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Diaphragmatic injuries
ABSTRACTS AND COMMENTARY Current Surgery presents a comprehensive review of recent surgical and medical literature for the surgeon who wants to stay well informed in the least amount of time. Our international board of editors selects significant articles to review and provides commentary. The editorial board welcomes suggestions of topics or specific articles from our readers.
Trauma
Diaphragmatic Injuries Guest Reviewer: John C. McDonald, MD OCCULT INJURIES TO THE DIAPHRAGM: PROSPECTIVE EVALUATION OF LAPAROSCOPY IN PENETRATING INJURIES TO THE LEFT LOWER CHEST.
Murray JA, Demetriades D, Asensio JA, et al. J Am Coll Surg 1998;187:626 – 630. To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest without indications for exploratory celiotomy other than the potential for a diaphragm injury.
Objective
Patients with penetrating trauma to the left lower chest, hemodynamically stable, and without indications for exploratory celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia.
Design
Level I trauma center at The University of Southern California, Los Angeles, California.
Setting
One hundred ten patients presenting to the trauma center from July 1995 to February 1997 with penetrating injury (94 stab wounds, 16 gunshot wounds) to the left thoracoabdominal region. This region was defined as the area bounded by the nipple line over the anterior and posterior chest, the costal margin inferiorly, the sternum anteriorly, and the spine posteriorly. These patients had no indication for laparotomy.
Participants
Patients were admitted to a specialized observation ward. The preoperative clinical examination and radiographic findings for each patient were recorded according to a written protocol. Exclusions included patients with obvious superficial wounds or tangential tracts as well as those who did not consent to laparoscopy. Chest tubes were available in the operating room, if not inserted preoperatively. Chest tubes were routinely placed when a diaphragmatic injury was found.
Methods
In 110 patients laparoscoped, 26 (24%) had diaphragmatic injuries. In victims of stab wounds, this incidence was 26%, and in those with gunshot wounds it was l3%. Comparison of patients with diaphragmatic injuries to those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% vs 24%, NS). The incidence of diaphragmatic injuries in
Results
CURRENT SURGERY
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© 1999 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/99/$20.00
277
patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injury in only 1 of 7 patients. The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries. Conclusions
The incidence of occult diaphragmatic injuries in penetrating trauma of the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and they would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest without any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury. REVIEWER COMMENTS. This clinical prospective study is well planned and executed. It provides sound evidence regarding the incidence of diaphragmatic injury in patients with penetrating injury of the defined anatomic area without indication of intra-abdominal injury. The incidence is 24%, and no clinical or laboratory study predicted the injury. Thus, if the concept that all such injuries should be repaired is accepted, it is logical to recommend laparoscopic examination in all such patients. The authors have demonstrated that laparoscopic examination can be performed safely and effectively in the study group, if their protocol is followed. Some of their precautions bear emphasis. All patients were observed for 6 hours for signs of injuries that would indicate laparotomy. Chest tubes were placed either preoperatively or at the time the diaphragmatic injury was diagnosed. Indications for chest tubes should be liberal to prevent tension pneumothorax. Further, some injuries were encountered that were so large that a pneumoperitoneum could not be produced, which presumably was an indication for laparotomy. LAPAROSCOPY IN THE MANAGEMENT OF DIAPHRAGMATIC RUPTURE DUE TO BLUNT TRAUMA.
Martin I, O’Rourke N, Gotley D, Smithers M. Aust N Z J Surg 1998;68:584 –586. Objective
To suggest a role for laparoscopy in the diagnosis and treatment of blunt injury to the diaphragm.
Design
Retrospective review of experience with 4 patients.
Setting
The Princess Alexandra Hospital and Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia.
Participants
Four victims of blunt trauma with the diagnosis of diaphragmatic rupture made by laparoscopy.
Methods
Chart review.
Results
One patient was treated in the acute situation by laparoscopic repair of a left diaphragmatic rupture diagnosed by chest X-ray. Three patients were laparoscoped at 2, 7, and 10 days postinjury. Each had a head injury, and each was on a ventilator. Two injuries were on the right, and the third was on the left. All required open laparotomy for repair.
