01Approach to the Critical Patient/attcp46

Immediate Priorities

›Airway and breathing threats

›Respiratory failure from herniated viscera compressing the lung

›Tracheal deviation away from affected side

›Absent or severely diminished breath sounds ipsilaterally

›Bowel sounds auscultated in the thorax

›If SpO2 < 90% or respiratory failure, immediate definitive airway management

›Rapid sequence intubation preferred

›Positive-pressure ventilation may temporarily splint defect and mask herniation

›Tension physiology from herniated bowel mimicking tension pneumothorax

›Hemodynamic collapse with contralateral mediastinal shift

›Do not place chest tube before CXR if diaphragmatic rupture suspected

›Circulation threats

›Hemorrhagic shock from associated vascular and solid organ injuries

›Occurs in 27-42% of cases

›SBP < 90 mmHg or HR > 120 bpm trigger massive transfusion protocol

›Activate massive transfusion protocol for hemorrhagic shock

›1:1:1 ratio packed red cells to plasma to platelets

›Tranexamic acid 1 g IV within 3 hours of injury

›Cardiac compression from mediastinal shift or herniated viscera

›Cardiac tamponade physiology has been reported with organ herniation

›Right heart strain on ECG may reflect significant herniation

Stabilization Priorities

›Primary survey per ATLS protocol

›Airway secured before imaging in hemodynamically unstable patient

›Avoid mask ventilation with high gastric pressure risk

›Cuffed endotracheal tube preferred

›Two large-bore peripheral IVs and type-and-crossmatch

02History/hx49

Mechanism of Injury

›Blunt thoracoabdominal trauma

›Motor vehicle collision (accounts for approximately 64% of cases)

›Steering wheel impact, seatbelt compression, ejection

›Front seat passenger position associated with higher risk (AOR 1.75)

›Falls from height, crush injuries, blast injuries

›Heavy object compression (AOR 1.68)

›ISS 16 or greater present in 77% of cases

›Penetrating thoracoabdominal injury

›Stab or gunshot wound below the nipple line anteriorly

›Or below scapular tip posteriorly

›Any wound in this zone may traverse the diaphragm

Symptom Characterization

›Respiratory symptoms (most common presentation)

›Dyspnea (reported in approximately 86% of cases)

›Orthopnea worsens with recumbency as herniation increases

›Progressive course over hours to days in acute phase

›Pleuritic chest pain

›Left or right-sided depending on rupture side

›Gastrointestinal symptoms (obstructive phase)

›Nausea and vomiting

›Abdominal distension and obstipation with bowel herniation

›Colicky pain with intermittent bowel obstruction

›Absence of symptoms does not exclude injury

›Latent phase may be clinically silent for weeks to years

›Referred pain

›Left or right shoulder pain from phrenic nerve irritation

›Diaphragmatic irritation by herniated contents or blood

03Physical Exam/exam45

Vital Signs and Hemodynamic Assessment

›Hemodynamic instability pattern

›Tachycardia and hypotension in 27-42% of cases

›Shock driven primarily by associated injuries

›Right-sided rupture associated with higher mortality

›Tachypnea with increased work of breathing

›Respiratory rate > 30 breaths per minute warrants immediate reassessment

›Accessory muscle use and paradoxical breathing

Chest and Lung Examination

›Auscultation findings

›Bowel sounds in the chest (pathognomonic but insensitive)

›Most reliably heard in left lower hemithorax with left-sided rupture

›Absence of bowel sounds does not exclude herniation

›Diminished or absent breath sounds ipsilateral to rupture

›Distinguish from hemothorax or pneumothorax by percussion

›Percussion findings

›Dullness over affected hemithorax (herniated solid organs or fluid)

›Tympany suggests herniated hollow viscus (stomach, colon)

›Shifting dullness if large pleural effusion coexists

›Chest wall inspection

›Seatbelt sign

›Contusion or abrasion across chest or abdomen

›Significantly increases probability of intra-abdominal injury

›Penetrating wound location

›Any wound below nipple line must prompt diaphragmatic evaluation

›Posterior wounds below scapular tip equally at risk

Abdominal Examination

›Scaphoid abdomen

04Differential Diagnosis/ddx43

Life-Threatening Differentials

›Tension pneumothorax (ICD-10: J93.0)

