During a traumatic injury, the focus is on immediate life-sustaining organs such as the heart, lungs, brain, spine, pelvis, and limbs. When the diaphragm sustains a tear, abdominal contents can herniate into the thoracic cavity. A tear in the diaphragm may be missed in the acute phase due to viscera plugging of the tear (Ryu et al., 2017) or positive-pressure ventilation via intubation as positive pressure may mask the diaphragmatic margin (Gribben et al., 2019). Providers and trauma nurses must be aware that mechanical ventilation can have a masking effect on a diaphragmatic tear.
Toh et al. (2020) suggest that a diaphragmatic hernia is not appreciated in the acute phase of trauma about 66% of the time. Critical injuries may portend a possible diaphragmatic injury. In pelvic injuries, 40% may have a diaphragmatic injury; a liver laceration may have a 25% diaphragmatic injury; a thoracic aortic tear has a 5%-10% chance of an associated diaphragmatic injury (Welsford & Conrad, 2020). It is essential that providers and trauma nurses take note of other injuries to appreciate their association with a diaphragmatic injury. Readily apparent life-threatening injuries are addressed in the trauma bay and may require intubation, chest tube insertion, and emergent surgical interventions.
BACKGROUND
The diaphragm is a muscle that all mammals, including humans, are born with and cannot live without (Kitaoka & Chihara, 2010). Lal et al. (2011) suggest that blunt trauma, such as motor vehicle crashes (MVCs) and falls, account for about 75% of diaphragmatic injuries; penetrating trauma involving gunshots and stab wounds account for about 25% of such injuries. Furthermore, approximately 75% of diaphragmatic injuries occur in the left hemidiaphragm, 24% in the right hemidiaphragm, and about 15% occurring bilaterally. The right hemidiaphragm is congenitally stronger than the left; therefore, right diaphragmatic injuries may not be apparent during the acute phase of trauma. Autopsy findings in one study suggest roughly an equal incidence between right and left diaphragmatic ruptures (Rashid et al., 2009).
The diaphragm deserves respect and consideration in the differential diagnosis. The first known diaphragmatic injury was documented in the 1500s when a French captain sustained a gunshot to the abdomen but died months later due to a strangulated colon that herniated through a diaphragmatic tear about the size of a small fingertip (El-Yakub et al., 2017). Clinical assessment, diagnostic tools, and treatment plans have evolved, enabling clinicians to recognize a delayed diaphragmatic injury faster before the patient suffers a prolonged and painful death.
KEY POINTS
* A diaphragmatic injury is relatively rare and a challenging diagnosis.
* A diaphragmatic injury in the delayed phase may occur days to decades postinjury.
* Patient history is essential to identify prior thoracic trauma.
* Recognition of diaphragmatic injury signs and symptoms is essential to treatment.
* Systematic follow-up postinjury remains key to identifying occult injuries.
DELAYED PRESENTATION OF DIAPHRAGMATIC CASE STUDIES
The literature is replete with case studies highlighting how a diaphragmatic injury can present in a delayed fashion or more emergently in the obstructive phase when abdominal contents migrate into the thoracic cavity. The delayed phase can occur from a day after injury up to 60 years later, as Williamson et al. (2014) described. Williamson et al. describe an elderly man who presented to the emergency department (ED) in cardiac arrest with a gastric volvulus as a likely complication of diaphragmatic rupture from a serious mid-body injury sustained in a motorcycle crash occurring in the patient's youth. A few days prior to ED presentation, the patient experienced epigastric pain and retching without vomiting. The ED was unable to pass a nasogastric tube. This collection of symptoms, known as Borchardt's triad, includes epigastric pain, retching, and inability to pass a nasogastric tube. The clinical examination revealed no breath sounds in the left lung fields. The computed tomographic (CT) scan showed the pancreas and small and large bowel in the thoracic cavity, a left lung collapse, and a midline shift of the heart. Williamson et al. (2014) suggest that the cardiac arrest was caused by cardiac compression and compromised venous return, though the position of the heart was compressed because of the diaphragmatic herniation. The body remembers its insults even decades later. The diaphragm can weaken during the trauma and over time. Small tears can evolve into bigger tears and ultimately herniate and strangle abdominal contents leading to significant morbidity and eventual death. The diaphragm can maintain a tenuous barrier after the acute phase, but, over time, the barrier can weaken due to additional forces that would not normally create a diaphragmatic hernia. Although the trauma nurse's attention is likely drawn to the cardiac arrest, as imaging and collaborative discussion of the patient's course occurs, the nurse is reminded to consider past truncal injury as an assessment question when time permits.
Toh et al. (2020) illustrate this point in an unusual presentation involving a middle-aged woman who developed sudden left shoulder and trunk pain first noticed when she had descended under the water about 10 ft while scuba diving. The patient remained at about 30 ft below water for approximately 30 min. After ascending to the surface and returning to land, she vomited several times and experienced shortness of breath and upper abdominal pain. Upon arrival at the ED, the CT scan showed old left-sided rib fractures and old bilateral pelvic fractures. Bowel sounds were auscultated in the patient's left chest. When queried about the old fractures, the patient recalled having been in a serious motor vehicle accident 5 years previously with severe injuries but recovered.
