So far yung LIs natin are: 1. Penetration - how to identify it, how deep? 2.

Hole in the diaphragm - how

does it something about shape 3. Tension pneumothorax - how do you reduce the pressure murag
process of thoracostomy (Marc) 4. Interpretation ng lab results
https://en.m.wikipedia.org/wiki/Penetrating_trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of
the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact,
but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back
out the way it entered, or pass through the tissues and exit from another area.[1] An injury in which
an object enters the body or a structure and passes all the way through is called a perforating injury,
while penetrating trauma implies that the object does not pass through.[2] Perforating trauma is
associated with an entrance wound and an often larger exit wound.
Penetrating trauma can be caused by a foreign object or by fragments of a broken bone. Usually
occurring in violent crime or armed combat,[3] penetrating injuries are commonly caused
by gunshots and stabbings.[4]
Penetrating trauma can be serious because it can damage internal organs and presents a risk
of shock and infection. The severity of the injury varies widely depending on the body parts
involved, the characteristics of the penetrating object, and the amount of energy transmitted to the
tissues.[4] Assessment may involve X-rays or CT scans, and treatment may involve surgery, for
example to repair damaged structures or to remove foreign objects. Following penetrating
trauma, spinal motion restriction is associated with worse outcomes and therefore its should not
be done routinely.

http://www.hsj.gr/medicine/wound-ballistics-analysis-of-blunt-and-penetrating-trauma-
mechanisms.php?aid=3579&fbclid=IwAR26SI4tCE3iuZFQiICsAhelytucQCULhS2M6O7HO-
YDZML0zbpQPkLp83I

In all penetrating trauma, tissue is crushed by the penetrating object. That tissue does not survive.
Similar to the effect of a bullet passing through tissue, if a penetrating object other than a bullet is large
enough or moving fast enough, some blunt trauma, due to displacement of tissue adjacent to the path
of the penetrating object, will occur. This is identical to the type of blunt trauma occurring during
temporary cavitation in certain gunshot wounds. The ability to survive temporary cavitation blunt
trauma is very specific. More elastic, more cohesive tissue, such as skeletal muscle, lung, empty
intestine, nerve, blood vessel and to some extent bone, can tolerate this quite well. Less elastic, less
cohesive organs, such as liver, brain and heart, do not tolerate temporary cavitation blunt trauma well
[1].
In typical urban gunshot wounds, all of the tissue injuries are caused by tissue crushed by the bullet,
its fragments or the secondary missiles it creates by breaking apart the structures through, which it
passes. Significant temporary cavitation is very uncommon in urban gunshot wounds, because the
most are caused by less potent handguns. A center-fire rifle or large handgun is usually required to
fire a bullet capable of causing significant temporary cavitation [2].
Blunt trauma can be local, such as from being struck with a hammer or the local blunt trauma of
temporary cavitation associated with penetrating trauma. Blunt trauma can be diffuse, such as that
resulting from failing from a height or being an unrestrained passenger in a high-speed motor vehicle
accident. The tissues that tolerate well the blunt trauma from tissue displacement during temporary
cavitation stretch also tolerate blunt trauma from other causes well [3].

Diaphragmatic rupture (also called diaphragmatic injury or tear) is a tear of the diaphragm, the
muscle across the bottom of the ribcage that plays a crucial role in respiration. Most commonly,
acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from
blunt or penetrating trauma[2] and occurs in about 5% of cases of severe blunt trauma to the trunk.[3]
Diagnostic techniques include X-ray, computed tomography, and surgical techniques such
as laparotomy. Diagnosis is often difficult because signs may not show up on X-ray, or signs that do
show up appear similar to other conditions. Signs and symptoms included chest and abdominal pain,
difficulty breathing, and decreased lung sounds. When a tear is discovered, surgery is needed to
repair it.
Injuries to the diaphragm are usually accompanied by other injuries, and they indicate that more
severe injury may have occurred. The outcome often depends more on associated injuries than on
the diaphragmatic injury itself.[4] Since the pressure is higher in the abdominal cavity than the chest
cavity, rupture of the diaphragm is almost always associated with herniation of abdominal organs
into the chest cavity, which is called a traumatic diaphragmatic hernia.[5] This herniation can
interfere with breathing, and blood supply can be cut off to organs that herniate through the
diaphragm, damaging them.[6]

