DIAGNOSTIC IMAGING REVIEW
Managing traumatic injury in an acute setting Waqas Shuaib, MD; Hira Shahzad, MD; Richard Alweis, MD; Edward A. Stettner, MD; Michelle D. Lall, MD; Jason Weiden, MD
CASE A 79-year-old woman is brought to the ED after being struck by a fast-moving car while crossing the street. Her body rolled over the hood, her head hit the windshield, and she was found unconscious by the paramedics. Supplemental oxygen was administered via face mask. On ED arrival, she is awake with a Glasgow Coma Scale score of 15. She complains of right shoulder pain, right-sided chest pain, and left-sided abdominal pain accentuated by deep breathing. She has a history of chronic kidney disease secondary to diabetes. Her vital signs are BP, 116/70 mm Hg; heart rate, 88; respirations, 26; and Spo2, 93% on 2 L/minute of supplemental oxygen. Her pupillary reflex is intact and her neurologic examination is nonfocal. Diffuse abdominal tenderness is present on examination without any visible bruising. Chest examination reveals absent breath sounds and dullness over the right lower lung field. Musculoskeletal examination reveals no obvious deformities. A chest radiograph is shown in Figure 1. Which is the next best step in managing this patient? • tube thoracostomy • focused assessment with sonography in trauma (FAST) • abdominal lavage • CT of the chest and abdomen • MRI of the chest and abdomen DISCUSSION CT of the chest and abdomen is the correct answer in this case. The chest radiograph in Figure 1 illustrates impenetrability of the right lower lung field, which could be due to a dense pulmonary consolidation, accumulation of Waqas Shuaib practices in the Department of Radiology and Imaging Sciences at Emory University in Atlanta, Ga. Hira Shahzad is a research collaborator at the Medical College at Aga Khan University Hospital in Karachi, Pakistan. Richard Alweis is an attending physician at Reading Health System in West Reading, Pa. Edward A. Stettner is an assistant professor in the Department of Emergency Medicine at Emory University. Michelle D. Lall is an assistant professor and assistant residency director in the Department of Emergency Medicine at Emory University. Jason Weiden is an assistant professor in the Department of Radiology and Imaging Sciences at Emory University. The authors have disclosed no potential conflicts of interest, financial or otherwise. Bryan Walker, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000458867.86182.6d Copyright © 2015 American Academy of Physician Assistants
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www.JAAPA.com
FIGURE 1. Chest radiograph of a 79-year-old woman hit by a
car at high speed
fluid in the pleural space implying a hemothorax, or an elevated or ruptured right hemidiaphragm. Given the variety of differentials that can account for this radiographic presentation and the patient’s hemodynamic stability, further investigation is required. Diaphragmatic injury is a diagnostic challenge primarily because of its clinically silent nature. Signs and symptoms are nonspecific and may include chest pain or abdominal discomfort, pericostal injury, diminished breath sounds, orthopnea, auscultation of bowel sounds in the chest, dullness on percussion of the chest, and cough often leading to respiratory distress.1-4 In the case scenario, the patient’s shoulder pain may be from a musculoskeletal injury, but also could be referred pain due to diaphragmatic irritation. Further complicating the diagnosis, diaphragmatic injuries are frequently overshadowed by life-threatening trauma, such as solid organ or vascular injury. As a result, up to 66% of diaphragmatic injuries may be missed on initial diagnostic evaluation, and the patient may develop visceral herniation and strangulation.5-7 Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing traumatic injury in an acute setting
FIGURE 2. Diaphragmatic rupture, illustrated by the raised
FIGURE 3. Rupture of the right hemidiaphragm with herniation
right hemidiaphragm compared with the left (A)
of the liver into the chest (A). Note the collar sign (B) at the rupture point.
