Renown Regional Medical Center
Trauma / Critical Care Guideline
Algorithm:
Assessment of Thoracoabdominal Wounds
Patient with penetrating thoracoabdominal wound
Unstable VS,
peritonitis, or
evisceration?
Yes
Laparotomy
No
STAT
Trauma Labs
CXR / FAST
DO NOT perform local wound exploration
Hemo/pneumothorax?
Yes
Chest tube.
Negative
No
Output > 10001500cc?
Yes
Thoracotomy
No
Further investigation:
CT Chest/Abdomen/Pelvis *
Clean/Close wound
Optional Observation
No
Penetration though
chest or abdominal
wall?
Yes
Definitive Evaluation
*see point 3 below
Diaphragm
Injury?
Yes
Yes
Abdominal
exploration and
diaphragm repair
* Consider IV/Oral/Rectal contrast
G:\Performance Improvement\Guidelines & Protocols\Thoracoabdominal Wounds
Initiated: 02/25/13
Reviewed / Revised: 09/08/14
No
Observe in
hospital
Renown Regional Medical Center
Trauma / Critical Care Guideline
Page 1 of 3
Guideline:
Assessment of Thoracoabdominal Wounds
Rational:
Penetrating wounds to the thoracoabdominal region may injure both intra-thoracic and
intra-abdominal structures, as well as the diaphragm between these two body cavities.
Delayed diagnosis of diaphragm injuries can be associated with a 25% incidence of
significant morbidity or mortality, compared to 3% risk with injuries identified and
managed in the acute period.2
Figure 16 The shaded
thoracoabdominal area that contains
the diaphragm throughout its
excursion extends superiorly to the
nipple level anteriorly, and to the
scapular tips posteriorly. The inferior
border is the costal margin.
Penetration wounds to this area are
considered to have caused a
diaphragmatic injury until proven
otherwise.
From: Wilson, Grande, & Hoyt1
Support:
Diaphragm injury is found in 1 to 6 % of multisystem blunt trauma and 7 to 40 % of
patients with penetrating torso trauma. Prospective assessment of penetrating
thoracoabdominal injuries has shown that 59% of gunshot wounds and 32% of stab
wounds are associated with diaphragm injuries. Injury is identified in the left
hemidiaphragm three times more often than the right.
Review of the National Trauma Databank showed that diaphragm injury is often
associated with other intra-abdominal or thoracic injuries; most frequently liver laceration
(48%) and hemopneumothorax (47%). One third of patients were found to have spleen
injuries, one forth may have bowel injuries and/or rib fractures, though any abdominal or
thoracic organ can potentially be wounded.
Timely identification sufficiently reduces the risk of morbidity and mortality associated
with diaphragm injuries (25  3%). Therefore, it is imperative to identify and repair
these early on. Presenting signs and symptoms can be misleading, with 30% of patients
having benign abdominal examination and 20-50% having normal chest x-rays.
Inappropriately low suspicion can result in a failure to investigate further in cases where
it is warranted. Further complicating the matter is the fact that most standard imaging
techniques have limited diagnostic ability when assessing the diaphragm (see table
below). Diagnostic laparoscopy has been prospectively shown to be 100% sensitive and
a small series utilizing thoracoscopy has shown similar results.
G:\Performance Improvement\Guidelines & Protocols\Thoracoabdominal Wounds
Initiated: 02/25/13
Reviewed / Revised: 09/08/14
Renown Regional Medical Center
Trauma / Critical Care Guideline
Page 2 of 3
Sensitivity
Specificity
X ray
L=27-62% R=17%
FAST
case reports/small series only
Helical CT
82.10%
99.70%
MRI
case reports/small series only
Laparoscopy
100%
87.50%
* Data obtained from available prospective analyses
Protocol11:
A.
NPV
81%
96.80%
Inclusion Criteria:
These guidelines apply only to those patients with penetrating injury in the
thoracoabdominal region, and who meet all four of the following criteria:
1.
2.
3.
4.
are hemodynamically normal
have no evidence of peritonitis
have no bowel or omental evisceration through the wound
have not met criteria for thoracotomy by virtue of chest tube blood output
The presence of any one or more of the above mandates immediate abdominal or
thoracic exploration - without delay for further investigative maneuvers or x-rays.