Signs and symptoms[edit]

Breath sounds on the side of the rupture may be diminished, respiratory distress may be present,
and the chest or abdomen may be painful.[3] Orthopnea, dyspnea which occurs when lying flat, may
also occur,[7] and coughing is another sign.[5] In people with herniation of abdominal organs, signs of
intestinal blockage or sepsis in the abdomen may be present.[5] Bowel sounds may be heard in the
chest, and shoulder or epigastric pain may be present.[4] When the injury is not noticed right away,
the main symptoms are those that indicate bowel obstruction.[4] These people present months later,
with vague symptoms that do not necessarily relate to an injury.[8]

Causes[edit]
The injury may be caused by blunt trauma, penetrating trauma, and by iatrogenic causes (as a result
of medical intervention), for example during surgery to the abdomen or chest.[4]Injury to the
diaphragm is reported to be present in 8% of cases of blunt chest trauma.[9] In cases of blunt
trauma, vehicle accidents and falls are the most common causes.[4]Penetrating trauma has been
reported to cause 12.3–20% of cases, but it has also been proposed as a more common cause than
blunt trauma; discrepancies could be due to varying regional, social, and economic factors in the
areas studied.[2] Stab and gunshot wounds can cause diaphragmatic injuries.[4] Clinicians are trained
to suspect diaphragmatic rupture particularly if penetrating trauma has occurred to the lower chest or
upper abdomen.[10] With penetrating trauma, the contents of the abdomen may not herniate into the
chest cavity right away, but they may do so later, causing the presentation to be delayed.[4] Since the
diaphragm moves up and down during breathing, penetrating trauma to various parts of the torso
may injure the diaphragm; penetrating injuries as high as the third rib and as low as the twelfth have
been found to injure the diaphragm.[11]

Mechanism[edit]
Although the mechanism is unknown, it is proposed that a blow to the abdomen may raise the
pressure within the abdomen so high that the diaphragm bursts.[4] Blunt trauma creates a large
pressure gradient between the abdominal and thoracic cavities; this gradient, in addition to causing
the rupture, can also cause abdominal contents to herniate into the thoracic cavity.[7] Abdominal
contents in the pleural space interfere with breathing and cardiac activity.[7] They can interfere with
the return of blood to the heart and prevent the heart from filling effectively, reducing cardiac
output.[7] If ventilation of the lung on the side of the tear is severely inhibited, hypoxemia (low blood
oxygen) results.[7]
Usually the rupture is on the same side as an impact.[11] A blow to the side is three times more likely
to cause diaphragmatic rupture than a blow to the front.[11]

Diagnosis[edit]
Initially, diagnosis can be difficult, especially when other severe injuries are present; thus the
condition is commonly diagnosed late.[3] Chest X-ray is known to be unreliable in diagnosing
diaphragmatic rupture;[7] it has low sensitivity and specificity for the injury.[5] Often another injury such
as pulmonary contusion masks the injury on the X-ray film.[4] Half the time, initial X-rays are normal;
in most of those that are not, hemothorax or pneumothorax is present.[7] However, there are signs
detectable on X-ray films that indicate the injury. On an X-ray, the diaphragm may appear higher
than normal.[3] Gas bubbles may appear in the chest, and the mediastinum may appear shifted to the
side.[3] A nasogastric tube from the stomach may appear on the film in the chest cavity; this sign
is pathognomonic for diaphragmatic rupture, but it is rare.[7] A contrast medium that shows up on X-
ray can be inserted through the nasogastric tube to make a diagnosis.[3] The X-ray is better able to
detect the injury when taken from the back with the patient upright, but this is not usually possible
because the patient is usually not stable enough; thus it is usually taken from the front with the
patient lying supine.[5] Positive pressure ventilation helps keep the abdominal organs from herniating
into the chest cavity, but this also can prevent the injury from being discovered on an X-ray.[7]

Diaphragmatic rupture in a dog

Diaphragmatic rupture with spleen herniation

Computed tomography has an increased accuracy of diagnosis over X-ray,[9] but no specific findings
on a CT scan exist to establish a diagnosis.[10] Although CT scanning increases chances that
diaphragmatic rupture will be diagnosed before surgery, the rate of diagnosis before surgery is still
only 31–43.5%.[9] Another diagnostic method is laparotomy, but this misses diaphragmatic ruptures
up to 15% of the time.[7] Often diaphragmatic injury is discovered during a laparotomy that was
undertaken because of another abdominal injury.[7]Because laparotomies are more common in those
with penetrating trauma then compared to those who experienced a blunt force injury, diaphragmatic
rupture is found more often in these persons.[12] Thoracoscopy is more reliable in detecting
diaphragmatic tears than laparotomy and is especially useful when chronic diaphragmatic hernia is
suspected.[7]

