ECMO-/ECLS

absorb a significant amount of kinetic energy. A common sequelae of
diaphragm injury is herniated abdominal viscera into the thoracic cavity through
the diaphragmatic defect. Abdominal contents in the pleural space can
subsequently compromise lung expansion, impair cardiac function, or volvulize
and strangulate.
Patients with traumatic diaphragmatic injuries may present with dyspnea,
abdominal pain, or vomiting. Physical examination may identify non-specific
findings such as abdominal tenderness or unilateral decreased breath sounds.
Unfortunately, diagnosis of diaphragmatic injury based solely on history and
physical exam is extremely challenging. Delay in diagnosis occurs in 15% to
77% of patients.
A surveillance chest x-ray usually provides the first clue to a
diaphragmatic injury with gastrointestinal contents seen in the thoracic cavity.
With a left sided injury, a nasogastric tube can be placed in the stomach and
the tip will be seen in the thoracic cavity confirming the diagnosis. Right sided
injuries are more difficult to identify and may be seen as an elevated right hemi-
diaphragm. Hemodynamically stable patients may undergo CT scan, which
has an 82% specificity and 87% sensitivity, and herniated liver or
gastrointestinal contents in the chest are more easily visualized. Up to one-
third of diaphragmatic injuries are not diagnosed after thorough evaluation with
imaging studies. In cases where there is significant concern for diaphragmatic
injury, such as penetrating injury traversing across the level of the diaphragm,
diagnostic laparoscopy should be considered.