Traumatische Zwerchfellverletzung: notfallmedizinische Diagnose und Behandlung

Abstract

BACKGROUND: Diaphragmatic injuries (DIs) occur relatively infrequently, but their diagnosis is often missed during the initial emergency department evaluation. Following approval by the Institutional Review Board, we explored our experience with emergency diagnosis and treatment of diaphragmatic injury in a mixed group of blunt and penetrating trauma patients. METHODS: The investigators conducted a retrospective analysis of all acute traumatic DI cases treated in a single university hospital from 1991 to 2002. Patients with chronic diaphragmatic hernias and those pronounced dead on arrival were excluded. Trauma cases were reviewed for mode of injury, clinical presentation, diagnostic workup, operative findings, associated injuries, and outcome. RESULTS: The study identified 45 DI patients (mean age, 43 years; range, 5–81). Pulmonary abnormalities were identified in all patients and were most frequently associated with high-speed motor vehicle accidents (73%), severe chest wall injuries (31%), and ipsilateral rib fractures (31%). All patients had life-threatening visceral injuries requiring emergency surgery. Shock, respiratory distress, pneumothorax, high splenic and hepatic injury grades, and orthopedic injuries correlated highly with DIs. Four patients (9%) died, none as a result of the diaphragmatic injury. CONCLUSIONS: Diaphragmatic injury should be suspected in trauma victims presenting with severe associated injuries. Diagnostic aids should be aggressively utilized for early detection. Emergency surgery for treatment of DIs minimizes the mortality associated with these high-risk traumas.