Let’s start with a case:
19 year-old Male presents after MVC as unrestrained driver in head on collision. He appears tachypneic and is noted to have decreased breath sounds on his left side. Just as the Trauma Team is prepping for a chest tube, POCUS shows +lung sliding at the apex and something that looks strange at the bases…
What does this patient have?
· Diaphragmatic rupture with herniation of the abdominal contents into the thoracic cavity
· Pathophysiology? Blunt trauma causes compression of the abdominal cavity and the pressure gradient between the thoracic and abdominal cavities
o Previously thought to be more common on left side due to absence of liver
No longer true! more or less the same frequency
Right sided injury with greater mortality
d/t force required for injury is higher
more delay in diagnosis
o Proceed cautiously if considering chest tube placement in these patients to avoid visceral injury from the chest tube
Keep in mind that ptx is more common
· Can lead to respiratory distress and the degree of his respiratory distress is related:
o size of the diaphragmatic tear
o amount of abdominal viscera that is herniated
· The mortality rate higher with blunt trauma than penetrating trauma because blunt diaphragmatic injury tends to lead to larger defects.
· If the injury is large enough, it can be detected on cxr
· CT scan can help identify these injuries when they are not visible on chest xray
· Small injuries are notoriously very difficulty to detect
Patients can even present from weeks to months to years later with symptoms from a previously undiagnosed injury
· Complications
o tension gastrothorax, visceral ischemia, perforated viscus
Sources:
ACEP Clinical Policy on acute blunt abdominal trauma
Tintinellis
Peer IX
Cxr from: https://www.semanticscholar.org/paper/Blunt-diaphragmatic-rupture%3A-four-year%E2%80%99s-experience-Matsevych/35f84bfd12f4633dcb29539464a67e9cca51bd29/figure/3