›Mimics diaphragmatic rupture with hemodynamic collapse and mediastinal shift

›Tracheal deviation, absent breath sounds, hypotension

›Tympany on percussion distinguishes from herniated solid organ

›CXR distinguishes: absent lung markings vs. bowel gas pattern in thorax

›Massive hemothorax (ICD-10: S27.1)

›Dullness on percussion, absent breath sounds, hemodynamic compromise

›May coexist with diaphragmatic rupture

›Chest tube may drain both blood and enteric contents if both present

›Traumatic aortic injury (ICD-10: S25.0)

›Associated in 3-5% of blunt traumatic diaphragmatic injury cases

›Widened mediastinum on CXR

›CT angiography required to exclude

Common Mimics

›Pulmonary contusion (ICD-10: S27.3)

›Patchy opacification on CXR resembling herniated viscera

›No bowel gas pattern

›Typically evolves over 24-48 hours

›Often coexists with diaphragmatic rupture

›Hemopneumothorax (ICD-10: J94.2)

›Most common concurrent finding

›Air-fluid level may mimic herniated stomach with air-fluid level

›NG tube position diagnostic if coiling into thorax

›Diaphragmatic eventration (ICD-10: J98.6)

›Elevated hemidiaphragm without true rupture

›No herniation of abdominal viscera into pleural space

›May be congenital or acquired (phrenic nerve palsy)

05Laboratory Tests/lt46

Trauma Resuscitation Labs

›Complete blood count

›Hemoglobin and hematocrit for hemorrhage quantification

›Serial measurements every 4-6 hours in active hemorrhage

›Transfusion trigger hemoglobin < 70 g/L in stable patients

›Platelet count for coagulopathy risk stratification

›Target > 50 x 10(9)/L in active hemorrhage

›Platelet transfusion if < 50 in ongoing bleeding

›Coagulation panel

›PT/INR and aPTT for trauma-induced coagulopathy

›Viscoelastic testing (TEG/ROTEM) preferred if available

›Fibrinogen < 1.5 g/L triggers cryoprecipitate administration

›Lactate for shock severity and resuscitation monitoring

›Lactate > 4 mmol/L indicates severe shock

›Serial lactate clearance targets: > 10% per hour

›Type and crossmatch

›Group and screen at minimum; crossmatch for hemorrhagic shock

›Activate massive transfusion protocol early if indicated

›Universal donor O-negative blood if crossmatch time not available

Metabolic and Organ Function Labs

›Comprehensive metabolic panel

›Electrolytes for resuscitation monitoring

›Potassium and ionized calcium correction with massive transfusion

›Sodium imbalance from crystalloid resuscitation

›Creatinine and BUN for renal perfusion assessment

›Acute kidney injury common with shock and rhabdomyolysis

›Myoglobin if crush injury suspected

›Arterial blood gas

06Diagnostic Tests/dt83

Scoring Systems

›Injury Severity Score (ISS)

›Mean ISS of 32.9 in patients with diaphragmatic rupture vs. 18.6 without

›ISS 16 or greater present in 77% of diaphragmatic rupture cases

›Used for mortality risk stratification and trauma registry classification

›Abbreviated Injury Scale (AIS) components

›Thoracic AIS, abdominal AIS, head AIS all contribute

›High thoracic and abdominal scores increase probability of diaphragmatic injury

›WSES and AAST classification of diaphragmatic injury

›AAST Grade I: contusion without defect

›AAST Grade II: laceration < 2 cm

›AAST Grade III: laceration 2-10 cm

›AAST Grade IV: laceration > 10 cm with herniation

›AAST Grade V: laceration with tissue loss > 25 cm

›Higher grade associated with greater mortality and repair complexity

›Revised Trauma Score (RTS)

›Combines GCS, SBP, and respiratory rate

›Used for triage and outcome prediction

›RTS < 4 predicts high mortality in polytrauma

MRI

›Indications for MRI in diaphragmatic rupture

›Hemodynamically stable patient with equivocal CT findings

›Subacute or chronic presentation with unclear anatomy

›Pregnant patient when CT radiation is to be minimized

›Superior soft-tissue contrast for diaphragmatic anatomy

›Coronal and sagittal reconstructions delineate diaphragm continuity

›No ionizing radiation

›MRI findings in diaphragmatic rupture

›Diaphragmatic discontinuity on coronal T2-weighted images

›Herniated viscera with characteristic signal intensity

›Collar sign visible at defect margins

›Limitations

›Prolonged acquisition time unsuitable for unstable patients

›Limited availability in acute trauma setting

›Motion artifact from breathing degrades image quality

CT

›Contrast-enhanced CT as gold standard imaging modality

›Sensitivity 80% (95% CI 65-90%), specificity 98% (95% CI 89-100%) for blunt traumatic diaphragmatic injury