Location[edit]
Between 50 and 80% of diaphragmatic ruptures occur on the left side.[5] It is possible that the liver,
which is situated in the right upper quadrant of the abdomen, cushions the diaphragm.[4] However,
 injuries occurring on the left side are also easier to detect in X-ray films.[7] Half of diaphragmatic
ruptures that occur on the right side are associated with liver injury.[5] Injuries occurring on the right
are associated with a higher rate of death and more numerous and serious accompanying
injuries.[11] Bilateral diaphragmatic rupture, which occurs in 1–2% of ruptures, is associated with a
much higher death rate (mortality) than injury that occurs on just one side.[5]

Treatment[edit]
Since the diaphragm is in constant motion with respiration, and because it is under tension,
lacerations will not heal on their own.[11] Surgery is needed to repair a torn diaphragm.[3]Most of the
time, the injury is repaired during laparotomy.[10] Other injuries, such as hemothorax, may present a
more immediate threat and may need to be treated first if they accompany diaphragmatic
rupture.[4] Video-assisted thoracoscopy may be used.[7]

Prognosis[edit]
In most cases, isolated diaphragmatic rupture is associated with good outcome if it is surgically
repaired.[4] The death rate (mortality) for diaphragmatic rupture after blunt and penetrating trauma is
estimated to be 15–40% and 10–30% respectively, but other injuries play a large role in determining
outcome.[4]

Complications[edit]
A significant complication of diaphragmatic rupture is traumatic diaphragmatic herniation: organs
such as the stomach that herniate into the chest cavity and may be strangulated, losing their blood
supply.[3] Herniation of abdominal organs is present in 3–4% of people with abdominal trauma who
present to a trauma center.[10]

Epidemiology[edit]
Diaphragmatic injuries are present in 1–7% of people with significant blunt trauma[4] and an average
of 3% of abdominal injuries.[10] A high body mass index may be associated with a higher risk of
diaphragmatic rupture in people involved in vehicle accidents.[4] It is rare for the diaphragm alone to
be injured, especially in blunt trauma; other injuries are associated in as many as 80–100% of
cases.[7][9] In fact, if the diaphragm is injured, it is an indication that more severe injuries to organs
may have occurred.[9] Thus, the mortality after a diagnosis of diaphragmatic rupture is 17%, with
most deaths due to lung complications.[9] Common associated injuries include head injury, injuries to
the aorta, fractures of the pelvis and long bones, and lacerations of the liver and spleen.[7] Associated
injuries occur in over three quarters of cases.[11]

https://www.nm.org/conditions-and-care-areas/pulmonary/thoracic-surgery/diaphragmatic-hernia
What Are Disorders of the Diaphragm?
The diaphragm is a muscular barrier between the chest and the abdominal cavity. Disorders of the
diaphragm often interfere with breathing. There are a number of disorders that can impact the
diaphragm, including:
 Congenital (present at birth) diaphragmatic hernia (CDH): Before birth, a hole in the diaphragm
allows the baby’s digestive organs to move into the chest cavity, reducing the space for the lungs
and causing breathing problems.
 Acquired diaphragmatic hernia (ADH): Blunt trauma, stab wounds or gunshot wounds can cause
a hole to develop in the diaphragm that allows the digestive organs to move into the chest cavity and
interfere with breathing.
 Hiatal hernia: This is when part of your stomach pushes through your diaphragm and into the
esophagus, leading to acid reflux.
 Diaphragmatic tumor: Tumors that begin in the diaphragm are rare and often benign
(noncancerous). Tumors can also appear in the diaphragm after metastasizing (spreading) from the
lungs or liver.
 Paralysis of the diaphragm: When the phrenic nerve is injured, one side or both sides of the
diaphragm can become paralyzed, compromising lung function.

https://www.healthline.com/symptom/abdominal-rigidity

What Causes Abdominal

Rigidity?
Abdominal rigidity is a state of stiffness of your stomach muscles that worsens when
you touch (or someone else touches) your abdomen. This is an involuntary response to
prevent pain caused by pressure on your abdomen. Another term for this... Read More

6 possible conditions
 Abdominal Pain
 Pain
 Fever
 Feels Hot to Touch
 Lower Abdominal Pain
 Abdominal Bloating
 Abdominal Tenderness
 Abdominal Mass
 Vomiting
 Abdominal Swelling
 Abdominal Pain Radiating to The Back
 Aversion to Food Or Drink
Add symptoms to narrow your search

1.

