Diafragmatic trauma - Forum

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Dottore

Diafragmatic trauma - Ärzteforum

Post#1 »

50 y.o. male was kicked by a horse in left hemitorax. Arrives to E.R. complaining of short breathness. On examination presents respiratory rate of 30. Hemodinamically stable. Contusion stigmas in skin over 3 last left ribs in its lateral aspect. On Rx chest image of hollow viscera in left hemitorax, no ribs fractures. Rx after a barium swallow shows contrast in lef hemitorax. Surgical team thinks in traumatic diafragmatic hernia. Pt. is taken to o.r. to laparotomy. Findings: left hemidiafragm completely elongated and pushed by stomach into torax. No continuity defect. No intraabdominal lesion.

What would you do? Diafragmatic plication? Nothing?

Not my case, just consulted about.


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Old surgeon

Re: Diafragmatic trauma - Ärzteforum

Post#2 »

You do nothing, as there is no -pathology here that needs fixing. Anything you do will be of no benefit, and subjects patient to needless risk. Now the picture found following significant trauma was perfectly consistent with diaphragmatic rupture, and I do agree that laparotomy was indicated--there was no other test to further confirm or exclude than laparotomy--in fact, as this case well demonstrates, too many tests were done as is--the contrast study is useless in this setting.

What is the most accurate diagnostic test for diaphragmatic rupture? The plain CXR--virtually 100% of cases have an abnormal CXR, tho admittedly most of these abnormalities are nonspecific--i.e. blurred or obscured diaphragm, hemothorax, rib fractures, etc. This case had a classic virtually pathognomonic finding that warranted laparotomy. I was involved in just such a case that ended up being an eventration found at lap, and the patient tried to sue--the case never got to the deposition stage before the mountain of supportive expert testimony caused the patient to withdraw the claim.

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A Doctor

Re: Diafragmatic trauma - Ärzteforum

Post#3 »

However, when in doubt concerning an isolated dipahragmatic injury - a laparoscopy is a good option. This, for me- is the only reasonable indication for a laparoscopy in abdominal trauma.

Avicenna

Re: Diafragmatic trauma - Ärzteforum

Post#4 »

Sounds like a chronic eventration of the diaphragm. I would do nothing.

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surgery

Re: Diafragmatic trauma - Ärzteforum

Post#5 »

I have had just such a case in an elderly woman with blunt torso trauma who had an elevated right hemidiaphragm (due to an antecedant eventration with anteromedial hump) and flail right chest. Thoracoscopy through the intercostal drain site provided the answer of an intact diaphragm and spared her unnecessary abdominal exploration. I do not believe that laparotomy is the only available diagnostic modality available in these circumstances. In clinically doubtful cases, thoracoscopy can be performed in the ER or ICU allowing the abdomen to be independently evaluated on it's merits.

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Treatment guru

Re: Diafragmatic trauma - Ärzteforum

Post#6 »

Do nothing, this is an eventration of the diaphragm which he has probably had lifelong unless some prior insult to phrenic nerve e.g. stab neck, chest. It gave him no symptoms before, and once he is over his chest injury he should have no symptoms after. I do think the error was totally understandable and the correct approach was to open the patient.

Priya

Re: Diafragmatic trauma - Ärzteforum

Post#7 »

Thoracotomy or laparotomy, I think it boils down to personal preference, abdominal surgeons tend to prefer their normal route, thoracic surgeons theirs.

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Alalo

Re: Diafragmatic trauma - Ärzteforum

Post#8 »

Interestingly, the next project of EAST's practice management guideline committee is to develop a set of guidelines for just this--the evaluation of blunt abdominal trauma--due in about a year.

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