Studies have found that chest radiographs are as specific as conventional CT images in the diagnostic workup of diaphragmatic injuries.8 Radiographic findings include obliteration of hemidiaphragm outline, elevation of hemidiaphragm (Figure 2), pleural effusion, air-fluid levels in thorax, mediastinal shift, visualization of nasogastric tube in thorax, and fracture of lower ribs.7,9,10 However, with the advent of helical and multidetector CT imaging, CT is
FIGURE 4. Rupture of the left hemidiaphragm with herniation
of the stomach (arrow) into the chest. JAAPA Journal of the American Academy of Physician Assistants
now recognized as a superior diagnostic tool.7 Features of diaphragmatic rupture on CT include diaphragmatic discontinuity, collar sign (Figure 3), visceral herniation into the chest (Figures 3 and 4), dependent viscera sign, and segmental nonrecognition of the diaphragm.7,9 Nevertheless, CT has a sensitivity of 70% to 90% for detecting diaphragmatic injury, and surgical exploration may be necessary if clinical suspicion is high enough.7 Although penetrating trauma more commonly causes the diaphragm to rupture, 0.8% to 8% of ruptures occur in patients who have experienced a blunt injury.7 In such cases, direct impact leads to a sudden rise in intra-abdominal pressure, resulting in upward rupture of the diaphragm. Shearing and avulsion forces from a laterally directed traumatic force also may disrupt the continuity of the diaphragm. The right hemidiaphragm is three times less susceptible to injury than the left; it is thought to be congenitally stronger, and the liver plays a significant role in buffering the forces delivered to the diaphragm via the abdomen or flank.7,11,12 Treatment of diaghragmatic rupture is mainly surgical via an open or laparoscopic approach through chest or abdomen, depending on the patient’s associated injuries and hemodynamic stability. Because diaphragmatic injuries can be easily missed in a patient with multiple trauma, the diaphragm should be meticulously inspected during surgery for defects and other injuries, regardless of radiographic findings.12 The case patient underwent laparoscopic surgery to repair the diaphragm and was discharged to home 2 days later with instructions for close follow-up. JAAPA www.JAAPA.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
59
DIAGNOSTIC IMAGING
REFERENCES 1. Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury. 2003;34(3): 169-172. 2. Rosati C. Acute traumatic injury of the diaphragm. Chest Surg Clin N Am. 1998;8(2):371-379. 3. Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol. 1999;173(6):1611-1616. 4. Dirican A, Yilmaz M, Unal B, et al. Acute traumatic diaphragmatic ruptures: a retrospective study of 48 cases. Surg Today. 2011;41(10):1352-1356. 5. Murray JG, Caoili E, Gruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol. 1996;166(5):1035-1039. 6. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their long-term sequelae. J Trauma. 1998;44(1): 183-188.
60
www.JAAPA.com
7. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012;32(2):477-498. 8. Shapiro MJ, Heiberg E, Durham RM, et al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol. 1996;51 (1):27-30. 9. Magu S, Agarwal S, Singla S. Computed tomography in the evaluation of diaphragmatic hernia following blunt trauma. Indian J Surg. 2012;74(4):288-293. 10. Scumpia AJ, Aronovich DA, Roman L, et al. Diaphragmatic rupture secondary to blunt thoracic trauma. West J Emerg Med. 2013;14(5):435-436. 11. Kuo IM, Liao CH, Hsin MC, et al. Blunt diaphragmatic rupture—a rare but challenging entity in thoracoabdominal trauma. Am J Emerg Med. 2012;30(6):919-924. 12. Beigi AA, Masoudpour H, Sehhat S, Khademi EF. Prognostic factors and outcome of traumatic diaphragmatic rupture. Ulus Travma Acil Cerrahi Derg. 2010;16(3):215-219.
Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing traumatic injury in an acute setting Waqas Shuaib, MD; Hira Shahzad, MD; Richard Alweis, MD; Edward A. Stettner, MD; Michelle D. Lall, MD; Jason Weiden, MD
CASE A 79-year-old woman is brought to the ED after being struck by a fast-moving car while crossing the street. Her body rolled over the hood, her head hit the windshield, and she was found unconscious by the paramedics. Supplemental oxygen was administered via face mask. On ED arrival, she is awake with a Glasgow Coma Scale score of 15. She complains of right shoulder pain, right-sided chest pain, and left-sided abdominal pain accentuated by deep breathing. She has a history of chronic kidney disease secondary to diabetes. Her vital signs are BP, 116/70 mm Hg; heart rate, 88; respirations, 26; and Spo2, 93% on 2 L/minute of supplemental oxygen. Her pupillary reflex is intact and her neurologic examination is nonfocal. Diffuse abdominal tenderness is present on examination without any visible bruising. Chest examination reveals absent breath sounds and dullness over the right lower lung field. Musculoskeletal examination reveals no obvious deformities. A chest radiograph is shown in Figure 1. Which is the next best step in managing this patient? • tube thoracostomy • focused assessment with sonography in trauma (FAST) • abdominal lavage • CT of the chest and abdomen • MRI of the chest and abdomen DISCUSSION CT of the chest and abdomen is the correct answer in this case. The chest radiograph in Figure 1 illustrates impenetrability of the right lower lung field, which could be due to a dense pulmonary consolidation, accumulation of Waqas Shuaib practices in the Department of Radiology and Imaging Sciences at Emory University in Atlanta, Ga. Hira Shahzad is a research collaborator at the Medical College at Aga Khan University Hospital in Karachi, Pakistan. Richard Alweis is an attending physician at Reading Health System in West Reading, Pa. Edward A. Stettner is an assistant professor in the Department of Emergency Medicine at Emory University. Michelle D. Lall is an assistant professor and assistant residency director in the Department of Emergency Medicine at Emory University. Jason Weiden is an assistant professor in the Department of Radiology and Imaging Sciences at Emory University. The authors have disclosed no potential conflicts of interest, financial or otherwise. Bryan Walker, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000458867.86182.6d Copyright © 2015 American Academy of Physician Assistants
58
www.JAAPA.com
FIGURE 1. Chest radiograph of a 79-year-old woman hit by a
car at high speed
fluid in the pleural space implying a hemothorax, or an elevated or ruptured right hemidiaphragm. Given the variety of differentials that can account for this radiographic presentation and the patient’s hemodynamic stability, further investigation is required. Diaphragmatic injury is a diagnostic challenge primarily because of its clinically silent nature. Signs and symptoms are nonspecific and may include chest pain or abdominal discomfort, pericostal injury, diminished breath sounds, orthopnea, auscultation of bowel sounds in the chest, dullness on percussion of the chest, and cough often leading to respiratory distress.1-4 In the case scenario, the patient’s shoulder pain may be from a musculoskeletal injury, but also could be referred pain due to diaphragmatic irritation. Further complicating the diagnosis, diaphragmatic injuries are frequently overshadowed by life-threatening trauma, such as solid organ or vascular injury. As a result, up to 66% of diaphragmatic injuries may be missed on initial diagnostic evaluation, and the patient may develop visceral herniation and strangulation.5-7 Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing traumatic injury in an acute setting
FIGURE 2. Diaphragmatic rupture, illustrated by the raised
FIGURE 3. Rupture of the right hemidiaphragm with herniation
right hemidiaphragm compared with the left (A)
of the liver into the chest (A). Note the collar sign (B) at the rupture point.
