Management of Penetrating and Blunt Diaphragmatic Injury

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Abstract
The past 5 yr experience with diaphragmatic injuries at a university health science center was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Patients (93) incurred penetrating trauma to the diaphragm and 9 patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in 4 and free air in 1. Peritoneal lavage was positive in 6 of 7 patients with blunt diaphragmatic injury, but was falsely negative in 2 of 5 patients (20%) with penetrating diaphragmatic injury. Ppatients (89; 87%) exprienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for 3 with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was 1 death in the series from a consumption coagulopathy. Injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries.

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