Conclusions
The authors conclude that a laparoscopic approach can be useful to diagnose diaphragmatic rupture in some settings. Repair on the right side was not possible. REVIEWER COMMENTS. This paper was included because it addresses the use of laparoscopy for the diagnosis and treatment of blunt rupture of the diaphragm. From these limited data, we can conclude that the role is limited. In the acute setting, blunt trauma, which produces diaphragmatic rupture, usually involves sufficient force to produce other injury (quoted as 85%). Ordinarily, this would seem to justify open laparotomy when such a diagnosis is made. In the delayed situation, perhaps it would be justified in association with a head injury, as reported here, but it would seem that other diagnostic methods would lead to indications for laparotomy. How many of the patients had other indications of diaphragmatic rupture is not clear from the text, but at least 2, if not 3 did. Further, 3 of 4 patients required open laparotomy for repair of the ruptures. Thus, the use of laparoscopic examination in the situation of blunt rupture of the diaphragm would seem less promising than with penetrating injury, at least at the present. IS TENSION PNEUMOTHORAX A THREAT IN TRAUMA LAPAROSCOPY?
Wiedeman JE, Knolmayer TJ, Bowyer MW. J Trauma 1998;45:677– 683. Objective
278
Tension pneumothorax is a reported risk with pneumoperitoneum in the presence of diaphragCURRENT SURGERY
•
Volume 56 / Number 6 • July/August 1999
matic injuries. A goat model with and without diaphragmatic injury was used to determine if varying levels of intra-abdominal pressure result in tension pneumothorax. Experimental animal study.
Design
David Grand Medical Center, Travis Air Force Base, California, and the Uniformed Services University of the Health Sciences.
Setting
Experimental animals (goats).
Participants
Pneumoperitoneum was induced laparoscopically in 24 goats that were divided into 4 groups: (1) 5 mm Hg intra-abdominal pressure (IAP) control, (2) 15 mm Hg IAP control, (3) 5 mm Hg IAP with diaphragmatic injury, and (4) 15 mm Hg IAP with diaphragmatic injury. The diaphragmatic injury consisted of a 5-cm incision through the lateral area of the left diaphragm. Chest x-ray films were made, and heart rate, mean arterial pressure, central venous pressure, arterial blood gasses, and airway pressure were measured at 10-minute intervals for up to 30 minutes. Statistical analysis was performed with 1-way analysis of variance and the Mann-Whitney test.
Methods
All animals with 15 mm Hg IAP (group 4) developed radiographic evidence of tension pneumothorax by 10 minutes. Mortality was 67% at 25 minutes. The expected physiologic changes occurred. All animals with 5 mm Hg IAP developed a pneumothorax without mediastinal shift. Physiologic changes were milder, but 1 animal died.
Results
In this model, tension pneumothorax is a significant threat when pneumoperitoneum is maintained at 15 mm Hg IAP. Pneumoperitoneum at 5 mm Hg IAP leads to simple pneumothorax with deleterious effects on oxygenation.
Conclusions
REVIEWER COMMENTS. This paper offers experimental evidence regarding the risk of pneumothorax produced by pneumoperitoneum in the presence of a diaphragmatic injury of substantial size. Insertion of a chest tube should be done before laparoscopy if there is any indication of a diaphragmatic injury. If no indication is present clinically, a chest tube should be inserted as soon as the diagnosis is made. MISSED DIAPHRAGMATIC INJURIES AND THEIR LONG-TERM SEQUELAE.
Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Buchler MW. J Trauma 1998;44:183–188. To determine the consequences of missed diaphragmatic injuries.
Objective
Retrospective chart review.
Design
Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, Bern, Switzerland.
Setting
Ten patients with posttraumatic diaphragmatic hernias.
Participants
A chart review of all patients admitted with late presentations of posttraumatic diaphragmatic hernias from 1980 to 1996.
Methods
Ten patients were identified, with a mean age of 65 years. Eight patients sustained blunt trauma and 2 sustained penetrating trauma. The hernias were on the right in 2 patients and on the left in 8. The time between trauma and the time the hernias became symptomatic ranged from 20 days to 28 years. All patients were operated on, and 1 died postoperatively of unspecified cause.
Results
Initial recognition and treatment of diaphragmatic rupture or injury is important in avoiding long-term sequelae.
Conclusions
REVIEWER COMMENTS. This paper speaks to the rarity of symptomatic posttraumatic diaphragmatic hernia. This center encountered only 10 cases in 16 years, which raises the question of how often small injuries to the diaphragm result in hernias.
