Wael Hanna, Lorenzo Ferri, David Mulder; McGill University, Montreal, QC, Canada
Objective: Diaphragmatic injury is an under-recognized sequela of trauma. Our understanding of this condition is based primarily on small outdated series. We sought to further characterize this patient population and identify risk factors for mortality using a prospectively entered trauma database.Methods: All patients admitted to a level 1 trauma center (approx. 450 Injury Severity Score>15 admissions/yr) with Traumatic Diaphragmatic Injury (TDI) from 1993-2005 were identified from a prospective trauma registry, and patient and trauma characteristics, associated injuries, and mortality were examined. Hospital charts were reviewed for TDI features, management, and short-term outcomes. To identify possible predictors for mortality, survivors (S) were compared to non-survivors (N-S). Data presented as median (range), Fisher's Exact or Mann-Whitney U-test determined significance (*p<0.05). Multivariate analysis defined predictors.
Results: TDI was identified in 84 patients: blunt trauma - 31/84 (37%); penetrating trauma 53/84 (63%). The majority were male (73/84 - 87%) with an age of 34 (16-79). Although initial trauma-bay chest x-ray was read as abnormal in 66/84 (78%), TDI was suspected in only 26/84 (31%). TDI was identified incidentally at surgery in 49/84 (58%). The external wounds in penetrating TDI was abdominal in 8/53 (15%), thoracic 29/53 (55%), and both 16/53 (30%). This was associated with intra-abdominal organ injury in 7/8 (87%), 16/29 (55%), and 14/16 (87%) respectively. Empyema was rare (4/84), and was not increased by hollow viscus injury, present in 31/84 (37%). Overall mortality was 15/84 (18%): penetrating (9/53-17%); blunt (6/31-19%). Associated injuries were more likely to be present in N-S (15/15) than S (52/69-75%).* Severe head trauma was present in 5/6 blunt TDI deaths. For penetrating TDI, proportion of pts>40 yrs (10/44 S: 6/9 N-S)*, ISS>15 (22/44 S: 8/9 N-S)*, and associated gastric injury (9/44 S: 5/9 N-S)* was higher in non-survivors. Mortality in penetrating TDI was predicted by ISS and gastric injury.
Conclusion: In this descriptive study, the largest in over 20 years, traumatic diaphragmatic injury is accompanied by significant mortality due primarily to associated injuries. For penetrating trauma the high rate of associated intra-abdominal injuries, irrespective of the site of the wound, mandates that a trans-abdominal approach be used in the acute setting.
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