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

Abstract

The objectives of this study are (1) to evaluate prevalence of traumatic diaphragmatic injury (TDI), (2) identify the predictors of mortality, and (3) study the accuracy of investigations in survivors of TDI. Retrospective analysis of prospectively maintained database of TDI from January 2007 to December 2011. Emergency department (ED) records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the SPSS ver.15 software. TDI was identified in 75 individuals. Thirty-two of 75 (42.6 %) cases were brought dead to the hospital, and 43/75 (57.3 %) were survivors presented to emergency department, diagnosed to have TDI intraoperatively. Seven of 43 (16.3 %) died postoperatively. Mortality in TDI was significantly related to age (p =0.001), injury severity (p <0.001), site of TDI (p =0.002), and associated injuries (p =0.021, odds ratio of 9). Death increased with increase in the number of organ injured (p <0.001, odds ratio of 12). Multi-detector computer tomography (MDCT) detected TDI in 23/26 (88.5 %) cases preoperatively. Laparotomy (p <0.001, odds ratio of 22) and thoracotomy (p =0.021, with odds ratio of 9) were associated with survival benefit when compared to minimal invasive surgery in injured cases. The prevalence of TDI was 2.67 %, TDI's mark severity of injury. Mortality increases with increasing number of organ injured. Right-sided or bilateral injury of diaphragm is associated with increased mortality.

Descriptive Analysis of Right and Left-sided Traumatic Diaphragmatic Injuries; Case Series from a Single Institution

“…Our findings are in accordance with these reports with predominance of LTDI (79%) followed by RTDI (21%). TDI is considered as a marker of severe trauma with high injury severity [23], which is evident from the overall mean ISS of 23 in our cohort. Furthermore, patients with LTDI had higher mean ISS than RTDI.…”

“…Table 4 summarizes the most recent TDI studies from different countries [1,3,[14][15][16][17][18][19][20][21][22][23][24][25][26][27]. However, we may underestimate the incidence of TDI as the majority of mild (missed) or severe (died before diagnosis) lesions can be difficult to diagnose or because of the unavailability of routine postmortem examination in the state of Qatar.…”

“…Motor vehicle crash (MVC) is the most frequent blunt injury mechanism involved in ~ 90% of the cases [4]. The possible cause of TDI in such cases may be lateral impacts which shear the stretched diaphragm as well as the frontal impacts and crushing which increase the intra-abdominal pressure resulted in avulsion and extensive rupture [5]. Penetrating injuries such as gunshot or stab wounds resulted in direct diaphragmatic rupture with small holes (<1 cm), which are often missed or difficult to diagnose [6].…”

“…Therefore, the initial radiological assessment might overlook TDI, and there may be a missed diagnosis, which leads to increased morbidity and mortality [8]. The recent adoption of non-operative management approach for blunt abdominal trauma also attributed to the increased underlying missed TDI injuries ranging from12%-66% [5]. This wide variation could be explained in part by the widespread adoption of nonoperative management strategy in hemodynamically stable patients.…”

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

“…4,9 Thus, delayed routine diagnostic laparoscopy is indicated for left thoracoabdominal trauma. [9][10][11][12] Finally, flank/back penetrating trauma is assessed mainly by im aging as the retroperitoneum is difficult to examine. From the radiologic perspective, there is evidence that oral and rectal contrast may enhance the ability to identify duo denal and colonic injuries, respectively, in such regions.…”