When taking a detailed patient history, providers and trauma nurses should inquire about previous trunk injuries occurring between the nipple line and the umbilicus, as these are the landmarks for diaphragmatic inspiration and expiration (Akar & Kaya, 2017). The totality of this presentation led to a differential diagnosis of a diaphragmatic injury. During surgical exploration, a 10-cm tear was found and surgically repaired in the left hemidiaphragm, which contained the stomach and the left lobe of the liver. The patient recovered without further issues.
Toh et al. (2020) further suggest that sports organizations should ask about past trauma, especially trauma sustained within the trunk, in medical questionnaires to rule out people who may be sensitive to pressure changes tolerated by uninjured peers. A pressure change in a subtly weak diaphragm may be just enough to act as the "final straw" to push abdominal contents into the thoracic cavity through a diaphragmatic herniation. Blunt trauma causes an abrupt increase in abdominal pressure to the diaphragm potentiating a diaphragmatic injury. Not only is it important to assess for past blunt or penetrating trauma but clinicians must also perform clinic follow-up after surgical repair to ensure a watertight closure of the diaphragm (Costa et al., 2020), so there is confidence in a nonrecurrence.
When the contents of the abdomen migrate upward through the diaphragmatic hernia, these organs can experience strangulation, ischemia, and an overwhelming systemic response, including peritonitis, sepsis, and multiple-organ failure (Lu et al., 2016). Trauma nurses must ensure a thorough patient history is obtained on presentation. See Table 1 for diaphragmatic hernia assessment tips. Patients frequently complain of nausea, vomiting, obstipation, and shortness of breath and may repeatedly present in the ED with the same complaints over time. The ED may treat patients for gastritis or a respiratory illness and discharge them to home. However, a careful medical history that includes assessment questions about past traumatic injuries can provide a clue to check the diaphragm for potential delayed herniation before the patient's condition progresses to obstruction. In addition, as people age, the body weakens so that a blunt force directed toward a younger person may have no effect; however, that same force directed at the older adult may cause a diaphragmatic injury due to generalized age-related muscle weakening and loss of core strength (Ganie et al., 2013).
Dwari et al. (2013) describe a case in which the abdominal ultrasound scan revealed an empty left renal fossa after a middle-aged man was kicked in the lower left chest and upper abdomen weeks earlier during a family quarrel. The patient eventually presented to the ED with dull chest pain and a cough. The physical examination revealed bowel sounds auscultated in the left chest. The CT scan showed bowel loops and the left kidney located in the left thorax. Dwari et al. (2013) suggest that the kidney rarely herniates but that the stomach, liver, spleen, and intestines are most likely to herniate through the diaphragm.
Tavakoli et al. (2019) suggest that the right hemidiaphragm is congenitally stronger than the left; therefore, diaphragmatic injuries may not be as apparent on the right side during acute trauma. They cite a case where an older man had fallen from his tractor several months earlier but managed to keep working. After 2 months, the patient presented to the ED with increasing complaints of nausea, vomiting, and no flatus for a period of 5 days. His chest and abdominal imaging showed his small intestines on the right side above the liver into his chest through a rupture in the right hemidiaphragm. Although the right hemidiaphragm is strong and has strength, providers and trauma nurses need to consider a diaphragmatic injury as a delayed presentation and carefully review findings of both hemidiaphragms.
ASSESSMENT AND CLASSIFICATION OF A DIAPHRAGMATIC INJURY
Trauma nurses are involved in trauma care from prehospital report through operative care. Surgeons grade the severity of the diaphragmatic injury, which can range from a contusion to a diaphragmatic laceration with appreciable tissue loss. The severity of the diaphragmatic repair is important to trauma nurses as the complexity of the surgical repair can affect downstream nursing assessments and the patient's recovery.
Over time, a tear can evolve until herniation of contents has passed into the thoracic cavity and, if not surgically corrected, can progress to the obstructive phase. According to Aghajanzadeh et al. (2018), approximately 50% of patients have no symptoms in the acute phase of diaphragmatic hernia that would draw clinician attention. However, the patient may present to the ED or clinic several times over weeks or months after sustaining a penetrating or blunt trauma with vague complaints of nausea, vomiting, and abdominal discomfort with a normal chest radiograph. Mousa et al. (2020) describe a case where a young male presented twice to the ED within the year after he had sustained a penetrating injury to his intercostals the previous year. After the initial wound was sutured, the patient self-discharged from the hospital and had no follow-up, only to return subsequent times with complaints of nausea, vomiting, and no bowel movement for 5 days. The CT scan showed his transverse colon to be in his left chest. The patient underwent a surgical repair of a 7-cm diaphragmatic tear, partial colectomy, and a temporary colostomy. During repeated ED visits for similar complaints, the trauma nurses can consider assessing for prior truncal injuries, which can illuminate a possible diaphragmatic injury.
CONCLUSIONS
Diaphragmatic injury, though relatively rare, has high morbidity and mortality. Clinicians must maintain a high index of suspicion for diaphragmatic injury, especially in patients with respiratory and abdominal complaints in the acute phase of hospitalization, and include it on the differential diagnosis list for those with delayed presentation.
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