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EMGuideWire's Radiology Reading Room: Diaphragm Injury Cases

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Diaphragm Injury Case Studies
Jacob Leedekerken, MD; Chelsea Wilson, MD;
Travis Barlock, MD
Departments of Emergency Medic...

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Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Prog...

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Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental ed...

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EMGuideWire's Radiology Reading Room: Diaphragm Injury Cases

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Jacob Leedekerken, MD, Chelsea Wilson, MD, and Travis Barlock, MD. It is has special guest editor: Kyle Cunningham, MD

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Jacob Leedekerken, MD, Chelsea Wilson, MD, and Travis Barlock, MD. It is has special guest editor: Kyle Cunningham, MD

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EMGuideWire's Radiology Reading Room: Diaphragm Injury Cases

  1. 1. Diaphragm Injury Case Studies Jacob Leedekerken, MD; Chelsea Wilson, MD; Travis Barlock, MD Departments of Emergency Medicine & Surgery Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Michael Gibbs, MD & Kyle Cunningham, MD Faculty Editors The Chest X-Ray Mastery Project
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process • Many are providing clinical cases and presentations are then shared with all contributors on our departmental educational website. • Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. • We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: Diaphragm Injury.
  4. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. It’s All About The Anatomy!
  6. 6. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  7. 7. Injury Demographics Maryland Shock Trauma Case Series 1995-2009, [n=773]: Penetrating 73% Blunt 27% Left 57% Right 40% Bilateral 3% Mortality: Left 17% Mortality: Right 26% *Overall Mortality 21% Factors Associated With Increased Mortality • Age • Injury severity score • Associated cardiac injury • Right diaphragm injury • Operative intervention Zarour A. JT&ACS 2013; 74:1391.
  8. 8. Injury Demographics National Trauma Data Bank Review: • Diaphragm injuries are rare, incidence: 0.46% • Mechanism: 67% penetrating and 33% blunt Penetrating Blunt  Gunshot wounds 67%  Motor vehicle crash 63%  Stab wounds 33%  Bicycle/pedestrian stuck 10% Mortality 9% Mortality 20% Fair KA. J Trauma 2015; 209:864-868.
  9. 9. Penetrating Injury The diaphragm is at risk with any penetrating wound occurring between: Williams, M. (2019). Recognition and management of diaphragmatic injuries in adults. In T.W. Post, E. Bulger, & K. Collins (Eds.), UptoDate. Available from https://www.uptodate.com/contents/recognition-and-management-of-diaphragmatic-injury-in-adults#H19492683 T4 and T8: Chest/Abdomen T4 and T12: Back
  10. 10. Associated Injuries In >50% Of Cases Williams, M. (2019). Recognition and management of diaphragmatic injuries in adults. In T.W. Post, E. Bulger, & K. Collins (Eds.), UptoDate. Available from https://www.uptodate.com/contents/recognition-and-management-of-diaphragmatic-injury-in-adults#H19492683
  11. 11. Radiologic Findings Chest X-ray signs: • Indistinct and/or elevated hemidiaphragm1 • Basilar atelectasis • Abdominal organs in the thorax • Abnormal nasogastric tube position 1Be cautious not to mistake a diaphragm injury for a hemothorax! CT scan signs: • Discontinuous diaphragm sign • Dependent viscera, dangling diaphragm, and collar signs (blunt) • Organ herniation into thorax • Diaphragm thickening • Contiguous injury (penetrating) Bonatti M, Lombardo F, Vezzali N, Zamboni GA, Bonatti G. Blunt diaphragmatic lesions: Imaging findings and pitfalls. World J Radiol 2016; 8(10): 819-828. Iochum, S., Ludig, T., Walter, F., Sebbag, H., Grosdidier, G., & Blum, A. G. (2002). Imaging of Diaphragmatic Injury: A Diagnostic Challenge? RadioGraphics, 22(suppl_1). doi: 10.1148/radiographics.22.suppl_1.g02oc14s103.
  12. 12. Discontinuous Diaphragm Sign The discontinuous diaphragm sign is present if there is visualization of direct discontinuity of the diaphragm, along with segmental non-visualization.
  13. 13. Dangling Diaphragm Sign The dangling diaphragm sign is present if the free edge of the torn diaphragm is visible, curled inward away from the chest wall towards the central abdomen.
  14. 14. Collar Sign The collar sign, also called the hourglass sign refers to a waist-like or collar-like appearance of herniated organs at the level of the diaphragm.
