic trauma causing diaphragmatic disruption. Rupture occurred 20 times on the left side of the diaphragm, and 3 times on the right side. There was one pericardiophrenic rupture. Motor vehicle accident was the most common cause of trauma. On arrival, 21 patients had acute diaphragmatic rupture. Clinical signs and radiography permitted early diagnosis in 15 patients, whereas diagnosis was made later in 3 other patients because of deterioration of vital signs. In two patients, diagnosis was made at laparotomy for another reason. Four patients were operated on for post-traumatic chronic diaphragmatic hernia. The abdominal approach was used in 18 patients, the thoracic approach in 4, and the thoracoabdominal approach in 2. Three patients died, two of whom had a late diagnosis. Fourteen patients had no complications. Diaphragmatic trauma can be easily managed surgically when diagnosis is made early after trauma. It must always be looked for in patients with multiple trauma.     

Acute diaphragmatic injuries

A 5-year experience with 43 patients with acute diaphragmatic injuries is reviewed. Thirty-three of the patients had penetrating trauma, and 10 suffered blunt trauma. All but 1 of the patients had associated intraabdominal trauma. Fifteen had traumatic diaphragmatic hernia at the time of operation. The operative approach was uniformly through the abdomen. Mortality and morbidity were directly related to the number of associated organs injured.Chest roentgenograms in 26 of the 43 patients were interpreted as suspicious or diagnostic of diaphragmatic injury when presented as unknowns to fully trained radiologists, but only 7 of these were originally so interpreted.Delay in operation was a significant contributing factor to morbidity, particularly in patients with thoracic stab wounds. Guidelines suggested to prevent delay include: (1) increased awareness of the possibility of acute diaphragmatic injury, (2) careful evaluation of the plain chest roentgenogram and liberal use of appropriate contrast studies when indicated, (3) prompt repair of recognized diaphragmatic injuries, (4) laparotomy as the operative approach in the acute injury, and (5) appropriate contrast studies after recovery from massive thoracoabdominal trauma and prior to hospital discharge.     

Traumatic diaphragmatic hernia

Thirty-four patients with traumatic diaphragmatic hernia treated between 1941 and 1972 were reviewed. The patients were analyzed as to the mode of trauma, location of the diaphragmatic injury and associated injuries, and the time and methods of diagnosis. The mortality rate was 23%, and deaths were due primarily to the severity of associated injuries, especially in patients sustaining blunt trauma. The necessity of immediate laparotomy in patients with acute diaphragmatic hernia appears indicated by the high incidence of associated intraabdominal injuries that required surgical management. Thoracotomy was employed primarily in patients undergoing delayed repair and was rarely necessary for control of acute associated intrathoracic injuries.     

Diagnosis of ruptured diaphragm following blunt trauma: results from 85 cases

Between 1975 and 1990, 85 patients with diaphragmatic rupture following blunt trauma were treated at the Royal Brisbane and Princess Alexandra Hospitals, Brisbane. There were 65 on the left, 17 on the right and three were bilateral. Road trauma was the cause in 88% of cases. In the first 48 h the diagnosis was made by chest X-ray in 51 patients, laparotomy in 22, autopsy in two, emergency room thoracotomy, ultrasound and pneumoperitoneum each in a single patient. Seven patients (8%) had delay in diagnosis greater than 48 h ranging from 6 days to 6 months. Diagnosis was subsequently made by pneumoperitoneum (3), chest X-ray (1) and exploratory thoracotomy (1). Two patients presented with a strangulated diaphragmatic hernia 3 and 6 months following an acute admission with blunt chest trauma and urological trauma respectively. During the study period a further five patients presented with an obstructing diaphragmatic hernia. Sixteen patients died (19%), fifteen from associated injuries and one related to the diaphragmatic repair. Ruptured diaphragm should be suspected in patients with severe chest trauma, particularly those requiring positive pressure ventilation, patients with intra-abdominal injuries and those with pelvic fractures. Early recognition and repair results in low morbidity and mortality. Measures that confirmed the diagnosis in patients with delay included repeated chest X-rays and pneumoperitoneum.     

Traumatic rupture of the diaphragm: experience with 65 patients

Traumatic diaphragmatic rupture is reported with increasing frequency and is associated with high morbidity and mortality. The purpose of this study was to present our experience with the management of this injury. Sixty-five patients with TDR were treated in our hospital between January 1989 and May 2000. They were 54 men (83%) and 11 women (17%). Mean age was 36.57 years (range 15-76 years). Rupture of the diaphragm was left-sided in 43 patients (66%), right-sided in 21 (32%), and bilateral in 1 (1.5%). Blunt trauma accounted for the injuries of 52 patients (80%). Early diagnosis was obtained in 57 patients (88%). The diagnosis was established preoperatively in 17 patients (26%), and intra-operatively in 48 (74%). Multiple associated injuries were observed in 62 patients (95%). Postoperative complications were observed in seven patients (11%), and the overall mortality was 14%. Injury severity score (ISS) and haemorrhagic shock upon admission strongly influence the outcome. A high index of suspicion and a thorough examination of both hemi diaphragms during laparotomy is recommended in order to avoid early or late complications.     