›MDCT specificity 100% for left-sided, 83% for right-sided injuries

›49% of blunt cases may not show diaphragmatic injury on preoperative CT

›ACS Best Practices Guidelines support CT as primary imaging modality

›Diagnostic CT signs

›Diaphragmatic discontinuity

›Direct visualization of defect in diaphragm

›Most reliable sign when present

›Collar sign

›Constriction of herniated organ at diaphragmatic defect

›High specificity for diaphragmatic rupture

›Dependent viscera sign

›Herniated viscera lie dependent against posterior thoracic wall

›Most sensitive CT sign for diaphragmatic rupture

›Dangling diaphragm sign

›Free edge of torn diaphragm curls inward

›Seen in larger defects

›Intrathoracic herniation of abdominal contents

›Stomach, colon, spleen, liver, omentum above diaphragm

›NG tube coiling into thorax on scout or axial images is diagnostic

›CT protocol considerations

›Multidetector CT with coronal and sagittal reconstructions mandatory

›Thin-slice acquisitions (1-2 mm) improve sensitivity

›Portal venous phase captures visceral injuries

›CT angiography if aortic injury suspected

›Associated aortic injury in 3-5% of cases

›CT-A sensitivity and specificity approach 100% for aortic injury

Ultrasound

›Extended Focused Assessment with Sonography in Trauma (E-FAST)

›Indicated in all trauma patients as initial bedside assessment

›Positive FAST is a strong predictor of diaphragmatic rupture (AOR 2.12)

›Detects associated hemothorax, pneumothorax, and free intraperitoneal fluid

›E-FAST does not reliably diagnose diaphragmatic rupture itself

›Herniated viscera may not be identifiable by bedside ultrasound

›Normal E-FAST does not exclude diaphragmatic injury

›Specific ultrasound findings in diaphragmatic rupture

›Absent diaphragmatic sliding or discontinuous diaphragm on ultrasound

›Bowel peristalsis identified above diaphragm level

›Sensitivity and specificity lower than CT for direct diagnosis

›Adjunct findings supporting diagnosis

›Free pleural fluid above liver or spleen

›Complex pleural effusion suggesting hemothorax

›Loss of normal hyperechoic diaphragmatic line

›Diagnostic laparoscopy and thoracoscopy

›Gold standard for penetrating diaphragmatic injury when CT is inconclusive

›Should be considered liberally in thoracoabdominal stab wounds

›Sensitivity approaches 100% for occult diaphragmatic injury

›Performed in hemodynamically stable patients

›Laparoscopy preferred for penetrating lower chest wounds

›Thoracoscopy for right-sided injury or adhesion-related approach

07Disposition/dispo22

Admission Criteria

›Mandatory admission for all confirmed or highly suspected diaphragmatic ruptures

›All confirmed injuries require operative repair without exception

›No conservative management pathway exists for traumatic rupture

›Surgical ICU admission given high ISS and associated injuries

›Surgical ICU indications

›Hemodynamic instability at presentation

›Respiratory failure requiring ventilatory support

›Postoperative monitoring after repair

Transfer Criteria

›Transfer to Level I or II trauma center if not at trauma center

›Trauma surgery capability required for definitive repair

›Stabilize before transfer: airway, hemorrhage control, chest tube if needed

›Expedite transfer for instability — do not delay for non-essential imaging

›Thoracic surgery involvement for complex or delayed repairs

›Adhesions between herniated organs and thoracic structures require thoracic expertise