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Volume 56 / Number 6 • July/August 1999
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SUMMARY The index article for this review was the publication by Murray et al. They demonstrated clearly, by prospective study, that laparoscopic evaluation of patients with penetrating injuries in patients with potential thoracoabdominal injuries can be done safely and that the incidence of injuries is 24%. The paper by Martin et al indicates that rupture of the diaphragm by blunt trauma is uncommon, usually diagnosed by other means, and usually associated with other injuries. Laparoscopic evaluation of these injuries would seem to be rarely indicated or necessary. The paper by Wiedeman et al calls attention to the risk of tension pneumothorax when patients with diaphragmatic injuries are laparoscoped, a problem recognized by Murray et al. A serious question that must be answered before routine laparoscopic evaluation for patients such as those described by Murray et al can be recommended is how many of these injuries will eventuate in a hernia. The paper by Reber et al was reviewed to approach this question. Because these injuries are so common, more than 10 hernias should have been discovered in a 16-year period at a university center. This paper is not ideal because the reviewer does not know how many trauma patients are seen in that center annually. Further, the incidence of penetrating injuries in Switzerland is small. A better paper is that of Feliciano et al,1 who located only 16 patients with a delay in diagnosis of an injury to the diaphragm in 9 years. (This paper was not
reviewed in detail because it was outside the time limits suggested by the Editor.) Nevertheless, it was from the Baylor Trauma Center, which treats a large number of patients with penetrating injuries. Surely, if 24% of patients with penetrating injuries of this anatomic region have injuries to the diaphragm, and if a large number of them progressed to significant hernia, more would be seen with this condition. This question should be susceptible to experimental study. It should be possible to determine in the experiment a relationship between the size of an injury and the occurrence of a hernia. Unfortunately, the reviewer has not been able to find any such published data. Therefore, we are left with the knowledge that patients with penetrating injury to the thoracoabdominal area have a substantial incidence of diaphragmatic injury, but do not have sufficient evidence of the consequence of the injuries to make a scientific recommendation as to how much effort and expense is appropriate to make the diagnosis. JOHN C. McDONALD, MD Department of Surgery LSU Medical Center Shreveport, Louisiana
Reference 1. Feliciano DV, Cruse PA, Mattox KL, et al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988; 28:1135–1144.
Trauma
Blunt Carotid Injury Guest Reviewer: William C. Mackey, MD BLUNT CAROTID INJURY: A REVIEW.
Mulloy JP, Flick PA, Gold RE. Radiology 1998;207:571–585. Objective
Design Conclusions
280
To review the incidence, pathogenesis, clinical presentation, evaluation, and management of blunt carotid injuries (BCI). In addition, the importance of screening blunt trauma patients at high risk for BCI is discussed. Literature review. Significant blunt carotid injury is diagnosed in approximately 0.4% of all blunt trauma patients and in up to 0.67% of patients with significant blunt injuries from motor vehicle accidents. The real incidence of this injury may be higher. Because BCI often accompany major head injuries, the signs and symptoms of carotid-injury–related cerebral ischemia may be masked by the signs and symptoms of the closed head injury. In fact, only about 6% of BCI are diagnosed appropriately at presentation, because of the characteristic interval of hours to days between the time of carotid injury and the onset of ischemia-related symptoms. Four distinct mechanisms of injury account for most BCI. Type I injuries result from a direct blow to the anterior or anterolateral neck. These injuries are uncommon and account for less than 5% of BCI. Type II injuries are by far the most common (⬎90% of BCI) and result from hyperextension and contralateral rotation of the neck, with resultant stretching of the distal internal carotid over the lateral masses of the first and second cervical vertebrae. Type III injuries are the rarest and result from intraoral injuries, such as children falling with a toothbrush or pencil in their mouths. Type IV injuries occur in association with basilar CURRENT SURGERY
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Volume 56 / Number 6 • July/August 1999
Trauma
Diaphragmatic Injuries Guest Reviewer: John C. McDonald, MD OCCULT INJURIES TO THE DIAPHRAGM: PROSPECTIVE EVALUATION OF LAPAROSCOPY IN PENETRATING INJURIES TO THE LEFT LOWER CHEST.
Murray JA, Demetriades D, Asensio JA, et al. J Am Coll Surg 1998;187:626 – 630. To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest without indications for exploratory celiotomy other than the potential for a diaphragm injury.
