Concern for esophageal perforation should be further evaluated with a
water-soluble esophagram. Up to 15% of perforations may be missed with
water-soluble contrast, so a negative study should be followed by a barium
contrasted esophagram. Endoscopic evaluation is used selectively in
inconclusive swallow studies.
Once an esophageal injury is identified, prompt intervention is necessary
to prevent mediastinitis. Operative repair is directed to the site of injury with
goals to debride areas of contamination, primarily close the perforation with
autologous tissue reinforcement, and control for esophageal leak with tube
thoracostomy drainage. Non-operative management may be considered in
select cases where there is a contained perforation without evidence of
mediastinitis.
H. Diaphragm Injuries
Diaphragmatic injuries occur in 1% to 2% of pediatric chest traumas.
Traumatic injuries are more commonly caused by lacerating penetrating
agents; however, blunt diaphragmatic rupture is possible in high energy
acceleration-deceleration traumas where a sudden elevation in intra-abdominal
pressure results in diaphragm avulsion. The most common mechanisms of
blunt diaphragm injury are motor vehicle accidents and falls.
Thoracoabdominal penetrating injuries may also result in diaphragmatic
injuries. Injuries to the diaphragm most commonly occur on the left side,
because the right hemi-diaphragm is well-protected by the liver, which can