Traumatic Diaphragmatic Hernia


Background
  1. Tear in diaphragm from blunt trauma

Pathophysiology

  1. Etiologies
  2. Anatomy
  3. Associated injuries
  4. Often go undiagnosed for years

Diagnosis

  1. Often masked by other injuries
  2. Can present in 3 phases
  3. History / Symptoms
  4. Physical findings
  5. Diagnostic testing
  6. Diagnostic imaging

Differential Diagnosis

  1. Hemothorax
  2. Pneumothorax
  3. Pulmonary contusion
  4. Rupture of hollow viscus/ intestinal injury
  5. Splenic trauma
  6. Hepatic trauma
  7. Pancreatic trauma
  8. Kidney trauma
  9. Pelvic fracture
  10. Abdominal wall injury

Treatment

  1. ATLS as usual
    1. ATLS primary surveyy
    2. ATLS secondary survey
  2. FAST exam to rule out intraperitoneal fluid and pericardial effusion
  3. NG/Foley
  4. BEWARE of chest tube placement
  5. Hemodynamically UNSTABLE
  6. If hemodynamically STABLE
  7. Emphasis on serial exams
  8. Consider need for antibiotics
  9. Tetanus prophylaxis
  10. Definitive management
  11. Complications

Disposition

  1. Admit patient
  2. Surgical repair for definitive treatment

 


  Physical Exam Investigations Management
Pulmonary Contusion - Blunt trauma to chest
- Interstitial edema impairs compliance and gas exchange
- CXR: areas of opacification of lung within 6 hours of trauma - maintain adequate ventilation
- monitor with ABG, pulse oximeter and ECG
- chest physiotherapy
- positive pressure ventilation if severe
 
Ruptured Diaphragm - Blunt trauma to chest or abdomen (e.g. high lap belt in MVC) - CXR:  abnormality of diaphragm/lower lung fields/NG tube placement   
- CT scan and endoscopy - sometimes helpful for diagnosis
- laparotomy for diaphragm repair and because of associated intra-abdominal injuries
Esophageal Injury - Usually penetrating trauma (pain out of proportion to degree of injury) - CXR: mediastinal air (not always)
- Esophagram (Gastrograffin)      
- Flexible esophagoscopy
- Early repair (within 24 hrs.) improves outcome but all require repair
Aortic Tear    
 
- 90% tear at subclavian (near ligamentum arteriosum), most die at scene
- salvageable if diagnosis made rapidly
- Sudden high speed deceleration (e.g. MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)

- Decreased femoral pulses, differential arm BP (arch tear)
- CXR, CT scan, transesophageal echo (TEE), aortography (gold standard)
- see below for CXR features
- Thoracotomy (may treat other severe injuries first)
Blunt Myocardial Injury (Rare) - Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)      
- Physical examination: overlying injury, i.e. fractures, chest wall contusion
- ECG: arrhythmias, ST changes
- Patients with a normal ECG and normal hemodynamics never get dysrhythmias
- O2
- Antiarrhythmic agents
- Analgesia