Traumatic Rupture of the Diaphragm
ABSTRACT Traumatic rupture of the diaphragm (TRD) is a rare occurrence, with variable morbidity and mortality. The aim of this study was to analyze cases of TRD in a tertiary hospital and assess prognostic factors associated with mortality.
A retrospective study was performed of patients diagnosed with TRD in Hospital Universitario La Fe, Valencia, Spain, between 1969 and 2006. The following variables were analyzed: sex, age, cause, diagnosis, associated lesions, surgical procedure, side and size of the lesion, visceral herniation, and postoperative morbidity and mortality.
The study group comprised 132 patients (105 men, 79.5%) with a mean (SD) age of 39.64 (17.04) years. Traffic accidents were the most common cause of TRD. Rupture involved the left hemidiaphragm in 96 cases (72.7%), and 113 patients (85.6%) had associated lesions, most often affecting the abdomen. Thoracotomy was performed in 83 cases (62.9%) and laparotomy in 41 (31.1%). Visceral herniation was reported in 90 patients (68.3%), most often involving the stomach. The rates of perioperative morbidity and mortality were 62.8% and 20.5%, respectively. Diagnostic delay and the presence of morbidity and serious associated lesions all had a statistically significant impact on mortality (P< .05). In the case of serious associated lesions, the odds ratio was 2.898 (95% confidence interval, 1.018-8.250) and for perioperative morbidity it was 1.488 (95% confidence interval, 1.231-1.798).
TRD is an infrequent occurrence in young men, is generally caused by traffic accidents, and is more common on the left side. Associated lesions are present in most cases and represent the main prognostic factor affecting morbidity and mortality. TRD can be considered a relative surgical emergency when not accompanied by other lesions that in themselves constitute surgical emergencies.
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ABSTRACT: Introduction Diaphragmatic rupture is a rare injury in multitrauma patients. It usually occurs as a consequence of a severe blunt thoracoabdominal injury. Patients-Method All laparotomies performed for blunt trauma in a single surgical department over the last decade were reviewed and all the cases of diaphragmatic rupture were analysed. Results Out of 109 laparotomies that were performed for blunt trauma in the study period, a diaphragmatic rupture was found in 8 cases (seven men and one woman with a mean age of 35 years). The seven male patients presented to the emergency department with haemodynamic instability due to an intraabdominal haemorrhage that necessitated an emergency laparotomy. The female patient, who had sustained multiple rib fractures secondary to a road traffic accident, developed a diaphragmatic hernia and underwent surgery 24 hours after the injury. The site of the rupture was at the left hemidiaphragm in seven patients, whereas the right hemidiaphragm was ruptured in one patient. As concerns accompanying intraabdominal injuries, six patients sustained splenic rupture, two patients renal rupture and one patient rupture of the urinary bladder. Additionally, one patient with thoracoabdominal injury sustained rupture of the left subclavian artery resulting in massive ipsilateral haemothorax. Postoperatively, four patients remained in the intensive care unit (ICU) for an average period of 78 days. Mortality reached twenty-five per cent. One patient died intraoperatively due to massive haemorrhage, and one postoperatively in the ICU due to multiorgan failure. Conclusions The rupture of the diaphragm following a blunt thoracoabdominal injury usually occurs in the left hemidiaphragm. It is associated with high morbidity and mortality mainly due to the coexistence of other severe injuries. More seldom it can be manifested as a delayed diaphragmatic hernia. Since this type of injury can be missed during preoperative assessment; a high degree of suspicion is required.Hellēnikē cheirourgikē. Acta chirurgica Hellenica 08/2012; 84(4):248-252. DOI:10.1007/s13126-012-0037-6
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ABSTRACT: BACKGROUDS: Diagnosing penetrating diaphragmatic rupture (PDR) is a challenging aspect of managing thoracoabdominal injuries due to the lack of a typical clinical presentation. The mortality from PDR is variable and center-specific. In this study, we identified the incidence and clinical presentation of PDR at our institution and analyzed the factors that affected the length of hospital stay and mortality. METHODS: We collected all patients who were diagnosed with PDR from January 2001 through December 2010 at a Level I trauma center. We recorded demographic characteristics, clinical parameters, diagnostic images, trauma mechanism, location and severity of injuries, injury severity score (ISS), time to diagnosis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and mortality. We analyzed the risk for mortality and prolonged hospitalization. RESULTS: Forty-one patients with a median age of 37 years were included. Thirty-six patients (87.8%) had an early diagnosis, and 5 patients (12.2%) had a delayed diagnosis requiring longer than 24 hours. The median ICU LOS and HLOS were 2 and 11 days, respectively. High-grade PDR and lung injury increased the ICU LOS and HLOS. The total mortality rate was 7.3%. Multivariate analysis showed that hypothermia and hypotension were independent risk factors for mortality. CONCLUSION: Overlooking diaphragmatic rupture in patients with thoracoabdominal penetrating injury is not infrequent. A high index of suspicion is important for making the diagnosis. A high-grade PDR and associated lung injury prolonged the length of hospital stay. Profound hemorrhagic shock and associated physical decompensation have an impact on mortality.International Journal of Surgery (London, England) 04/2013; DOI:10.1016/j.ijsu.2013.03.014 · 1.65 Impact Factor
Article: Imaging Assessment of Gunshot Wounds[Show abstract] [Hide abstract]
ABSTRACT: Gunshot injuries occur when someone is shot by a bullet or other sort of projectile from a firearm.Wounds are generally classified as low-velocity (less than 2,000 ft/sec) or high-velocity (more than 2,000 ft/sec). Those with higher velocity may be expected, on this basis, to dissipate more energy into surrounding tissue as they slow and cause more tissue damage but this is only a very approximate guide. However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as kinetic energy, stability, entrance profile and path traveled through the body, and the biologic characteristics of the tissues injured. Hemodynamically stable patients, and patients who stabilize after simple immediate resuscitation were evaluated with a careful history and physical examination. A routine X - ray is performed in patients with gunshot wound (GSW). Indication for total body Computed Tomography (CT) is based on the presence of signs and symptoms of vascular damage at clinical examination. Patients are immediately transferred in the operating room for surgery if more serious injuries that require immediate surgical are not diagnosed or hemostasis may be preliminary eached the emergency room. Hemodynamically stable patients with a negative history and clinical examination suspected vascular damage are allowed in the radiology department in order to perform total body CT with intravenous contrast medium and then transferred to the surgical ward trauma for observation. After 24 hours without the complications' patient could be discharged.CT is the choice procedure to identify hemorrhage, air, bullet, bone fragments, hemothorax, nerve lesion, muscolosckeletal lesions, vessels injuries, and is useful for identifying medico-legal aspect as trajectory and the anatomic structures at risk.Seminars in Ultrasound CT and MRI 10/2014; 36(1). DOI:10.1053/j.sult.2014.10.005 · 1.08 Impact Factor