What is Diaphragm Trauma (Chest Wounds and Breathing)?
Traumatic diaphragm injuries (TDI) can be hard to diagnose, but it’s critical to do so promptly as delayed diagnosis can lead to serious complications. These injuries can happen due to severe blows or penetrations and are often hidden or difficult to detect. Patients’ symptoms can vary depending on the exact location and extent of the injury, whether organs have been moved around, and if there are other injuries. Thus, understanding how the injury happened is key to suspecting a diaphragm injury.
The first case of a diaphragm injury was recorded in 1541, but the first time someone diagnosed a diaphragm injury before death due to trauma only happened in 1853. The first successful repair of a traumatic diaphragm injury was done in 1888.
The diaphragm, a dome-shaped muscle, starts developing from the fourth week of pregnancy. It plays a vital role in breathing and also acts as a floor for the chest cavity and a wall between the stomach and chest. It also helps with actions like going to the bathroom and throwing up by helping regulate the pressures inside the chest and stomach. The diaphragm is controlled by the phrenic nerve, which starts from the neck and travels down to the diaphragm.
Traumatic diaphragm injuries do not occur very often, but it is essential to diagnose them quickly. Missing this type of injury can have serious consequences, including death in 30 to 60% of cases. Complications can range from organs moving out of place and getting trapped to serious breathing problems and even death. Despite its importance, there isn’t a widely accepted method that consistently detects the presence of diaphragm injuries. Some reports suggest that both high-resolution CT scans and laparoscopy may be effective for early diagnosis.
The best way to manage a traumatic diaphragm injury depends on the nature of the injury, the patient’s overall stability, when the injury was diagnosed, and whether there is any contamination. Blunt injuries typically require more complex repair, while penetrating injuries can usually be closed up without too much trouble. If a patient is unstable, the repair may need to be delayed until they’ve fully recovered. The repair method can vary greatly, from stitching to replacement with a synthetic mesh, and in severe cases, complete diaphragm reconstruction might be necessary. The type of repair also depends on whether the injury was identified just after it happened or after some delay. In extreme cases, the repair might be done in stages, using muscle flaps to restore the chest and belly’s normal structure and functions.
What Causes Diaphragm Trauma (Chest Wounds and Breathing)?
Traumatic diaphragm injuries can happen in two ways: through blunt and penetrating injuries. Blunt injuries can happen in car crashes, falls from a great height, or if a pedestrian is hit by a vehicle. Penetrating injuries can occur from gunshot wounds, stabbings, or any foreign object crossing the diaphragm and disturbing its function.
Normally, the diaphragm is a curved structure acting like a flexible barrier between the chest and the abdomen. During rest, the diaphragm pushes down on the organs in the abdomen, causing the belly to expand outwardly. While exhaling, the diaphragm tightens and becomes flatter to help push the air out of the lungs. The shift in the diaphragm during breathing is small, only between one and two inches, but this constant movement helps maintain a pressure difference inside the chest.
Blunt traumas can harm the diaphragm by causing a sudden increase in pressure. The sudden force can tear the diaphragm. Researchers suggest that the left side of the diaphragm is more likely to be injured due to a weakness that is present since birth. Some believe that the right side is less likely to get injured because the liver, which is located directly below, provides protection. In addition to sudden pressure changes, the shearing force created by the blunt trauma could also cause the diaphragm to tear since it’s anchored in all directions.
Penetrating traumas, where an external object enters the body, typically cause small injuries, with more than 80% being smaller than an inch. These kinds of injuries are more frequent and also tend to occur on the left side. Some propose that this could be related to increased death rates associated with right-sided injuries because these injuries tend to involve more organs in the abdomen. Therefore, the higher mortality might explain why there are fewer reported cases of right-sided injuries in the literature.
Risk Factors and Frequency for Diaphragm Trauma (Chest Wounds and Breathing)
Traumatic diaphragm injuries (TDIs) are not very common, with studies showing incidence rates from as low as 0.46% up to 15%. The large variation in incidence rates can be attributed to several factors:
- The data collected might not cover all patients, as not every patient receives treatment at major trauma centres, leading to possible underreporting.
