Once diaphragmatic injury is identified, operative repair is indicated.
Primary repair can be achieved through a laparotomy incision and the
abdominal approach is preferred in the acute setting to rule out associated
injuries to other abdominal organs. The defect is closed with non-absorbable
sutures in horizontal mattress fashion. Large defects with significant tension
may require repair with a synthetic mesh patch or muscle flap. In cases where
there is a delay in diagnosis, a thoracic or combined thoracoabdominal
approach is preferred to reduce a mature diaphragmatic hernia sac.
I. Blunt Cardiac Injuries
Blunt cardiac injury in children occurs in less than 3% of pediatric trauma
patients. Majority of children who suffer blunt cardiac trauma are involved in a
motor vehicle crash. Cardiac contusions account for over 95% of blunt cardiac
injuries, while ventricular rupture and valvular disruption occur less frequently.
Suggestive physical findings for blunt cardiac injury include anterior
chest wall tenderness, visible chest wall contusion, anterior ribs fractures, or
sternal fracture. In addition, patients may present with dysrhythmias or
unexplained hypotension. Concern for blunt cardiac injury should be initially
evaluated with an EKG to rule out arrhythmias. Cardiac specific enzyme levels,
including CPK, CPK-MB, and troponin-I, may be elevated with blunt thoracic
trauma; however, their utility in identifying clinically significant blunt cardiac
injury is negligible. Echocardiography is only indicated in cases with an