›Delayed presentation with chronically herniated bowel

Observation and Serial Assessment

›High clinical suspicion with negative initial imaging

›Serial CXR every 6-12 hours in first 24 hours

›Evolving opacity or new bowel gas in thorax warrants repeat CT

›Repeat CT at 24 hours if initial CT negative but high suspicion

›Serial abdominal exams for evolving peritoneal signs

›Worsening pain, distension, or vomiting may indicate bowel herniation

›Low threshold for operative exploration

08Treatment/t71

Initial Resuscitation

›Airway management

›Rapid sequence intubation for respiratory failure or airway compromise

›Ketamine 1-2 mg/kg IV or etomidate 0.3 mg/kg IV for induction

›Succinylcholine 1.5 mg/kg IV or rocuronium 1.2 mg/kg IV for paralysis

›Positive-pressure ventilation parameters

›Tidal volume 6-8 mL/kg ideal body weight

›PEEP 5-8 cmH2O initially, titrate for oxygenation

›Note: PPV may temporarily mask herniation by reducing intra-abdominal pressure

›Hemorrhagic shock resuscitation

›Massive transfusion protocol activation for SBP < 90 mmHg with suspected hemorrhage

›1:1:1 ratio packed red blood cells to fresh frozen plasma to platelets

›Target hemoglobin 70-80 g/L, platelet count > 50 x 10(9)/L

›Tranexamic acid

›1 g IV over 10 minutes within 3 hours of injury

›Follow with 1 g IV over 8 hours

›Do not administer after 3 hours from injury (increased mortality risk)

›Calcium chloride 1 g IV for ionized calcium < 1.1 mmol/L during massive transfusion

›Repeat every 4 units blood products

›Citrate toxicity depletes ionized calcium

Surgical Repair (Definitive Treatment)

›Operative approach selection

›Acute setting: laparotomy preferred approach

›Allows evaluation and repair of associated abdominal injuries

›Lower rate of additional exploration vs. thoracotomy (9.1% vs. 56.2%)

›Permits bowel reduction and diaphragmatic repair through single access

›Delayed presentation: thoracotomy preferred

›Adhesions between herniated organs and thoracic structures require thoracic access

›Allows lysis of adhesions under direct visualization

›Minimally invasive approach (laparoscopy or thoracoscopy)

›Feasible in hemodynamically stable patients with experienced teams

›Laparoscopic repair suitable for hemodynamically stable penetrating injury

›Conversion to open surgery if significant hemorrhage or complex repair needed

›Repair technique

›Primary closure with non-absorbable or slowly absorbable monofilament sutures

›Interrupted or running technique depending on defect geometry

›Polypropylene or polydioxanone sutures preferred

›Mesh reinforcement for defects greater than 3 cm or tension-free closure not achievable

›Reduces recurrence risk compared to primary suture alone

›Biologic mesh preferred in contaminated field

›Chest tube placement mandatory after all diaphragmatic repairs

›Drains pleural space of blood, air, and reactive fluid

›Water seal drainage at 20 cmH2O suction

›Damage control surgery

›Indicated in unstable patients with lethal triad (hypothermia, coagulopathy, acidosis)

›Temporary diaphragmatic closure with running suture or silo

›Pack abdomen and close temporarily

›Return to operating room in 24-48 hours after physiologic restoration

›Target temperature > 35 degrees C before definitive repair

›Ionized calcium > 1.1 mmol/L

›pH > 7.35 and lactate < 2 mmol/L before planned return

Perioperative Medical Management

›Antibiotic prophylaxis

›Indicated for all penetrating injuries and surgical explorations

›Cefazolin 2 g IV preoperatively (3 g if > 120 kg)

›Metronidazole 500 mg IV added for bowel contamination or hollow viscus injury

›Duration: single preoperative dose for elective repair; 24 hours for contaminated field

›Prolonged antibiotics if peritonitis or established infection

›Analgesia

›Multimodal analgesia preferred to avoid respiratory depression

›Acetaminophen 1 g IV every 6 hours as baseline

›Ketorolac 15-30 mg IV every 6 hours if no coagulopathy or renal dysfunction

›Opioid analgesia with caution

›Morphine 2-4 mg IV PRN or fentanyl 25-50 mcg IV PRN

›Avoid excessive sedation masking respiratory deterioration

›Thoracic epidural or intercostal nerve blocks for post-thoracotomy pain

›Regional anesthesia reduces opioid requirement

›Bupivacaine 0.25% or ropivacaine 0.2% per standard regional protocol

›Nasogastric decompression

›Mandatory in all patients with suspected or confirmed gastric herniation

›Reduces aspiration risk and decompresses herniated stomach

›Do not force NG tube if resistance suggests gastric volvulus

›NPO status maintained until operative repair and bowel function returns

›Post-repair diet advancement per standard post-laparotomy protocol

09Special Populations/sp75

Pregnancy

›Epidemiology and risks in pregnancy

›Traumatic diaphragmatic rupture in pregnancy is rare but highly morbid

›Fetal mortality approaches 50% with maternal hemorrhagic shock

›Uterine enlargement may alter injury patterns and displacement of viscera

›Right-sided rupture more common in advanced pregnancy due to uterine displacement

