The diagnosis and management of acute traumatic diaphragmatic injury: A Western Trauma Association clinical decisions algorithm
Authors
Morgan Schellenberg, From the Division of Acute Care Surgery, Department of Surgery (M.S., M.J.M.), Los Angeles General Medical Center, Los Angeles; Division of Acute Care Surgery, Department of Surgery (R.C.), Loma Linda University School of Medicine, Loma Linda, California; Division of Acute Care Surgery, Department of Surgery (C.A.C.), University of Florida College of Medicine, Gainesville, Florida; Division of Acute Care Surgery, Department of Surgery (C.F.), University of Maryland School of Medicine, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (J.H.), University of Kansas Medical Center, Kansas City, Kansas; Division of Acute Care Surgery, Department of Surgery (N.K.), University of Arizona College of Medicine-Phoenix, Phoenix, Arizona; Division of Acute Care Surgery, Department of Surgery (M.L.), Methodist Dallas Medical Center, Dallas, Texas; Division of Vascular Surgery and Endovascular Therapy (G.A.M.), Keck Medical Center of USC, Los Angeles, California; Division of Acute Care Surgery, Department of Surgery (L.J.M.), The University of Texas McGovern Medical School-Houston Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, Texas; Division of Acute Care Surgery, Department of Surgery (A.R.P.), Medical University of South Carolina, North Charleston, South Carolina; Division of Acute Care Surgery, Department of Surgery (K.M.S.), Yale School of Medicine, New Haven, Connecticut; UCSF Department of Surgery at Zuckerberg San Francisco General Hospital (R.T.), University of California, San Francisco, San Francisco, California; Division of Acute Care Surgery, Department of Surgery (J.A.W.), St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and Program in Trauma (D.M.S.), University of Maryland School of Medicine, Baltimore, Maryland.
Raul Coimbra
Chasen A. Croft
Charles Fox
Jennifer L. Hartwell
Natasha Keric
Manuel Lorenzo
Matthew J. Martin
Gregory A. Magee
Laura J. Moore
Alicia R. Privette
K M. Schuster, Yale School of Medicine New Haven, Connecticut, Department of Surgery, USA.
Ronald Tesoriero, From the Department of Surgery (R.T.), University of California, San Francisco, San Francisco, California; Comparative Effectiveness and Clinical Outcomes Research Center (R.C.), Riverside University Health Systems Medical Center, Moreno Valley; Loma Linda University School of Medicine (R.C.), Loma Linda, California; Scripps Memorial Hospital La Jolla (W.L.B.), La Jolla, California; University of Colorado (C.C.B.), Aurora, Colorado; University of Florida College of Medicine (C.A.C.), Gainesville, Florida; University of Maryland School of Medicine (C.F.), Baltimore, Maryland; University of Kansas Medical Center (J.L.H.), Kansas City, Kansas; University of Arizona College of Medicine-Phoenix (N.K.), Phoenix, Arizona; Methodist Dallas Medical Center (M.L.), Dallas, Texas; Division of Acute Care Surgery, Department of Surgery (M.J.M., M.S.), Los Angeles General Medical Center, Los Angeles, California; Division of Vascular Surgery and Endovascular Therapy (G.A.M.), Keck Medical Center of USC, Los Angeles, California; Division of Acute Care Surgery, Department of Surgery (L.J.M.), The University of Texas McGovern Medical School - Houston Red Duke Trauma Institute, Memorial Hermann Hospital, Houston, Texas; Medical University of South Carolina (A.R.P.), North Charleston, South Carolina; Yale School of Medicine (K.M.S.), New Haven, Connecticut; St. Joseph's Hospital and Medical Center (J.A.W.), Phoenix, Arizona; and Program in Trauma (D.M.S.), University of Maryland School of Medicine, Baltimore, Maryland.
Jordan A. Weinberg
Deborah M. Stein
Publication Title
Journal of Trauma and Acute Care Surgery
Abstract
SUMMARY:
Acute traumatic injuries to the diaphragm remain difficult to diagnose and manage. This is due to limitations in noninvasive diagnostic methods and a lack of definition of specific patient populations who stand to benefit from diaphragmatic injury screening and closure among those with CT-occult injuries.
In general, concern for diaphragmatic injury should arise after high-energy blunt trauma mechanisms and penetrating thoracoabdominal trauma. Patients with indications for emergent surgical exploration should undergo direct intraoperative visualization of the diaphragm, with repair of any identified injuries after reduction of any herniated contents. From there, the algorithm diverges according to blunt and penetrating trauma mechanisms due to the increased ability of CT scan to diagnose large as opposed to small injuries of the diaphragm. Patients with blunt diaphragmatic injury on CT necessitate repair and otherwise need no further screening for CT-occult diaphragmatic injury.
Penetrating trauma patients with visualized or implied injuries to the diaphragm are managed according to laterality. Left-sided thoracoabdominal injuries generally need screening prior to hospital discharge with a diagnostic laparoscopy and repair of any identified injuries. Management of right-sided injuries are controversial and lacking in data regarding which, if any, ought to be repaired.
DOI
10.1097/TA.0000000000004554
Publication Date
4-1-2025
Recommended Citation
Schellenberg M, Coimbra R, Croft CA, Fox C, Hartwell J, Keric N, Lorenzo M, Martin MJ, Magee GA, Moore LJ, Privette AR, Schuster KM, Tesoriero R, Weinberg JA, Stein DM. The diagnosis and management of acute traumatic diaphragmatic injury: A Western Trauma Association clinical decisions algorithm. J Trauma Acute Care Surg. 2025 Apr 1;98(4):621-627. doi: 10.1097/TA.0000000000004554. Epub 2025 Jan 28. PMID: 39874492.