- There are often other injuries associated with TDIs. Therefore, many patients may die from these related injuries before a TDI can be diagnosed, leading to an underestimation of diaphragm injuries.
- There is a great deal of variation in how doctors treat diaphragm injuries. Some patients might not need surgery initially, which could contribute to underreporting.
TDIs can also be divided based on how the injury happened – either blunt or piercing. The frequency of TDIs due to blunt force trauma ranges from 1 to 7%, whereas TDIs due to sharp force trauma is roughly 15%. However, a large-scale review suggested 33% of TDIs are from blunt force and that 67% are due to sharp objects like needles or knives. Of these, car crashes are the leading cause of blunt TDI, and gunshot wounds are the most common cause of sharp force TDIs.
Signs and Symptoms of Diaphragm Trauma (Chest Wounds and Breathing)
Injuries to the diaphragm, the muscle that helps us breathe, can be difficult to diagnose. These injuries, known as traumatic diaphragm injuries (TDIs), require a high level of suspicion, especially if someone has been involved in high-speed car crashes, fallen from high places, been punched in the stomach, been stabbed or shot in the chest or stomach, or suffered from severe crush injuries. This is because TDI’s can often co-occur with hernias.
The severity of the injury can sometimes be interpreted from how the accident occurred. For example, in car crashes, the speed of impact, the extent of car damage, seatbelt usage, and the difficulty experienced in removing victims from the wreck can provide some clues about the energy forces involved in the injury. The manner in which the patient was found after a fall can also give some clue into the severity and direction of the energy during impact. Moreover, in accidents, TDI can also co-exist with other injuries such as other abdominal injuries, which occur 60-100% of the times, and cardiac injuries that occur in 20% to 60% of all cases. Similar results have been found in other reviewed research, showcasing a variety of injuries alongside TDI which include pelvic fractures (40% to 55%), fractures in long bones (75%), and closed head injuries (42%).
Symptoms related to TDI can range from none at all to life-threatening conditions like low blood pressure, breathing issues, and death. In cases where TDI is not associated with a hernia, it becomes difficult to diagnose it as the signs can easily be overridden by other visible injuries. In such a scenario, the patient could complain of shoulder or stomach pain along with breathing difficulties which can mistakenly be attributed to possible damage to the liver, spleen, or lung.
Patients who have suffered a TDI but come to seek medical help after a delay usually exhibit a hernia of the abdominal organs. These symptoms depend on how large the tear in the diaphragm has gotten, which tends to increase over time. Depending on which point the organ is obstructing and how severe the herniation is, the trapped organs might cause mild blockage-like symptoms, or in severe cases may lead to death of the trapped tissue (ischemia) due to loss of blood supply, rupture (perforation) and extreme septic shock.
Past trauma could indicate the potential for a delayed traumatic diaphragmatic hernia. However, these patients usually have vague symptoms like feeling sick, vomiting, and pain, which could be mistaken for stomach ulcers or gallbladder disease, especially if the condition has been going on for a while. If the small intestines get trapped in the hernia, the symptoms are similar to a blockage of the small intestines – nausea, vomiting, inability to eat and a bloated abdomen with hollow sounds on physical examination. The effected organs produce these sounds which might be heard in the chest. Patients with a trapped stomach may show severe signs such as severe nausea, vomiting and frothy saliva. The abdominal bloating in these conditions could be less apparent, and hollow sounds on physical examination would be less likely. If the colon gets trapped in the hernia, patients may have a distended abdomen with bowel sounds heard in the chest. As the blockage becomes worse, the intestine becomes more swollen, and patients may have shortness of breath. As the trapped intestine dilates and the hernia becomes bigger, patients may feel more breathless, have chest pain and difficulty in breathing while lying flat (orthopnea).
Testing for Diaphragm Trauma (Chest Wounds and Breathing)
Traumatic diaphragm injury can be difficult to identify, since there aren’t any specific lab tests that can effectively diagnose this condition. Doctors often rely on a combination of physical examination and imaging studies to determine the presence of injury. After ruling out injuries to the liver or pancreas through basic chemistries, hepatic panel, and pancreatic enzymes tests, they usually resort to imaging techniques.
