Diaphragmatic Injury - Emergency Management 22/03/23, 9:41 p.m.

Diaphragmatic Injury - Emergency Management

Critical Points
● Injuries to the diaphragm may occur from blunt or penetrating trauma and are a
diagnostic challenge with serious morbidity and mortality in delayed presentations, thus
the provider must maintain a high level of suspicion
● Possible diagnostic studies include chest x-ray, point-of-care ultrasound, and computed
tomography (CT); however operative evaluation with laparoscopy/thoracoscopy can both
be diagnostic and therapeutic
● Initial emergency department management consists of patient stabilization including
airway, breathing, and circulation

General Information
Description
● Penetrating or blunt injury can compromise both the contents of the thorax and the
abdomen when the diaphragm is injured

Anatomy
● Diaphragm: dome-shaped muscle that creates a partition between the thorax and
abdomen
⚬ Held in place by attachments to the sternum, lower ribs (sixth laterally, 12th
posteriorly), and upper lumbar vertebrae
⚬ Muscle attachments circumferentially join to create the central tendon of the
diaphragm

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Image 1 of 3

Anatomy of diaphragm

Finite element model showing anatomy of diaphragm.

Zhang G, Chen X, Ohgi J, et al. Biomechanical simulation of

thorax deformation using !nite element approach. Biomed Eng
Online 2016 Feb 6;15:18. Modi!ed with permission from BioMed
Central.

● The diaphragm has 3 openings at consistent levels

⚬ T8: inferior vena cava
⚬ T10: esophagus and vagus nerves
⚬ T12: aorta, thoracic duct, azygos vein
● Blood supply: pericardiophrenic arteries, intercostal arteries, direct branches o"
abdominal aorta
● Nerve innervation: from phrenic nerves o" C3-C5 roots

Etiology
● Mechanism classically from blunt trauma with high kinetic energy or penetrating trauma
to the thoracoabdominal region 1
● In blunt trauma, injury caused by pressure gradient between intra-abdominal and
intrathoracic cavities
● In 1 study of the American College of Surgeons National Trauma Data Bank, patients with
blunt traumatic diaphragmatic injury were more likely to have injuries to thoracic aorta,
lungs, bladder, and spleen compared with penetrating injury patients who were more
likely to have liver and hollow viscous injuries 2
● Injury severity of diaphragmatic injury

Table 1. Injury Severity Scale for Diaphragmatic Injuries

Grade Injury Description

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I Confusion

II Laceration 2 cm

III Laceration 2-10 cm

IV Laceration > 10 cm with tissue loss 25 cm2

V Laceration (any size) with tissue loss > 25 cm2

Epidemiology
● Typical patient: young male individual in high-speed motor vehicle crash 1
● Di#cult to assess true incidence due to high rate of delayed and missed diagnoses;
infrequently reported, even in busy trauma centers
⚬ National Trauma Data Bank in 2012 showed 3,873 diaphragm injuries or 0.46% of total
encounters; of these, 33% were due to blunt trauma and 67% were due to penetrating
trauma 2

History and Physical

History
● Complaints may be variable
⚬ Chest pain
⚬ Shoulder pain (referred)
⚬ Shortness of breath
⚬ Abdominal pain
⚬ Nausea and vomiting
● TIP: maintain a high degree of clinical suspicion for diaphragmatic injuries for patients
who sustained high-velocity blunt trauma and penetrating trauma to the
thoracoabdominal region

Physical

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Diaphragmatic Injury - Emergency Management 22/03/23, 9:41 p.m.

● Presentation ranges greatly from hemodynamic stability with no physical !ndings to

shock and signi!cant evidence of trauma
● Abnormal thoracic !ndings (if present) are related to thoracic contents being displaced by
intra-abdominal viscera 1 , 3
⚬ Bowel sounds on chest auscultation
⚬ Crepitus/$ail chest from associated rib fractures
⚬ Decreased breath sounds
⚬ Dullness to percussion
⚬ May present like a tension pneumothorax but placement of a chest tube may cause
further injury
⚬ Tachypnea
● Abnormal abdominal !ndings (if present) are due to displaced intra-abdominal
contents 1 , 3
⚬ Localized or di"use abdominal tenderness
⚬ Scaphoid abdomen

Diagnostic Studies
Lab Tests
● May consider obtaining
⚬ A trauma panel including complete blood count (CBC), chemistry panel, prothrombin
time/international normalized ratio (PT/INR), type and screen, and venous blood
gas/arterial blood gas (VBG/ABG) in the setting of signi!cant injury, but are not
diagnostic of diaphragmatic injury

Imaging Tests
● Highly consider obtaining
⚬ Chest x-ray: although has low sensitivity and speci!city for detecting diaphragmatic
injuries, look for abnormal !ndings such as
– Nasogastric tube tip, gastric bubble, colonic bubble, or stomach located in thoracic
cavity
– Elevated hemidiaphragm
– May be associated with rib fractures

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– In 1 pediatric review of the literature, chest x-ray showed suspect or pathognomonic

!ndings in 85% of cases 4
⚬ Focused assessment with sonography for trauma (FAST) exam may reveal
– Nonvisualization of spleen or heart due to relocation into chest
– Disrupted or poor movement of diaphragm
– Abdominal organs in chest
⚬ Computed tomography (CT) with contrast may show
– Herniated organs into chest
– If small defect, may not be as sensitive

Image 2 of 3

Diaphragmatic injury

Left-sided diaphragmatic hernia after motor vehicle

crash.