  15. 15. Intrathoracic Herniation Of Viscera Intrathoracic herniation of viscera is present if intrabdominal organs are visible within the thoracic cavity through the defect in the diaphragm.
  16. 16. Dependent Viscera Sign The dependent viscera sign is present if the liver abuts the posterior ribs on the right, and/or if bowel abuts the ribs, or lays posterior to the spleen on the left.
  17. 17. Contiguous Injury Across The Diaphragm Contiguous injury across diaphragm implying transdiaphragmatic penetration, is an indirect sign of (typically penetrating) diaphragmatic injury. Hemothorax & Lung ContusionLiver Laceration
  18. 18. Thickening Of The Diaphragm Thickening of the diaphragm may be present at the site of injury with or without retraction of the edges.
  19. 19. Carolinas Medical Center Case Studies
  20. 20. Case #1 61-Year-Old In A High Speed MVC Complains Of Chest And Abdominal Pain. While In The ED She Develops Worsening Respiratory Distress Requiring Intubation And Transfer To CMC.
  21. 21. Case #1 61-Year-Old In A High Speed MVC Complains Of Chest And Abdominal Pain. While In The ED She Develops Worsening Respiratory Distress Requiring Intubation And Transfer To CMC. Ruptured Diaphragm Elevated Hemidiaphragm
  22. 22. 61-Year-Old With A Ruptured Left Hemidiaphragm CT Scout Film Elevated Hemidiaphragm
  23. 23. 61-Year-Old With A Ruptured Left Hemidiaphragm Viscera Herniated Into The Chest
  24. 24. 61-Year-Old With A Ruptured Left Hemidiaphragm Courtesy: K. Cunningham, MD
  25. 25. 61-Year-Old With A Ruptured Left Hemidiaphragm Courtesy: K. Cunningham, MD
  26. 26. 61-Year-Old With A Ruptured Left Hemidiaphragm Post-Operative CXR
  27. 27. Case #2 17-Year-Old In A High Speed MVC Complains Of Abdominal Pain.
  28. 28. Case #2 17-Year-Old In A High Speed MVC Complains Of Abdominal Pain. Elevated Hemidiaphragm
  29. 29. Ruptured Diaphragm Viscera Herniated Into The Chest Case #2 17-Year-Old In A High Speed MVC Complains Of Abdominal Pain.
  30. 30. Case #3 57-Year-Old In A High Speed At An Outside ED.
  31. 31. Case #3 57-Year-Old In A High Speed At An Outside ED. Chest Tube Placed Initial Interpretation: Left Hemothorax
  32. 32. Ruptured Diaphragm Chest Tube In The Abdomen 57-Year Old In A High Speed MVC – Now At CMC.
  33. 33. Ruptured Diaphragm With Chest Tube Next To The Stomach 57-Year Old In A High Speed MVC – Now At CMC.
  34. 34. Case #4 45-Year-Old Male Involved In A Roll-Over Car Crash. Intubated In The Field.
  35. 35. Elevated Hemidiaphragm Case #4 45-Year-Old Male Involved In A Roll-Over Car Crash. Intubated In The Field.
  36. 36. Ruptured Diaphragm Viscera Herniated Into The Chest 45-Year-Old MVC
  37. 37. Case #4 45-Year-Old Male With Rupture Of The Left Hemidiaphragm. Chest X-Ray After Repair
  38. 38. Case #5 60-Year Old In A Motor Vehicle Crash.
  39. 39. The Left Hemidiaphragm Is Indistinct. Case #5 60-Year Old In A Motor Vehicle Crash.
  40. 40. 60-Year Old In A Motor Vehicle Crash. Ruptured Diaphragm Collar Sign
  41. 41. Case #6 46-Year Old In A Motor Vehicle Crash. Elevated Hemidiaphragm Disarticulated Rib
  42. 42. Case #6 46-Year Old In A Motor Vehicle Crash. Spleen Herniated Into The Thorax Viscera Herniated Through The Chest Wall
  43. 43. Case #6 46-Year Old In A Motor Vehicle Crash. The Patient Also Has A Tear Of The Descending Aorta
  44. 44. 46-Year-Old With A Ruptured Left Hemidiaphragm Courtesy: G. Sachdev, MD
  45. 45. 46-Year-Old With A Ruptured Left Hemidiaphragm Courtesy: G. Sachdev, MD
  46. 46. 46-Year-Old With A Ruptured Left Hemidiaphragm - Repaired ***** Courtesy: G. Sachdev, MD
  47. 47. Case #6 46-Year Old In A Motor Vehicle Crash. Chest X-Ray After Repair And Aortic Endograph Placement
  48. 48. SUMMARY Of 2018 EAST Practice Management Guidelines #1 In stable patients with left thoracoabdominal stab wounds, laparoscopy is recommended rather than CT imaging to decrease the incidence of missed diaphragm injuries. #2 In stable patients with confirmed or suspected penetrating injuries of the right diaphragm, non-operative management is recommended over operative management. #3 In stable patients with acute diaphragm injuries, the abdominal rather than the thoracic approach is preferred for injury repair. #4 In patients with acute penetrating diaphragm injuries without concerns for other intraabdominal injuries, laparoscopic repair is recommended over open repair.
  49. 49. If you have interesting cases of Diaphragm Injury, we invite you to send a set of digital PDF Images and a brief descriptive clinical history to: michael.gibbs@atriumhealth.org Your De-Identified case(s) will be posted on our education website and you and your institution will be recognized!

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