Impact of deferred treatment of blunt diaphragmatic rupture: a 15-year experience in six trauma centers in Quebec

BACKGROUND: The purpose of this study was to show that blunt diaphragmatic rupture does not require immediate emergency operation in the absence of other indications. METHODS: We reviewed all patients with blunt diaphragmatic rupture admitted within 24 hours of injury to one of six university trauma centers providing trauma care for the province of Quebec from April 1, 1984, to March 31, 1999. Multivariate analysis of demographic profiles, severity indices, indications for operation, and preoperative delays was performed. RESULTS: There were 160 patients (91 men and 69 women) with blunt diaphragmatic rupture. Mean age was 40.1 +/- 16.2 years. Mean Injury Severity Score was 26.9 +/- 11.5 and mortality was 14.4%. Patients undergoing emergency surgery for indications other than diaphragmatic rupture had a significantly higher Injury Severity Score than those undergoing surgery for repair of diaphragmatic rupture alone (34.7 +/- 10.7 vs. 22.0 +/- 9.0, p < 0.001). In patients undergoing surgery for diaphragmatic rupture alone, delay before repair of the diaphragmatic hernia did not lead to an increased mortality compared with patients undergoing immediate surgery (3.4% vs. 5.0%, p = NS). CONCLUSION: Blunt diaphragmatic rupture in the absence of other surgical injuries carries low mortality. Operative repair of diaphragmatic rupture can be deferred without appreciable increased mortality if no other indication mandates immediate surgery.     

Traumatic Lesions of the Diaphragm Our Experience in 33 Cases and Review of the Literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.     

Traumatic lesions of the diaphragm. Our experience in 33 cases and review of the literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.     

Civilian Airway Trauma: A Single-Institution Experience

Background

Injuries to the airway in the neck and thorax are uncommon, but may be potentially life threatening. The objective of this study is to determine the clinical characteristics and outcomes for patients with airway injury.

Methods

From 1974 to 2014, a prospectively entered trauma database at a Level 1 trauma center was accessed to identify patients with injuries to the larynx, cervical trachea, or thoracic airway. Hospital charts were reviewed to obtain data on demographics, presentation, injury management, in-hospital and long-term morbidity and in-hospital mortality. Multivariate logistic regression was used to estimate predictors of mortality and long-term vocal cord morbidity. Data are expressed as N (%).

Results

One hundred and twenty patients were included (median injury severity score: 19 [interquartile range: 10–27]). There were 65 (54 %) blunt and 55 (46 %) penetrating injuries, with 90 (75 %) suffering multiple injuries. Sixteen (13 %) patients died from associated injuries (7: in ER; 9: after admission). Injuries were located in the cervical airway [101 (84 %)], thoracic airway [21 (18 %)], or both [2 (2 %)]. Eighty-six (72 %) patients were managed surgically. Predictors of in-hospital mortality included hemodynamic instability (OR 6.54, 95 % CI 1.11–37.14), GCS < 8 upon presentation (OR 4.35, 95 % CI 3.24–5.41), and head trauma (OR 4.10, 95 % CI 1.91–6.30). Fracture of cricoid or thyroid cartilages was a strong predictor of long-term vocal cord injury (OR 3.93, 95 % CI 1.25–12.59).

Conclusions

Airway trauma remains a major challenge for early diagnosis, airway control, and management of both acute life-threatening injury and long-term morbidity.

     

Verkannte Zwerchfellrupturen nach stumpfem Brust-Bauch-Trauma

The histories of 67 patients with a diaphragmatic rupture due to blunt trauma were reviewed in four hospitals. In 45 patients the diagnosis was made within 24 hours after the accident, in the other 22 patients the rupture was diagnosed in a later stage. In the first group there were much abdominal injuries and during emergency laparotomy for some other reasons in 29% of these cases the diaphragmatic rupture was found accidentally. Not recognizing a rupture in the acute phase and therefore delaying operation was caused by the fact that the initial chest X-ray was not thoroughly checked for signs of a diaphragmatic rupture. The reasons for operation in the “delayed” group were mainly typical abnormalities for diaphragmatic rupture of the chest X-rays and other investigations proving the diagnosis. Only in one patient the delay in diagnosis has led to a very serious complication: because of incarceration with gangrene of a part of the small bowel it was necessary to remove this part. The other 21 patients in the group where the diagnosis was initially missed did not suffer from any serious complication.