A chest x-ray can be the initial preferred study, however, it can often appear normal or non-specific. In some cases, the x-ray might show subtle signs of diaphragm injury, or might be instantly diagnostic if there are significant herniation where bowels are seen in the chest cavity. But, a chest x-ray alone is not enough to confirm a traumatic diaphragm injury and therefore, more investigations are needed.
Computerized tomography, or a CT scan, is widely accepted as the gold standard for diagnosing diaphragmatic injuries. Previously, CT scans were considered unreliable due to their low sensitivity. But with the advent of multidetector CT scans, which provide higher resolution images from different angles, as well as the use of contrast dyes, doctors can now much more easily and accurately detect these types of injuries.
There are a range of signs that they look for when reading a CT scan. Direct signs include a discontinuity in the diaphragm, herniation of the organs into the chest, and a visible “collar” or compression at the site of the injury. Indirect signs might include an elevated diaphragm, a calculation of how severe the injury is (ISS and AIS scores), associated injuries, and bleeding around the diaphragm.
Despite these advancements, not all of these signs are always present together, and they often lack both high sensitivity and specificity. Therefore, further evaluations are typically performed in the operating room, depending upon the stability of the patient, any other associated injuries, and the surgeon’s decision.
While ultrasonography and magnetic resonance imaging (MRI) may also help to diagnose the injury, these methods are typically not suitable for emergency situations due to the time they take, the difficulty in interpreting the images, or even due to the location of the MRI machine in relation to the emergency department.
In some cases, invasive diagnostic procedures, such as laparoscopy or thoracotomy (opening up the chest), can be used for evaluation. Determining the best approach will often depend on several factors, including the initial diagnosis, the patient’s condition, any additional injuries present, and the need for immediate surgical intervention.
Treatment Options for Diaphragm Trauma (Chest Wounds and Breathing)
The surgical approach to treating traumatic diaphragm injuries depends on several factors, ranging from the patient’s condition upon arrival to the cause of their injury and other related injuries. Initial treatment involves rapidly assessing and addressing any life-threatening injuries. Patients in severe shock, or with low blood pressure, follow the Advanced Trauma Life Support guidelines for rescue operations. Procedures like intubation or chest tube placement may be carried out depending on the patient’s condition.
If a patient’s condition is unstable, they’re swiftly moved to the operating room to treat immediate threats to their life. Normal hospital procedures such as chest x-rays may still be carried out, although they are at the lead trauma surgeon’s discretion and may be hard to interpret due to the presence of other injuries.
Once the patient is stable, the trauma surgeon must figure out if a diaphragmatic injury is present. These injuries should be repaired quickly, since they tend to worsen over time and do not heal on their own. A surgical procedure called laparotomy is often used in this case as it provides good exposure for repair of diaphragmatic injuries and efficient management of related injuries within the abdomen.
In patients who are more stable upon arrival, the decision to perform surgery is influenced largely by the cause of the injury. Penetrating injuries, which are commonly reported, often present with minimal signs and are typically assessed via laparoscopy. This approach allows for less invasive procedures to detect and confirm the injury.
During surgery, it’s important that the diaphragm be thoroughly examined. If a diaphragm injury is identified, the principles of repair are universal. If any internal organs have displaced into the chest through the injury, they need to be carefully returned to their original position. The wound should be well cleaned, especially if it’s contaminated. Then, the diaphragm is stitched back together using durable, typically non-absorbable sutures like polyester or polypropylene.
Late detection of diaphragm injuries follow the same repair principles as immediate ones, but may require the use of non-absorbable prosthetic mesh to cover the defect if the tissue cannot be reconnected. This kind of procedure would be performed via a thoracotomy, a surgical procedure to access the chest, to avoid any possible injury from internal adhesions.
What else can Diaphragm Trauma (Chest Wounds and Breathing) be?
When checking for a traumatic diaphragmatic injury, the possibilities can be wide, especially in a blunt trauma case. This is due to several associated injuries that display similar signs on initial scans such as a collapsed lung, lung tissue damage, a condition causing a lack of air in the lungs, and blood in the lung cavity.