›Liver protected by gravid uterus on left

›Diagnostic approach in pregnancy

›Chest X-ray as first-line imaging (minimal fetal radiation)

›Acceptable in any trimester when clinically indicated

›Fetal shielding when possible

›CT with contrast acceptable in hemodynamically unstable patient

›Maternal benefit outweighs fetal radiation risk in acute trauma

›Iodinated contrast safe in pregnancy for single exposure

›MRI preferred for stable patient with equivocal CT

›No ionizing radiation

›Gadolinium contrast avoided in pregnancy unless essential

›Treatment considerations in pregnancy

›Operative repair as in non-pregnant patients

›Left lateral uterine displacement during surgery after 20 weeks gestation

›Obstetric involvement for fetal monitoring during repair

›Preoperative fetal heart rate monitoring

›Urgent obstetric consultation for all pregnant trauma patients

›Emergent cesarean delivery if fetal distress and viable gestation (> 23-24 weeks)

›Teratogenic medication avoidance

›Succinylcholine and rocuronium acceptable for RSI

›NSAIDs avoided after 30 weeks gestation (premature ductus closure)

Geriatric

›Physiologic considerations

›Reduced physiologic reserve limits tolerance of herniation

›Smaller defects may cause significant respiratory compromise

›Baseline pulmonary conditions (COPD, restrictive disease) worsen prognosis

›Reduced cardiac reserve with higher risk of cardiac complications

›Atrial fibrillation common with mediastinal shift or hypoxia

›Higher baseline medication burden (anticoagulants increase hemorrhage risk)

›Diagnostic considerations

›Lower mechanism trauma may cause diaphragmatic injury in elderly

›Osteoporosis increases rib fracture rate with lower force

›Rib fractures present in higher proportion of elderly diaphragmatic rupture cases

›Pre-existing diaphragmatic eventration may confound diagnosis

›Baseline elevated hemidiaphragm from aging complicates interpretation

›Comparison with prior imaging helpful when available

›Treatment considerations

›Perioperative risk assessment with cardiopulmonary evaluation

›Higher anesthetic risk with ASA III-IV status

›Frailty assessment may guide surgical approach selection

›Anticoagulation reversal before emergent surgery

›Warfarin: vitamin K 10 mg IV plus 4-factor PCC per weight-based dosing

›DOAC: specific reversal agents if available (andexanet alfa, idarucizumab)

›Postoperative pulmonary complications more common

›Early physiotherapy and incentive spirometry

›Aggressive DVT prophylaxis given higher baseline risk

Pediatrics

›Epidemiology in pediatric patients

›Diaphragmatic rupture less common in children than adults

›More pliable chest wall transmits force differently

›Blunt mechanism still predominates (MVCs, bicycle accidents, sports)

›Right-sided rupture relatively more common in children than adults

›Liver not as protective given smaller size relative to injury force

›Diagnostic approach in pediatrics

›ALARA principle for radiation: minimize CT exposure

›CXR and ultrasound as first-line where possible

›Low-dose CT protocol when CT required

›Lower CXR sensitivity in children (smaller defects, more cartilaginous)

›High clinical suspicion drives CT even with normal CXR

›Pediatric trauma team involvement early

›Treatment considerations in pediatrics

›Weight-based dosing for all resuscitation and anesthetic agents

›Ketamine 1-2 mg/kg IV for induction

›Succinylcholine 2 mg/kg IV (higher dose per kg than adults)

