The diagnosis and management of acute traumatic diaphragmatic injury: A Western Trauma Association clinical decisions algorithm

Abstract

Acute traumatic injuries to the diaphragm remain difficult to diagnose and manage. This is due to limitations in noninva sive diagnostic methods and a lack of definition of specific pa tient populations who stand to benefit from diaphragmatic in jury screening and closure among those with CT-occult injuries. In general, concern for diaphragmatic injury should arise after high-energy blunt trauma mechanisms and penetrating thoracoabdominal trauma. Patients with indications for emergent surgical exploration should undergo direct intraoperative visuali zation of the diaphragm, with repair of any identified injuries after reduction of any herniated contents. From there, the algorithm di verges according to blunt and penetrating trauma mechanisms due to the increased ability of CT scan to diagnose large as op posed to small injuries of the diaphragm. Patients with blunt dia phragmatic injury on CT necessitate repair and otherwise need no further screening for CT-occult diaphragmatic injury. Penetrating trauma patients with visualized or implied in juries to the diaphragm are managedaccordingtolaterality. Left sided thoracoabdominal injuries generally need screening prior to hospital discharge with a diagnostic laparoscopy and repair of any identified injuries. Management of right-sided injuries are controversial and lacking in data regarding which, if any, ought to be repaired.