Blunt traumatic rupture of the diaphragm: sonographic diagnosis

Symptomatic hepatothorax presenting 25 years after penetrating thoracoabdominal injury

Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation. A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home. CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.

Ultrasound-guided perioperative management of 28-month-old patient with congenital diaphragmatic eventration

Diaphragmatic eventration is a rare anomaly. When patients with this condition undergo general anesthesia, anesthetic management should be performed with particular care owing to the risk of diaphragmatic rupture. Such a rupture can be perioperatively diagnosed using multiple tools including lung ultrasonography. This case report describes the anesthetic management of a male infant with osteochondroma in the distal ulna, presenting with diaphragmatic eventration on the right side.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Beyond E-FAST scan in trauma: Diagnosing of traumatic diaphragmatic rupture with bedside ultrasound

Traumatic diaphragmatic rupture is relatively rare, and even more difficult to diagnose. Physical examination often fails to identify this injury, and basic investigation like chest x-ray can miss this half of the time. Although not part of standard FAST (focused assessment with sonography for trauma) ultrasound scan in trauma, bedside ultrasound has the potential to pick up this pathology. This case illustrates that ultrasound in trauma can go beyond standard E-FAST (extended FAST) protocol.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTION

Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

PRESENTATION OF CASE

A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

DISCUSSION

We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

CONCLUSION

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.

Hepatothorax: a rare outcome of high-speed trauma

Diaphragmatic ruptures are the result of severe blunt trauma or penetrating trauma. Motor vehicle crashes are a common mechanism associated with blunt diaphragmatic rupture (BDR). Incorporating diagnostic tools and laparotomy assist in the diagnosis and treatment of BDR. However, diagnosing BDR can be a challenge for practitioners. Early diagnosis and treatment improve the patient's outcomes. This paper details the events of a patient received in a level I trauma unit.

FAST scan in the diagnosis of acute diaphragmatic rupture

Focused assessment with sonography in trauma (FAST) scan can be used by emergency physicians in the diagnosis of diaphragmatic rupture in blunt abdominal trauma. We introduce a new feature 'Rip's absent organ sign' on FAST scan in the diagnosis of acute diaphragmatic rupture.

[The value of sonography in traumatology and orthopedics : Part 2: emergency diagnostics in blunt abdominal and thoracic trauma]

Ultrasound examinations in trauma patients should be done in the emergency department using curved-array (3.5-7.5 MHz) probes. Blunt trauma of the abdomen and thorax must be regarded as a single organ injury. Sonography is the imaging technique of first choice and has completely replaced peritoneal lavage. Paramount advantages are its ability to provide rapid information and reproducible results at short intervals and in a noninvasive manner. The sensitivity and specificity of sonography in detecting intraabdominal fluid are 97-100% and 80-90%, respectively. To achieve such good results, though, adequate education in ultrasound and state-of-the-art devices is crucial. Clinical experiences prove that standardized sonography must be part of polytrauma management and should be integrated in advanced trauma life support courses. Technical improvements with better image quality and miniaturization of hardware will contribute to increase the use of this technique. However, ultrasound does not replace computed tomography for follow-up in answering more sophisticated questions in multiple injured patients.

Imaging of diaphragm injuries

Diaphragm injuries are uncommon consequences of blunt and penetrating trauma. Early diagnosis and repair prevent potentially devastating complications that typically result from visceral herniation through the posttraumatic diaphragm defect. Although clinical and radiographic manifestations frequently are nonspecific, the stalwarts of trauma imaging--chest radiography and CT--typically demonstrate these injuries. To render the appropriate diagnosis, the radiologist must be familiar with the varied imaging manifestations of injury, and maintain a high index of suspicion within the appropriate clinical setting.

Diaphragm ultrasonography as an alternative to whole-body plethysmography in pulmonary function testing

OBJECTIVE

Whole-body plethysmography is a common method of measuring pulmonary function. Although this technique provides a sensitive measure of pulmonary function, it can be problematic and unsuitable in some patients. The development of more accessible techniques would be beneficial.

METHODS

A prospective study was performed to validate diaphragm ultrasonography as an alternative to whole-body plethysmography in patients referred for pulmonary function testing. Diaphragm movement and position were assessed by ultrasonography after standard pulmonary function testing using whole-body plethysmography.

RESULTS

A wide range of lung function was observed. Standard lung volumes were as follows: total lung capacity, 5.57 +/- 1.31 L, residual volume, 2.27 +/- 0.56 L; and vital capacity, 3.30 +/- 0.98 L (mean +/- SD). The ratio of forced expiratory volume in 1 second to forced vital capacity was calculated as 0.69 +/- 0.08. Ultrasonography showed that mean diaphragm excursion values were 11.1 +/- 3.8 mm (2-dimensional), 14.7 +/- 4.1 mm during quiet breathing (M-mode), and 14.8 +/- 3.9 mm during a maximal sniff (M-mode). The velocity of diaphragm movement rose sharply during the sniff maneuver from 15.2 +/- 5.8 mm/s during quiet breathing to 104.0 +/- 33.4 mm/s. Static 2-dimensional measures of diaphragm position at the end of quiet inspiration or expiration correlated with standard measures of lung volume on plethysmography (eg, a correlation coefficient of 0.83 was obtained with end inspiration and vital capacity). All measures of diaphragm movement (whether by 2-dimensional or M-mode techniques) were poorly correlated with any lung volumes measured.

CONCLUSIONS

These data suggest that dynamic measurements using diaphragm ultrasonography provide a relatively poor measure of pulmonary function in relation to whole-body plethysmography.

