Traumatic Diaphragmatic Injuries

Diaphragmatic injuries are uncommon but are associated with high mortality rates in acute and chronic presentations. Mortality increases with complications of diaphragmatic hernia, which include strangulated bowel, perforation, and peritonitis. Traumatic diaphragmatic injury (TDI) is notoriously underdiagnosed and delayed presentations are common. Firearm injuries and stab wounds account for the majority of TDI. Blunt TDI is frequently associated with severe injuries including pneumothorax and hemorrhaging shock. Contrast enhanced computed tomography imaging is the gold standard for diagnosis in both blunt and penetrating mechanisms of injury. Laparoscopy is a useful nonoperative tool for diagnosing TDI. Small lacerations may not warrant further investigation or repair at the index admission. Patients with clinical instability and/or evidence of TDI with blunt trauma warrant emergent operative intervention. Recognition of TDI is essential for nurse practitioners and physician assistants, given disease mortality, frequency of delayed presentations, and the lack of guidance on surveillance for initially nonoperative injuries.