Diaphragmatic injury

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Diaphragmatic injury

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  • มีลมออกทาง ICD

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  • 1. DIAPHRAGMATIC INJURYDepartment of surgerySongkhla hospital
  • 2. CONTENT Anatomy Etiology Mechanism of injury Associated injury Sign and symptom Diagnostic approach Complication of Diaphragmatic injury Management
  • 3. ETIOLOGY DI 0.63% National Trauma Data Bank (NTDB) 65 % Penetrating injury 35 % Blunt injury
  • 4. ASSOCIATED INJURY 80-100% DI Spleen 50.0 % Rib 47.2 % Liver 38.9 % Lung 30.9 % Head 27.7 % Pelvic 27.7 % Other bones 30.5 % Bowel 19.4 % Kidney 13.9 % Great vessel 11.1 %
  • 5. ASSOCIATED INJURY Rt.diaphragmatic injury Associated intraabdominal injury ~100% Lt.diaphargmatic hernia injury Associated intraabdominal injury ~77% Descending aorta injury 5-8%
  • 6. MECHANISM OF INJURY Penetrating injury stabs, gunshot, shotgun and impalements Small wound (1-3 cm.) Blunt injury More common in left side (3-4 times) Posterolateral aspect Blunt force to abdomen or chest elevatepressure > +150-200 cmH2O Wound size 5-10 cm.
  • 7. SIGN AND SYMPTOM Early Shortness of breath Dyspnea Decreased breath sound Paradoxical movement of chest wall Late Abdominal pain Clinical of gut obstruction Audible bowel sound from chest area
  • 8. DIAGNOSTIC Suspected DI in patient with Blunt injury Blunt thoracic or abdomen injury Multiple fracture lower rib Penetrating injury Thoracoabdominal area (T4-T12) Delayed presentation Herniation of abdominal organ
  • 9. WORK UP Chest radiography Ultrasound Computer tomography Magnetic resonance imagine Laparoscopy Explore-Laparotomy
  • 10. CHEST RADIOGRAPHY Visualization of the stomach or otherabdominal organs in the chest Elevation of the diaphragm Lack of clarity of the hemidiaphragm Abnormal positioning of a nasogastric tube Basilar atelectasis Hemothorax from bleeding in the abdomen
  • 11. CHEST RADIOGRAPHY Collar sign
  • 12. CHEST RADIOGRAPHY
  • 13. ULTRASOUND FAST not standardized and a negative studycannot be used to exclude the diagnosis Finding discontinuity of diaphragm Hernia Floating diaphragm Nonvisualized diaphragm
  • 14. DPL To improve its sensitivity for diagnosingdiaphragmatic injuries in penetratingthoracoabdominal trauma, many clinicianshave modified the red blood count (RBC)criteria, accepting lower RBC counts(>10,000/mm3) to decrease the rate of falsenegative results.
  • 15. CT Discontinuity of the diaphragm Herniation of the abdominal contents into the chest Abnormal positioning of a nasogastric tube Waist-like constriction of bowel Viscera (liver, stomach) are in direct contact with theposterior ribs Contiguous injury from one side of the diaphragm tothe other (ie, left pulmonary laceration and spleniclaceration) Sensitivity 82-87 % Specificity 72-99 % - in bluntabdominal injury
  • 16. CT Discontinuity of the diaphragm
  • 17. CT Herniation of the abdominal contents into thechest
  • 18. CT Viscera (liver, stomach) are in direct contactwith the posterior ribs
  • 19. MRI High suspicious with others negative studied Time-consuming Hemodynamic patient
  • 20. MRICT MRI
  • 21. LAPAROSCOPY High sensitivity and specificity especially inpenetrating injury Have benefit in case that no indication forimmediated surgery
  • 22. EXPLORE-LAPAROTOMY Gold standard Unstable hemodynamic patient
  • 23. DIAPHRAGM INJURY SCALE Grade I: Contusion Grade II: Laceration ≤2 cm Grade III: Laceration 2 to 10 cm Grade IV: Laceration >10 cm; tissue loss ≤25 cm2 Grade V: Laceration and tissue loss >25 cm2
  • 24. COMPLICATION Herniation Left side - stomach, spleen, colon, small intestineomentum Right side - Liver or colon Cardiac herniation Diaphragm paralysis Pulmonary complication Rib fractures Pulmonary contusion Atelectasis Pleural effusion Empyema Biliary fistula biliary-pleural or bronchobiliary fistula formation
  • 25. MANAGEMENT Acute setting Explor laparotomy - Midline laparotomy incision Suture from abdomen: Small lacerations - interrupted, horizontal mattress,or figure-of-eight stitches: Larger lacerations - continuous or mesh(0,1-0 monofilament nonabsorbable suture) Avoid Thoracotomy Chronic stage (Delayed diagnosis) Anterolateralthoracotomy
  • 26. THANK YOU