Studies have found that chest radiographs are as specific as conventional CT images in the diagnostic workup of diaphragmatic injuries.8 Radiographic findings include obliteration of hemidiaphragm outline, elevation of hemidiaphragm (Figure 2), pleural effusion, air-fluid levels in thorax, mediastinal shift, visualization of nasogastric tube in thorax, and fracture of lower ribs.7,9,10 However, with the advent of helical and multidetector CT imaging, CT is
FIGURE 4. Rupture of the left hemidiaphragm with herniation
of the stomach (arrow) into the chest. JAAPA Journal of the American Academy of Physician Assistants
now recognized as a superior diagnostic tool.7 Features of diaphragmatic rupture on CT include diaphragmatic discontinuity, collar sign (Figure 3), visceral herniation into the chest (Figures 3 and 4), dependent viscera sign, and segmental nonrecognition of the diaphragm.7,9 Nevertheless, CT has a sensitivity of 70% to 90% for detecting diaphragmatic injury, and surgical exploration may be necessary if clinical suspicion is high enough.7 Although penetrating trauma more commonly causes the diaphragm to rupture, 0.8% to 8% of ruptures occur in patients who have experienced a blunt injury.7 In such cases, direct impact leads to a sudden rise in intra-abdominal pressure, resulting in upward rupture of the diaphragm. Shearing and avulsion forces from a laterally directed traumatic force also may disrupt the continuity of the diaphragm. The right hemidiaphragm is three times less susceptible to injury than the left; it is thought to be congenitally stronger, and the liver plays a significant role in buffering the forces delivered to the diaphragm via the abdomen or flank.7,11,12 Treatment of diaghragmatic rupture is mainly surgical via an open or laparoscopic approach through chest or abdomen, depending on the patient’s associated injuries and hemodynamic stability. Because diaphragmatic injuries can be easily missed in a patient with multiple trauma, the diaphragm should be meticulously inspected during surgery for defects and other injuries, regardless of radiographic findings.12 The case patient underwent laparoscopic surgery to repair the diaphragm and was discharged to home 2 days later with instructions for close follow-up. JAAPA www.JAAPA.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
59
DIAGNOSTIC IMAGING
REFERENCES 1. Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury. 2003;34(3): 169-172. 2. Rosati C. Acute traumatic injury of the diaphragm. Chest Surg Clin N Am. 1998;8(2):371-379. 3. Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol. 1999;173(6):1611-1616. 4. Dirican A, Yilmaz M, Unal B, et al. Acute traumatic diaphragmatic ruptures: a retrospective study of 48 cases. Surg Today. 2011;41(10):1352-1356. 5. Murray JG, Caoili E, Gruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol. 1996;166(5):1035-1039. 6. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their long-term sequelae. J Trauma. 1998;44(1): 183-188.
60
www.JAAPA.com
7. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012;32(2):477-498. 8. Shapiro MJ, Heiberg E, Durham RM, et al. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol. 1996;51 (1):27-30. 9. Magu S, Agarwal S, Singla S. Computed tomography in the evaluation of diaphragmatic hernia following blunt trauma. Indian J Surg. 2012;74(4):288-293. 10. Scumpia AJ, Aronovich DA, Roman L, et al. Diaphragmatic rupture secondary to blunt thoracic trauma. West J Emerg Med. 2013;14(5):435-436. 11. Kuo IM, Liao CH, Hsin MC, et al. Blunt diaphragmatic rupture—a rare but challenging entity in thoracoabdominal trauma. Am J Emerg Med. 2012;30(6):919-924. 12. Beigi AA, Masoudpour H, Sehhat S, Khademi EF. Prognostic factors and outcome of traumatic diaphragmatic rupture. Ulus Travma Acil Cerrahi Derg. 2010;16(3):215-219.
Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