Objective
Patients with penetrating trauma to the left lower chest, hemodynamically stable, and without indications for exploratory celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia.
Design
Level I trauma center at The University of Southern California, Los Angeles, California.
Setting
One hundred ten patients presenting to the trauma center from July 1995 to February 1997 with penetrating injury (94 stab wounds, 16 gunshot wounds) to the left thoracoabdominal region. This region was defined as the area bounded by the nipple line over the anterior and posterior chest, the costal margin inferiorly, the sternum anteriorly, and the spine posteriorly. These patients had no indication for laparotomy.
Participants
Patients were admitted to a specialized observation ward. The preoperative clinical examination and radiographic findings for each patient were recorded according to a written protocol. Exclusions included patients with obvious superficial wounds or tangential tracts as well as those who did not consent to laparoscopy. Chest tubes were available in the operating room, if not inserted preoperatively. Chest tubes were routinely placed when a diaphragmatic injury was found.
Methods
In 110 patients laparoscoped, 26 (24%) had diaphragmatic injuries. In victims of stab wounds, this incidence was 26%, and in those with gunshot wounds it was l3%. Comparison of patients with diaphragmatic injuries to those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% vs 24%, NS). The incidence of diaphragmatic injuries in
Results
CURRENT SURGERY
•
© 1999 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/99/$20.00
277
patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injury in only 1 of 7 patients. The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries. Conclusions
The incidence of occult diaphragmatic injuries in penetrating trauma of the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and they would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest without any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury. REVIEWER COMMENTS. This clinical prospective study is well planned and executed. It provides sound evidence regarding the incidence of diaphragmatic injury in patients with penetrating injury of the defined anatomic area without indication of intra-abdominal injury. The incidence is 24%, and no clinical or laboratory study predicted the injury. Thus, if the concept that all such injuries should be repaired is accepted, it is logical to recommend laparoscopic examination in all such patients. The authors have demonstrated that laparoscopic examination can be performed safely and effectively in the study group, if their protocol is followed. Some of their precautions bear emphasis. All patients were observed for 6 hours for signs of injuries that would indicate laparotomy. Chest tubes were placed either preoperatively or at the time the diaphragmatic injury was diagnosed. Indications for chest tubes should be liberal to prevent tension pneumothorax. Further, some injuries were encountered that were so large that a pneumoperitoneum could not be produced, which presumably was an indication for laparotomy. LAPAROSCOPY IN THE MANAGEMENT OF DIAPHRAGMATIC RUPTURE DUE TO BLUNT TRAUMA.
Martin I, O’Rourke N, Gotley D, Smithers M. Aust N Z J Surg 1998;68:584 –586. Objective
To suggest a role for laparoscopy in the diagnosis and treatment of blunt injury to the diaphragm.
Design
Retrospective review of experience with 4 patients.
Setting
The Princess Alexandra Hospital and Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia.
Participants
Four victims of blunt trauma with the diagnosis of diaphragmatic rupture made by laparoscopy.
Methods
Chart review.
Results
One patient was treated in the acute situation by laparoscopic repair of a left diaphragmatic rupture diagnosed by chest X-ray. Three patients were laparoscoped at 2, 7, and 10 days postinjury. Each had a head injury, and each was on a ventilator. Two injuries were on the right, and the third was on the left. All required open laparotomy for repair.
Conclusions
The authors conclude that a laparoscopic approach can be useful to diagnose diaphragmatic rupture in some settings. Repair on the right side was not possible. REVIEWER COMMENTS. This paper was included because it addresses the use of laparoscopy for the diagnosis and treatment of blunt rupture of the diaphragm. From these limited data, we can conclude that the role is limited. In the acute setting, blunt trauma, which produces diaphragmatic rupture, usually involves sufficient force to produce other injury (quoted as 85%). Ordinarily, this would seem to justify open laparotomy when such a diagnosis is made. In the delayed situation, perhaps it would be justified in association with a head injury, as reported here, but it would seem that other diagnostic methods would lead to indications for laparotomy. How many of the patients had other indications of diaphragmatic rupture is not clear from the text, but at least 2, if not 3 did. Further, 3 of 4 patients required open laparotomy for repair of the ruptures. Thus, the use of laparoscopic examination in the situation of blunt rupture of the diaphragm would seem less promising than with penetrating injury, at least at the present. IS TENSION PNEUMOTHORAX A THREAT IN TRAUMA LAPAROSCOPY?