Signs pointing toward injury in the diaphragm, a muscle that helps in breathing, could actually suggest damage or injury to the phrenic nerve, which controls the diaphragm. If there is a defect present, it’s important to note that not all defects are a result of an injury. Some could be due to present from birth or developed over time, such as Bochdalek, Morgagni, and paraesophageal hernias, or a condition where parts of the diaphragm are abnormally high, called diaphragmatic eventration.
What to expect with Diaphragm Trauma (Chest Wounds and Breathing)
Diaphragm injuries due to trauma usually have a good prognosis on their own. However, if missed initially, these injuries can lead to complications such as hernias, which can result in an increase in complications and death, emphasizing the importance of initial diagnosis.
Complications from diaphragm injuries can vary widely – from minor issues, such as atelectasis (collapse of the lung), to serious concerns such as prolonged respiratory failure. Other potential complications can include pleural effusion (fluid around the lung), lung abscess, long-term pneumothorax (collapsed lung), empyema (pus in the lung), and pneumonia.
Interestingly, the health of a person at the time of their injury seems to have more of an influence on these complications than the diaphragm rupture itself. Also, left-sided diaphragmatic injuries are often associated with more organ damage and longer hospital stays than right-sided injuries. However, right-sided injuries usually result in more deaths and poorer outcomes.
Death rates for these injuries can range from 4% to 38%. Blunt diaphragm ruptures come with longer hospital stays, more ventilation days, and more ICU days than injuries caused by penetration. They also have higher death rates because these patients usually have higher injury severity scores, multiple associated injuries, and often arrive at the hospital in shock due to blood loss. Importantly, patients with injury severity scores over 25 have higher death rates.
With regards to treatment, there isn’t much research showing how patients fare after diaphragm repair during their initial hospital stay. However, a study of 103 patients who had diaphragm repair after a traumatic injury showed that the simple act of suturing the diaphragm reduced death rates by 24%. When other injuries were taken into account, the presence of each additional injury increased the predicted death rate. In cases where the only injury was to the diaphragm (like with a stabbing), the death rate was reported as 0%.
This reinforces the stark difference between injuries caused by penetration and blunt force – the latter is especially associated with worse outcomes, longer hospital stays, and increased ICU days.
Possible Complications When Diagnosed with Diaphragm Trauma (Chest Wounds and Breathing)
According to Petrone and colleagues, complications from Traumatic Diaphragmatic Injury (TDI) can be grouped into two categories. The first category includes complications directly connected to the repair of the diaphragm, while the latter are connected to the trauma itself.
The repair-related complications can include involuntary phrenic nerve paralysis and suture separation. These issues can lead to necessary additional surgeries and may give rise to long-term complications.
The trauma-related complications depend on the presence of additional injuries and may include conditions such as empyema (a collection of pus within the pleural cavity), subphrenic abscess (an accumulation of pus beneath the diaphragm), or life-threatening, prolonged ventilator-required breathing failure.
There are also cases when some of these problems aren’t apparent right away following the trauma, with symptoms appearing anything from a few weeks to years later. When this happens, patients can experience complications such as:
- Atelectasis (collapse of all or part of a lung)
- Respiratory failure
- Pneumonia
- Bowel obstruction
- Strangulation
- Perforation
Preventing Diaphragm Trauma (Chest Wounds and Breathing)
Preventing these types of injuries can be tough due to the various ways they can occur. However, focusing on preventing typical injuries may be the way forward. This could include teaching individuals about the risks and consequences related to knife and gun violence for puncture wounds. For injuries caused by blunt force, such as car accidents, prevention might consist of using seat belts correctly, obeying traffic laws, and taking part in defensive driving courses.
There’s been research that supports treating patients with chest and abdominal injuries without surgery, assuming they aren’t critically ill. Patients in this situation should be taught about the possibility of an injury that hasn’t been found or diagnosed yet, as well as signs or symptoms that would indicate that they need to seek immediate medical attention. For patients who were unable to completely rule out injury, it’s crucial they follow up regularly with medical professionals. Additional medical tests are recommended at 6 to 12-month intervals to double-check or discover any injuries that have gone unnoticed.