Image courtesy of Dr. James Davis

Image 3 of 3

Diaphragmatic injury

CT coronal view showing the delayed presentation

of a left-sided diaphragmatic hernia (arrow pointing
to superiorly displaced stomach into left
hemithorax) in a patient complaining of intermittent
abdominal pain and with a remote history of a left
$ank stab wound. Abbreviation: CT, computed
tomography.

Image courtesy of Dr. James Davis

● May consider obtaining

⚬ Upper gastrointestinal (GI) series: stomach in left thoracic cavity

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⚬ Barium enema: may show herniated colon through diaphragm

⚬ Magnetic resonance imaging (MRI): similar !ndings to CT

Other Diagnostic Tests

● Operative evaluation with laparoscopy/thoracoscopy has been suggested in all patients
with penetrating trauma to the thoracoabdominal region with repair of diaphragmatic
defect if found; this is to prevent future herniation/strangulation of intra-abdominal
contents 5 , 6 , 7
● Laparoscopy has also been suggested in blunt abdominal trauma for diagnostic purposes
if there is a high index of suspicion for diaphragmatic injury 8

Management
Overview
● Initial assessment: focus on the primary survey, as described in Advanced Trauma Life
Support (ATLS), aimed at recognizing and treating immediate life threats
● Secondary survey: once patient is stabilized, assess for related injuries
● TIP: a diaphragmatic injury with herniation of intra-abdominal contents into the thorax
may present with symptoms resembling a tension pneumothorax; note that placement of
a chest tube could cause further injury of abdominal contents that have herniated into the
chest
⚬ Both acute and chronic diaphragmatic injuries require operative intervention
⚬ If diaphragmatic injury is suspected but not proven by imaging modalities, consultation
from a trauma surgeon for laparoscopy or thoracoscopy for diagnosis should be
obtained

Medications
● IV crystalloid $uids
⚬ Indications: !ndings of hypovolemia or need to maximize preload (for example,
endotracheal intubation, pericardial tamponade)
– Give 1-L bolus
● Pain medications

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⚬ Fentanyl 1-2 mcg/kg IV, if concern for hemodynamic instability or early in resuscitation
because of short-acting duration (typical adult dosage 50-100 mcg IV)
⚬ Morphine 0.1 mg/kg IV (typical adult dosage 4-10 mg IV)
⚬ Patient-controlled analgesia (PCA) may be considered with signi!cant chest trauma (for
example, $ail chest)

Disposition

Prognosis and Complications

Prognosis
● Prognosis depends on severity of diaphragm injury and associated injuries

Complications
● Acute phase: atelectasis, lobar collapse, tension pneumothorax physiology,
cardiopulmonary insu#ciency
● Chronic phase: recurrent bowel obstruction, strangulation of intra-abdominal viscera
● Postoperative phase
⚬ Suture line failure and dehiscence
⚬ Hemi-diaphragmatic paralysis from phrenic nerve injury
⚬ Pleural e"usion
⚬ Infection: empyema, intra-abdominal abscess

Associated Conditions
● Rarely is the diaphragm injured alone
● Blunt trauma: due to the high kinetic force, there are likely to be solid organ or
deceleration injuries (for example, thoracic aortic tears, splenic injury, pelvic fractures,
and/or hepatic injuries)
● Penetrating trauma: the injuries are dependent on the course of the penetrating object;
most commonly are associated injuries to liver, stomach, lung, spleen, colon, kidneys

Indications for Hospital Admission

● All patients with suspected diaphragmatic injury should be admitted for management of
concomitant injuries and repair of diaphragmatic injuries, if found

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Discharge Planning
● These patients should not be discharged from the emergency department (ED)

Consultation
● Trauma or general surgeon

References
General References Used
The references listed below are used in this DynaMed topic primarily to support background
information and for guidance where evidence summaries are not felt to be necessary. Most
references are incorporated within the text along with the evidence summaries.

1. Rei" DA, McGwin G Jr, Metzger J, Windham ST, Doss M, Rue LW 3rd. Identifying injuries
and motor vehicle collision characteristics that together are suggestive of diaphragmatic
rupture. J Trauma. 2002 Dec;53(6):1139-45

2. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA. Traumatic
diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a
new examination of a rare diagnosis. Am J Surg. 2015 May;209(5):864-8
EBSCOhost Full Text

3. Davis J, Eghbalieh B. Injuries to the diaphragm. In: Feliciano DV, Mattox KL, Moore EE, eds.
Trauma. 6th ed. New York, NY: McGraw Hill Medical; 2008

4. Marzona F, Parri N, Nocerino A, et al. Traumatic diaphragmatic rupture in pediatric age:

review of the literature. Eur J Trauma Emerg Surg 2019 Feb;45(1):49-58

5. Friese RS, Coln CE, Gentilello LM. Laparoscopy is su#cient to exclude occult diaphragm
injury after penetrating abdominal trauma. J Trauma. 2005 Apr;58(4):789-92
6. Powell BS, Magnotti LJ, Schroeppel TJ, et al. Diagnostic laparoscopy for the evaluation of
occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008
May;39(5):530-4
7. Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture. Am J
Emerg Med. 2010 Mar;28(3):387.e1-3
8. Justin V, Fingerhut A, Uranues S. Laparoscopy in Blunt Abdominal Trauma: for Whom?

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Diaphragmatic Injury - Emergency Management 22/03/23, 9:41 p.m.

When? and Why? Curr Trauma Rep. 2017;3(1):43-50 full-text

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Related Topics
● Blunt Abdominal Trauma in Adults - Emergency Management
● Penetrating Abdominal Trauma - Emergency Management
● Blunt Chest Trauma - Emergency Management

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