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.
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
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
WORK UP Chest radiography Ultrasound Computer tomography Magnetic resonance imagine Laparoscopy Explore-Laparotomy
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
ULTRASOUND FAST not standardized and a negative studycannot be used to exclude the diagnosis Finding discontinuity of diaphragm Hernia Floating diaphragm Nonvisualized diaphragm
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.
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