Factors affecting outcomes in penetrating diaphragmatic trauma

BACKGROUDS: Diagnosing penetrating diaphragmatic rupture (PDR) is a challenging aspect of managing thoracoabdominal injuries due to the lack of a typical clinical presentation. The mortality from PDR is variable and center-specific. In this study, we identified the incidence and clinical presentation of PDR at our institution and analyzed the factors that affected the length of hospital stay and mortality.

We collected all patients who were diagnosed with PDR from January 2001 through December 2010 at a Level I trauma center. We recorded demographic characteristics, clinical parameters, diagnostic images, trauma mechanism, location and severity of injuries, injury severity score (ISS), time to diagnosis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and mortality. We analyzed the risk for mortality and prolonged hospitalization.

Forty-one patients with a median age of 37 years were included. Thirty-six patients (87.8%) had an early diagnosis, and 5 patients (12.2%) had a delayed diagnosis requiring longer than 24 h. The median ICU LOS and HLOS were 2 and 11 days, respectively. High-grade PDR and lung injury increased the ICU LOS and HLOS. The total mortality rate was 7.3%. Multivariate analysis showed that hypothermia and hypotension were independent risk factors for mortality.

Overlooking diaphragmatic rupture in patients with thoracoabdominal penetrating injury is not infrequent. A high index of suspicion is important for making the diagnosis. A high-grade PDR and associated lung injury prolonged the length of hospital stay. Profound hemorrhagic shock and associated physical decompensation have an impact on mortality.