0071643192.pdf

TREATMENT

In penetrating chest trauma, ED thoracotomy is indicated if:

■ Patient loses signs of life in the ED or immediately before arrival (espe-

cially with narrow PEA).

■ SBP < 50 mmHg not responsive to fluids/blood

■ Severe shock with signs of tamponade

A 14–year-old male presents to the ED after falling forward onto the handle

bars of his bike. CT scan of the abdomen is negative. The patient complains

of persistent pain. What injuries should you be worried about?

Pancreas and duodenal injuries are classic for this mechanism. An occult dia-

phragmatic rupture should also be considered.

BLUNT ABDOMINAL TRAUMA

Diaphragmatic Injury

Diaphragmatic injury occurs in 1–6% of patients with multisystem trauma.

Only 22% of patients have diaphragmatic injury diagnosed at the time of injury.

MECHANISMS

■ Blunt trauma accounts for the majority of diaphragmatic injuries and typi-

cally results in a 5- to 15-cm defect in left posterolateral area.

■ Theleft diaphragmis injured three times more often than the right, due

to protection from the liver.

■ Tension viscerothorax, when the herniated abdominal contents shift the

mediastinum compressing the other lung, may occur.

SYMPTOMS/EXAM

■ Findings result from presence of abdominal contents in chest.

■ Shortness of breath

■ Abdominal pain radiating to the ipsilateral shoulder, worse when supine

■ Absent breath sounds or positive bowel sounds in the chest

■ Visceral obstruction (obstructive phase) will eventually develop, at which

time patients will have clear signs of bowel strangulation or respiratory

compromise.

DIAGNOSIS

■ None of the imaging modalities is sensitive for diaphragm injury. CXR has

only 40–50% accuracy.

■ Initial CXR usually shows blurring of left hemidiaphragm, LLL atelectasis.

■ CXR showing coiling of a nasogastric tube in the chest is diagnostic.

■ CT, MRI, and contrast studies aid in the diagnosis.

TREATMENT/COMPLICATIONS

■ Missed injuries tend not to healbecause of the negative intrathoracic

pressure promoting upward herniation of abdominal contents. For this

reason, surgical repair is required for even small diaphragmatic injuries.

TRAUMA

Evaluate possible esophageal

injury with a contrast

esophagram. Consider

endoscopy in patients with a

high likelihood of injury.

Unilateral absence of radial

pulse following chest trauma

implies subclavian artery

occlusion/disruption.