›Tranexamic acid: 15 mg/kg IV (maximum 1 g) within 3 hours

›Follow with 2 mg/kg/hour infusion for 8 hours

›Massive transfusion protocol with pediatric-specific ratios

›10-15 mL/kg packed red blood cells as initial bolus

›1:1:1 ratio maintained as in adults for ongoing hemorrhage

›Congenital diaphragmatic hernia must be excluded

›Bochdalek hernia presenting in older child or adolescent

›Family history and prior CXR comparison helpful

10Background/b74

Epidemiology

›Incidence and prevalence

›Diaphragmatic rupture occurs in approximately 0.3-0.5% of all trauma patients

›Incidence up to 5% in severe thoracoabdominal trauma

›Predominantly left-sided (68-81%) due to protective buffering effect of liver on right

›Demographic profile

›Male sex in 72-84% of cases

›Mean age approximately 46 years

›Motor vehicle collisions account for approximately 64% of cases

›Mortality and morbidity

›Overall mortality 13-20%, driven primarily by severity of associated injuries

›Right-sided rupture associated with significantly higher mortality

›Preoperative shock is the strongest independent predictor of death

›Morbidity 40-60%

›Pulmonary complications most frequent postoperative morbidity

›Empyema, subphrenic abscess, suture dehiscence reported

›Associated injuries

›87% of patients have concomitant organ injuries

›Splenic injury in 25-45% of cases

›Liver laceration in approximately 25% of cases

›Lung injury in 44-49% of cases

›Pelvic fracture in approximately 40% of cases

›Aortic injury in 3-5% of cases

›Mean ISS of 32.9 in diaphragmatic rupture patients

Pathophysiology

›Mechanisms of diaphragmatic rupture

›Blunt trauma mechanism

›Sudden increase in intra-abdominal pressure transmitted to diaphragm

›Combined with shear forces at points of diaphragmatic fixation

›Posterolateral left hemidiaphragm most vulnerable point

›Penetrating trauma mechanism

›Direct laceration of diaphragm by projectile or blade

›Small penetrating wounds may seal temporarily and present late

›Stab wounds produce smaller defects than gunshot wounds

›Left-sided predominance

›Liver provides structural support to right hemidiaphragm

›Acts as a buffer distributing and absorbing force

›Right-sided injuries require greater force to occur

›Posterolateral left hemidiaphragm is embryologically weakest point

›Site of pleuroperitoneal canal closure in embryogenesis

›Corresponds to Bochdalek foramen location

›Herniation pathophysiology

›Pressure gradient between negative intrathoracic and positive intraperitoneal pressure

›Drives progressive herniation of abdominal contents

›Herniation worsens with positive-pressure ventilation cessation

›Organs most commonly herniated

›Stomach (most common), colon, spleen, small bowel, omentum

›Right-sided: liver herniation with high associated mortality

›Strangulation and obstruction

›Defect edge constricts herniated bowel (collar sign)

›Venous congestion progresses to ischemia and perforation if untreated

›Obstructive phase represents surgical emergency

Therapeutic Considerations

›Evidence base for surgical approach

›All traumatic diaphragmatic ruptures require operative repair

›No level I evidence for conservative management; expert consensus mandates repair

›Laparotomy preferred in acute setting (WSES position paper recommendation)

›Laparotomy vs. thoracotomy approach

›Acute injury: laparotomy lower rate of additional exploration (9.1% vs. 56.2%)

›Delayed injury: thoracotomy preferred for adhesion management

›Minimally invasive surgery evidence

›Laparoscopic repair feasible in hemodynamically stable patients

›Thoracoscopic repair for penetrating injury with experienced teams

›Mesh vs. primary repair

›Primary suture repair acceptable for small defects under 3 cm

›Recurrence rate up to 42% after primary repair without mesh

›Non-absorbable monofilament sutures recommended

›Mesh augmentation for large or high-tension defects

›Biologic mesh preferred in contaminated field

›Synthetic mesh (polypropylene) for clean elective repair

›Damage control considerations

›Indicated when lethal triad present (hypothermia, coagulopathy, acidosis)

›Temporary closure allows physiologic restoration

›Definitive repair in 24-48 hours when physiology normalized

›Massive transfusion and TXA reduce mortality in hemorrhagic shock

›1:1:1 resuscitation ratio supported by PROPPR trial

›TXA within 3 hours of injury reduces mortality (CRASH-2 trial)

11Patient Discharge Instructions/pdi35

copy discharge instructions

›Discharge instructions for diaphragmatic rupture

›You have been treated for a tear in the diaphragm, the breathing muscle separating your chest from your abdomen