B.
Protocol: (From the Alameda County Medical Center/Highland General Hospital, Trauma Service
Manual)
1.
Local Wound Exploration is not performed. Inserting fingers, probes, q-tips and
other objects into the wound in an attempt to determine depth of penetration risks
causing an iatrogenic pneumothorax and will not help diagnose a diaphragmatic
injury.
2.
Chest x-ray should always be obtained promptly after placing a radio-opaque
marker at the wound edge. The CXR may demonstrate any one or more (or none)
of the following abnormalities: pneumothorax, hemothorax, hemo-pneumothorax,
pneumoperitoneum, visceral herniation into left thorax. If a hemo /
pneumothorax is noted, it should be drained / decompressed with a [28-32] french
chest tube in the usual manner. [A single dose of prophylactic Cefazolin (1-2
grams IV) is acceptable, but not necessary.]
3.
Definitive Evaluation consists in ruling out an injury to the left diaphragm and
other adjacent intra-abdominal organs (stomach, colon, pancreas, spleen).
Therefore, asymptomatic patients with Penetrating wounds to the left thoracoabdominal region should undergo either a diagnostic laparoscopy or, if a chest
tube has been inserted, thoracoscopy. This is performed under general anesthesia
with the understanding that should peritoneal violation be found, a formal
exploration (via midline abdominal incision) is warranted to fully appreciate
and repair any occult hollow viscus injuries.
G:\Performance Improvement\Guidelines & Protocols\Thoracoabdominal Wounds
Initiated: 02/25/13
Reviewed / Revised: 09/08/14
Renown Regional Medical Center
Trauma / Critical Care Guideline
Page 3 of 3
Right diaphragmatic injuries caused by knives are probably much less clinically
significant (the liver is thought to prevent bowel herniation through the defect)
and may be left untreated. Thus, asymptomatic patients (i.e. - no peritonitis, no
shock, etc.) with isolated stab wounds to the right thoracoabdominal region may
be observed for presence of hollow visceral injury without the need to perform
diagnostic laparoscopy or thoracoscopy.
References:
1. Wilson, Grande and Hoyt. Trauma, Emergency Resuscitation, Perioperative Anesthesia and Surgical
Management. Pp 482-483. 2007 Informa Healthcare USA, New York, NY
2.
Jay Menaker and Thomas M. Scalea. Penetrating Thoraco-abdominal Injury. Trauma Reports. 2010 Nov/Dec;
11(6)
3.
Nagy KK, Barrett J. Diaphragm. In: Ivatury RR, Cayten CG, eds. The Textbook of Penetrating Trauma.
Baltimore: Williams & Wilkins, 1996:564–570.
4.
Murray JA, Demetriades D, Asencio JA, et al. Occult injuries to the diaphragm: prospective evaluation of
laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg. 1998 Dec;187(6):626-630.
5.
Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal
trauma: a multicenter experience. J Trauma. 1997 May;42(5):825-829
6.
Ortega AE, Tang E, Froes ET, et al. Laparoscopic evaluation of penetrating thoracoabdominal traumatic
injuries. Surg Endosc. 1996 Jan;10(1):19-22.
7.
Renz BM, Feliciano DV. Gunshot wounds to the right thoracoabdomen: a prospective study of nonoperative
management. J Trauma 1994; 37:737–744.
8.
Murray JA, Demetriates D Cornwell EE, et al. Penetrating left thoracoabdominal trauma: the incidence and
clinical presentation of diaphragm injuries. J trauma 1997; 43:824.
9.
Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after
abdominal penetrating trauma. J Trauma 2005; 58:789.
10. Ochsner MG, Rozycki GS, Lucente F, Wherry DC, et al. Prospective evaluation of thoracoscopy for diagnosing
diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma. 1993 May;34(5):704-709
11. http://eastbay.surgery.ucsf.edu/eastbaytrauma/Protocols/ER%20protocol%20pages/thoracoabdom-stab.htm
G:\Performance Improvement\Guidelines & Protocols\Thoracoabdominal Wounds
Initiated: 02/25/13
Reviewed / Revised: 09/08/14