Traumatic Diaphragmatic Injury: A Marker of Serious Injury Challenging Trauma Surgeons

Diaphragmatic rupture secondary to trauma from falling sacks: A case report

Key Clinical Message

Diaphragmatic hernia does not only occur during high velocity impact or penetrating injury, but also can occur when heavy loads impact the torso. Diaphragmatic hernia must be ruled out in a patient with polytrauma with a chest X-ray at the least.

Abstract

Trauma-induced diaphragmatic hernia is a protrusion of abdominal contents through the defect in diaphragm and is an uncommon and less heard of injury. This case report conveys that diaphragmatic hernia should be ruled out in any polytrauma case presenting with shortness of breath with the chest X-ray at the least.

Selective nonoperative management of penetrating abdominal trauma at a level 1 Canadian trauma centre: a quest for perfection

Background

Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre.

Methods

We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies.

Results

We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9–43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects.

Conclusion

Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.

Traumatic rupture of the diaphragm resulting in the sub-acute presentation of an incarcerated intra-thoracic transverse colon

The traumatic rupture of the diaphragm after blunt or penetrating injuries is a well described but uncommon entity. Its presentation in the form of herniated abdominal contents into the thoracic cavity is generally obscure and the recognition of this condition is often challenging. Although many cases remain asymptomatic, significant morbidity and mortality ensues with patients who present with incarceration, strangulation and eventual visceral compromise. Definitive guidelines in the management of traumatic diaphragmatic injuries are still lacking. This report outlines a case of sub-acute presentation of a traumatic diaphragmatic rupture in an elderly female following a motor vehicle accident that required urgent surgical intervention. We reviewed the pertinent literature, with an emphasis on the operative approach and the type of repair of the traumatic diaphragmatic defect.