Management of penetrating and blunt diaphragmatic injury

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.