(P46) Trust Your Gut: A Case of Diaphragmatic Injury Secondary to Penetrating Trauma with Negative Imaging Results

Chief Complaint: Stab wound to the left chest

History of Present Illness: A 47-year-old female with a past medical history of asthma, arthritis, and bilateral total knee replacement is brought in as a Level 1 trauma after being stabbed in the left anterior chest with a kitchen knife. Patient reports pain in the area of the wound. She denies chest pain, shortness of breath, dizziness, or nausea/vomiting.

Pertinent Physical Exam: Initial vitals showed blood pressure 141/105, heart rate 64 beats per minute, respiratory rate 18, and oxygen saturation 95% on room air. On primary survey, patient was protecting airway; breath sounds were present bilaterally with equal chest rise; radial and distal pulses were equal and intact with no active hemorrhage; and patient had a Glasgow Coma Scale (GCS) of 15 and was moving all extremities. Upon exposure and secondary survey, the patient was noted to have three 1 cm lacerations to the inferior aspect of the left breast at the inframammary fold. No other injuries were seen on the exam.

Pertinent Laboratory Data: An Extended Focused Assessment with Sonography in Trauma (E-FAST) exam was negative for pneumothorax, pericardial effusion, or free fluid in the abdomen. Laboratory results showed hemoglobin 12.8 g/dL, hematocrit 41.4%, and platelets 246 /nL. Computed tomography (CT) of the chest, abdomen, and pelvis was read as a left pleural effusion with complex fluid, possibly representing a hemothorax. A diagnostic laparoscopy was done the next day, revealing a 5 cm defect to the left diaphragm, < 2 cm laceration to the left lobe of the liver, and a small serosal laceration to the lesser curve of the stomach.

Case Discussion: Diaphragmatic injuries occur in 0.8 to 15% of all thoracoabdominal traumas [1]. The risk of an occult diaphragmatic injury in an asymptomatic patient with an anterior or flank stab wound can be up to 7%. The sensitivity of CT for detecting a diaphragmatic injury is 77%, while the specificity is 91% [2]. Laparoscopy has been shown to miss fewer diaphragmatic injuries when compared to CT imaging, with a sensitivity of 87.5% and specificity approaching 100% [3]. As such, the Eastern Association for the Surgery of Trauma (EAST) guidelines for management of traumatic diaphragmatic injuries conditionally recommend diagnostic laparoscopy over CT imaging in patients who are hemodynamically stable and without peritonitis [2].
Diaphragm injuries are graded on the American Association for the Surgery of Trauma (AAST) diaphragm injury scale, which ranges from Grade I to Grade V. This patient had an AAST Grade III diaphragm injury (Table 1), which requires surgical repair of the defect [4]. All left-sided injuries require repair, and most right-sided injuries also require repair [5]. Without immediate repair, diaphragmatic injuries can result in delayed complications, including herniation of abdominal viscera into the pleural cavity; this can lead to respiratory compromise, as well as obstruction, incarceration, and eventual rupture of the abdominal viscera into the pleural space [4,6]. Therefore, it is important to consider diaphragmatic injury in patients presenting to the Emergency Department with left-sided penetrating trauma, even in those with negative imaging.
This patient underwent diagnostic laparoscopy with repair of the diaphragmatic defect and gastrorrhaphy, along with placement of a chest tube and Jackson-Pratt (JP) drain. The chest tube was removed on postoperative day 3 and the JP drain was removed on postoperative day 5. The patient remained stable throughout the course of the hospital stay and was ultimately discharged on hospital day 9.

References and Acknowledgements (Optional): [1] Thiam, Ousmane et al. “Traumatic diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects.” SpringerPlus vol. 5,1 1614. 20 Sep. 2016, doi:10.1186/s40064-016-3291-1.

[2] McDonald, Amy A et al. Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery 85(1):p 198-207, July 2018. | DOI: 10.1097/TA.0000000000001924.

[3] Friese, Randall S et al. “Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma.” The Journal of trauma vol. 58,4 (2005): 789-92. doi:10.1097/01.ta.0000158243.78299.b5.

[4] Lee, Kenny et al. Diaphragm Injury. [Updated 2022 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482207/.

[5] Simon, Leslie V et al. Diaphragm Rupture. [Updated 2023 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470214/.

[6] Zhao, Luo et al. “Delayed traumatic diaphragmatic rupture: diagnosis and surgical treatment.” Journal of thoracic disease vol. 11,7 (2019): 2774-2777. doi:10.21037/jtd.2019.07.14.