›This injury required surgical repair during your hospital stay

›Recovery depends on your other injuries and the surgical approach used

›Activity restrictions after repair

›No heavy lifting (more than 5 kg) for 6-8 weeks after open repair

›No strenuous activity or contact sports until cleared by your surgeon

›Driving restrictions apply while on opioid pain medications

›Wound care instructions

›Keep surgical incision clean and dry for 48-72 hours

›Steri-strips or staples: do not remove; surgeon will remove at follow-up visit

›Signs of infection: redness, swelling, warmth, discharge, or fever above 38 degrees C

›Breathing exercises

›Use incentive spirometer 10 times every hour while awake

›Deep breathing and coughing exercises prevent pneumonia after surgery

›Splint incision with pillow when coughing

›Return to emergency department immediately if

›Worsening shortness of breath or inability to breathe lying flat

›New or worsening chest pain

›Fever above 38.5 degrees C

›Severe abdominal pain, nausea, or vomiting (possible bowel obstruction)

›Inability to pass stool or gas for more than 48-72 hours

›Abdominal distension worsening

›Wound concerns

›Significant bleeding or discharge from wound

›Wound edges opening (dehiscence)

›Increasing redness or warmth around incision

12References/r33

Guidelines and Key Sources

›Weber C, Willms A, Bieler D, et al. Traumatic Diaphragmatic Rupture: Epidemiology, Associated Injuries, and Outcome — an Analysis Based on the TraumaRegister DGU. Langenbeck's Archives of Surgery. 2022.

›Provides epidemiologic data including mortality rates, associated injury frequency, and risk predictors

›Source for ISS data, left-sided predominance, and preoperative shock as mortality predictor

›Lim KH, Park J. Blunt Traumatic Diaphragmatic Rupture: Single-Center Experience With 38 Patients. Medicine. 2018.

›Source for CT diagnostic criteria, Carter's three-phase classification, and surgical approach selection

›CXR sensitivity data and normal imaging rate in diaphragmatic injury

›Fair KA, Gordon NT, Barbosa RR, et al. Traumatic Diaphragmatic Injury in the American College of Surgeons National Trauma Data Bank. American Journal of Surgery. 2015.

›Large database study on epidemiology and outcomes

›Source for penetrating injury zone and antibiotic prophylaxis recommendations

›Furák J, Athanassiadi K. Diaphragm and Transdiaphragmatic Injuries. Journal of Thoracic Disease. 2019.

›Comprehensive review of surgical management and thoracotomy vs. laparotomy evidence

›Source for thoracotomy preference in delayed presentation

›Giuffrida M, Perrone G, Abu-Zidan F, et al. Management of Complicated Diaphragmatic Hernia in the Acute Setting: A WSES Position Paper. World Journal of Emergency Surgery. 2023.

›WSES expert consensus on repair indications, mesh use, and damage control strategy

›Authoritative guideline for surgical management decisions

›Coccolini F, Cremonini C, Moore EE, et al. Thoracic Trauma WSES-AAST Guidelines. World Journal of Emergency Surgery. 2025.

›Current joint guidelines for thoracic trauma management including diaphragmatic injury

›Source for serial imaging recommendations and observation criteria

›Reitano E, Cioffi SPB, Airoldi C, et al. Current Trends in the Diagnosis and Management of Traumatic Diaphragmatic Injuries: A Systematic Review and Diagnostic Accuracy Meta-Analysis of Blunt Trauma. Injury. 2022.

›Meta-analysis providing CT sensitivity 80% and specificity 98% data

›Systematic evidence base for diagnostic imaging performance

›Keyes S, Spouge RJ, Kennedy P, et al. Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities. Radiographics. 2024.

›Detailed imaging review of CT signs including collar sign, dependent viscera sign, dangling diaphragm sign

›MRI role in equivocal cases and differential diagnosis

›Ryu H, Byun CS, Kim S, et al. Clinical Indicators and Imaging Characteristics of Blunt Traumatic Diaphragmatic Injury. Journal of Clinical Medicine. 2025.

›Contemporary analysis of risk factors and AOR data

›Source for FAST positive AOR 2.12 and consciousness disturbance AOR 1.64

Evidence & Review

Evidence & Review