Change in differential diagnosis and patient management with the use of portable ultrasound in a remote setting

OBJECTIVE

Physicians practicing in remote areas are typically limited in their choice of diagnostic tools. The goal of this study was to determine whether the use of a portable ultrasound (US) device on selected patients in a remote setting would alter physician diagnosis and management.

METHODS

This was a prospective observational study of the affects of US on physician decision making deep in the Amazon jungle. A battery-operated Sonosite 180 Plus with 2 interchangeable transducers (4-7-MHz broadband intercavitary transducer and 2-5-MHz broadband abdominal transducer) was used. The patient population consisted of local tribal people. Two of the physicians on the team performed all US examinations. Team physicians requesting US examinations filled out a survey before and after the US examination. Before the US, the referring physician filled out a survey describing the patient's initial complaint, pertinent past medical history and physical findings, and an initial (pre-US) differential diagnosis and planned treatment with expected disposition. After the results of the US were reviewed with the referring physicians, the doctors were asked to fill out the remainder of the survey, allowing comparison of pre- and post-US differential diagnosis, treatment plan, and disposition.

RESULTS

A total of 25 US studies were performed during this study (1 trauma US scan, 6 hepatobiliary studies, 5 transabdominal pelvic scans, 7 transvaginal pelvic studies, 3 renal studies, and 3 abdominal aortic scans). The monitor on the US unit experienced a rare failure shortly after being used at 17,000 ft and then 10 times at sea level, and no further US scans could be performed. US scan results dramatically altered the disposition of 7 patients, including 4 patients who avoided a potentially dangerous 2-day evacuation to more definitive medical care. Three patients were found to need rapid referral to the nearest clinic for surgical evaluation.

CONCLUSIONS

When used in a remote location, portable US provides a significant benefit that can dramatically alter disposition and treatment.

Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma

Abdominal injury from significant blunt trauma can include injury to bowel, kidneys, liver, and spleen. In approximately 5% of all injuries one of the diaphragms is ruptured. Diaphragmatic rupture may not be easily detected and this can lead to significant morbidity and even mortality. Rupture may be suggested on chest X-ray film especially with abnormal nasogastric tube location but the accuracy of this method is modest only. Abdominal computed tomography is not accurate and magnetic resonance imaging, although very sensitive and specific, is not feasible in most trauma situations. Surgeons have often resorted to exploratory laparotomy or laparoscopy to make the diagnosis. Although not typically part of the basic Focused Abdominal Sonography for Trauma (FAST) examination, ultrasonographic diagnosis of diaphragmatic rupture is possible with little added time to the examination. We present 3 cases of diaphragmatic rupture discovered shortly after the patients' arrival, on initial trauma evaluation with the FAST. A discussion of previous literature and ultrasound technique for diagnosis follows the cases.

Asymptomatic liver segment herniation through a postoperative defect in the right hemidiaphragm following aortic bypass graft surgery

We present a 16-year-old girl with asymptomatic liver segment herniation following aortic graft surgery for atypical coarctation of the aorta. The defect in the right hemidiaphragm was caused by the implantation of an ascending thoracic aorta to upper abdominal aortic bypass graft. The differential diagnosis of diaphragmatic defects as well as the role of various imaging modalities in establishing the diagnosis are discussed.

The diagnostic dilemma of traumatic rupture of the diaphragm

BACKGROUND

Traumatic rupture of diaphragm is caused by blunt or penetrating trauma. Early diagnosis is difficult, and complications such as visceral herniation may arise. A 10-year evaluation of all diagnostic procedures used in patients with surgically proved traumatic rupture of the diaphragm is presented.

METHODS

A review of all patients with surgically proved diaphragmatic injury from 1988 to 1998 was conducted. All diagnostic methods were analyzed in terms of their ability to identify diaphragmatic rupture.

RESULTS

During the study period, 31 patients with a mean age of 34 years were treated. Of these patients, 20 sustained blunt trauma and 11 experienced penetrating trauma. The initial chest x-ray was diagnostic for 6 of the 31 patients, nonspecific for 15 of the patients, and normal for 10 of the patients. In no case was sonography diagnostic. Thoracoabdominal computed tomography (CT), performed in 22 of the patients, led to diagnosis for 5 patients and unspecific findings for 17 patients. Statistical analyses showed no significant difference between initial chest x-ray and thoracoabdominal CT. No significant difference between blunt or penetrating trauma or between left-side and right-side ruptures could be recognized with any diagnostic tool.

CONCLUSIONS

All the diagnostic methods investigated in this study showed unsatisfying results, and traumatic rupture of the diaphragm seems to remain a diagnostic dilemma. Endoscopic techniques not tested in this study and discussed controversially may offer a good chance for early diagnosis and repair of the injured diaphragm.

Diaphragmatic rupture and the association with occupant position in right-hand drive vehicles

Ruptured diaphragm following blunt trauma occurs with an incidence of 3 to 8% with right-sided rupture recognised with increasing frequency. This study aimed to investigate the influence of occupant position in right-hand drive (RHD) vehicles on the side of diaphragmatic injury. A retrospective analysis of the Scottish Trauma Audit Group database was performed to gather data on blunt diaphragmatic lacerations. Police records were also searched to ascertain the point of impact in the accidents studied. In total, 35 patients were studied, 25 drivers and 10 front-seat passengers. The incidence of right-sided rupture was 40% in drivers and 20% in FSPs. The incidence of associated pulmonary contusion, rib fracture and liver injury was also higher in drivers. Given the small sample size, these differences were not statistically significant, but they show an interesting trend. The right side of a driver's body is more exposed to injury in RHD vehicles, a fact that explains the significant association between driver's side impact and right-sided rupture. As right-sided injury is more difficult to detect, it is important that a high index of suspicion is maintained, especially when managing drivers from RHD vehicles.