Management of diaphragmatic rupture from blunt trauma

Published in Singapore Medical Journal on December 2009

K.K. Tan, Z.Y. Yan, A. Vijayan, M.T. Chiu
Department of General Surgery, Tan Tock Seng Hospital, Singapore

Abstract

Introduction

Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. We reviewed our institution’s management of patients with diaphragmatic rupture after blunt trauma.

Methods

All patients in this study were treated at Tan Tock Seng Hospital, Singapore, from March 2002 to October 2008. Patients with penetrating injuries were excluded. The parameters included age, mechanism of injury, haemodynamic status at admission, Glasgow coma scale (GCS) score, injury severity score (ISS), imaging studies, location of diaphragmatic injuries, associated injuries and outcome.

Results

14 patients with a median age of 38 years formed the study group. Vehicular-related incidents accounted for 71.4 percent of the injuries. The median GCS score on admission was 14 (range 3–15), while the median systolic blood pressure and heart rate were 94 (range 50–164) mmHg and 110 (range 76–140) beats per minute, respectively. The median ISS was 41 (range 14–66). All had chest radiographs performed in the emergency department, six (42.9 percent) had computed tomography performed before surgery, while the remaining eight (57.1 percent) were sent straight to the operating theatre from the emergency department. There were five (35.7 percent) right-sided and nine (64.3 percent) left-sided diaphragmatic ruptures. The mortality rate was 35.7 percent. Some of the associated injuries included eight (57.1 percent) splenic lacerations, five (35.7 percent) haemothorax and lung injuries, four (28.6 percent) bone fractures and three (21.4 percent) liver lacerations. 12 (85.7 percent) patients underwent repair of the diaphragmatic rupture using interrupted polypropylene suture, while the remaining two (14.3 percent) were too haemodynamically unstable to undergo def initive treatment. Advanced age, haemodynamic instability and raised ISS were associated with mortality.

Conclusion

An accurate diagnos is of diaphragmatic rupture in trauma patients is difficult, and a thorough examination of both the hemidiaphragms is mandatory during emergency laparotomy for these patients. Those with more severe injuries and decreased physiological reserves usually fare worse.