Everything You Need to Know About

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This condition is considered a medical emergency. Urgent care may be required.

The aorta carries blood from your heart to your abdomen, legs, and pelvis.
When the abdominal aortic walls are swollen, it's known as abdominal aortic
aneurysm.

https://www.healthline.com/symptom/abdominal-tenderness

What Causes Abdominal

Tenderness?
Abdominal tenderness, or point tenderness in your abdomen, is when pressure on an
area of your abdomen causes pain. It may also feel sore and tender. If the removal of
pressure causes pain, then that’s known as rebound tenderness or Blumberg
sign.... Read More
 15 possible conditions
 Abdominal Pain
 Fever
 Pain
 Lower Abdominal Pain
 Feels Hot to Touch
 Vomiting
 Abdominal Swelling
 Chills
 Diarrhea
 Blood In Stool
 Pain With Intercourse
 Gastrointestinal Bleeding
Add symptoms to narrow your search

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This condition is considered a medical emergency. Urgent care may be required.

Appendicitis is inflammation of the appendix. Here's what it feels like, what

causes it, and what tests to expect at your doctor's office.
 READ MORE

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Peritonitis
This condition is considered a medical emergency. Urgent care may be required.

Peritonitis is the inflammation of a thin layer of tissue inside the abdomen,

caused by bacteria or fungus. Get the facts on this medical emergency.

READ MORE

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poisoning. The Salmonella bacteria live in the intestines of humans and
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caused by a viral infection, but there are other possible causes of hepatitis.

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abuse cause the liver to become inflamed and swollen.

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This condition is considered a medical emergency. Urgent care may be required.

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women. It's marked by pain in the abdomen, especially during urination or sex.

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A thoracostomy is a small incision of the chest wall, with maintenance of the opening
for drainage.[1] It is most commonly used for the treatment of a pneumothorax. This is performed by
physicians, and paramedics, usually via needle thoracostomy or with a thoracostomy tube (chest
tube).
A thoracostomy is often confused with thoracotomy, which is a larger incision commonly used to
gain access to organs within the chest.

Medical uses[edit]
When air, blood, or other fluids accumulate in the pleural cavity it may be drained by thoracostomy.
Whereas air in this space (pneumothorax) may be released by needle thoracostomy, other
substances require drainage with a thoracostomy tube.[2]

Contra-indications[edit]
There are no absolute contraindications to thoracostomy. There are relative contraindications (such
as coagulopathies); however, in an emergency setting these are outweighed by the necessity to re-
inflate a collapsed lung or drain fluid from the lungs.[2]

Technique[edit]
Drainage of the pleural cavity is achieved by the surgeon making a primary incision in the skin
followed by a second incision through the muscle between the ribs. This way a tube may be guided
into the chest to allow for drainage. Chest tubes are designed to collect this drainage and prevent
anything from leaking back into the pleural space. This is accomplished by a check valve, usually
part of a specialized drainage system with an underwater seal. Depending on the amount of air/fluid
to be drained, the collection bottle may need to be periodically changed.[2]

Risks/complications[edit]
Complications are mostly due to placement technique, inexperience of the physician, and emergent
vs. elective circumstances. The most common complications are recurrent pneumothorax
(incomplete recovery), infection, and organ injury (due to mechanical damage).

Glossary Terms
Ballistics: The study of projectiles, their movement and impact. Although this term
applies to any projectile, it’s most often used to refer to bullets and their damage.
Cavitation: The formation of a cavity, such as from a high-velocity projectile striking the
body.
Hypotension: Lowered systolic and diastolic blood pressure.
Kinetics: The study of forces that produce or modify motion.
Perfusion: Supplying an organ or tissue with nutrients and oxygen via the circulatory
system.
Yaw: The vertical axis of three-dimensional movement.