Wiedeman JE, Knolmayer TJ, Bowyer MW. J Trauma 1998;45:677– 683. Objective
278
Tension pneumothorax is a reported risk with pneumoperitoneum in the presence of diaphragCURRENT SURGERY
•
Volume 56 / Number 6 • July/August 1999
matic injuries. A goat model with and without diaphragmatic injury was used to determine if varying levels of intra-abdominal pressure result in tension pneumothorax. Experimental animal study.
Design
David Grand Medical Center, Travis Air Force Base, California, and the Uniformed Services University of the Health Sciences.
Setting
Experimental animals (goats).
Participants
Pneumoperitoneum was induced laparoscopically in 24 goats that were divided into 4 groups: (1) 5 mm Hg intra-abdominal pressure (IAP) control, (2) 15 mm Hg IAP control, (3) 5 mm Hg IAP with diaphragmatic injury, and (4) 15 mm Hg IAP with diaphragmatic injury. The diaphragmatic injury consisted of a 5-cm incision through the lateral area of the left diaphragm. Chest x-ray films were made, and heart rate, mean arterial pressure, central venous pressure, arterial blood gasses, and airway pressure were measured at 10-minute intervals for up to 30 minutes. Statistical analysis was performed with 1-way analysis of variance and the Mann-Whitney test.
Methods
All animals with 15 mm Hg IAP (group 4) developed radiographic evidence of tension pneumothorax by 10 minutes. Mortality was 67% at 25 minutes. The expected physiologic changes occurred. All animals with 5 mm Hg IAP developed a pneumothorax without mediastinal shift. Physiologic changes were milder, but 1 animal died.
Results
In this model, tension pneumothorax is a significant threat when pneumoperitoneum is maintained at 15 mm Hg IAP. Pneumoperitoneum at 5 mm Hg IAP leads to simple pneumothorax with deleterious effects on oxygenation.
Conclusions
REVIEWER COMMENTS. This paper offers experimental evidence regarding the risk of pneumothorax produced by pneumoperitoneum in the presence of a diaphragmatic injury of substantial size. Insertion of a chest tube should be done before laparoscopy if there is any indication of a diaphragmatic injury. If no indication is present clinically, a chest tube should be inserted as soon as the diagnosis is made. MISSED DIAPHRAGMATIC INJURIES AND THEIR LONG-TERM SEQUELAE.
Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Buchler MW. J Trauma 1998;44:183–188. To determine the consequences of missed diaphragmatic injuries.
Objective
Retrospective chart review.
Design
Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, Bern, Switzerland.
Setting
Ten patients with posttraumatic diaphragmatic hernias.
Participants
A chart review of all patients admitted with late presentations of posttraumatic diaphragmatic hernias from 1980 to 1996.
Methods
Ten patients were identified, with a mean age of 65 years. Eight patients sustained blunt trauma and 2 sustained penetrating trauma. The hernias were on the right in 2 patients and on the left in 8. The time between trauma and the time the hernias became symptomatic ranged from 20 days to 28 years. All patients were operated on, and 1 died postoperatively of unspecified cause.
Results
Initial recognition and treatment of diaphragmatic rupture or injury is important in avoiding long-term sequelae.
Conclusions
REVIEWER COMMENTS. This paper speaks to the rarity of symptomatic posttraumatic diaphragmatic hernia. This center encountered only 10 cases in 16 years, which raises the question of how often small injuries to the diaphragm result in hernias.
CURRENT SURGERY
•
Volume 56 / Number 6 • July/August 1999
279
SUMMARY The index article for this review was the publication by Murray et al. They demonstrated clearly, by prospective study, that laparoscopic evaluation of patients with penetrating injuries in patients with potential thoracoabdominal injuries can be done safely and that the incidence of injuries is 24%. The paper by Martin et al indicates that rupture of the diaphragm by blunt trauma is uncommon, usually diagnosed by other means, and usually associated with other injuries. Laparoscopic evaluation of these injuries would seem to be rarely indicated or necessary. The paper by Wiedeman et al calls attention to the risk of tension pneumothorax when patients with diaphragmatic injuries are laparoscoped, a problem recognized by Murray et al. A serious question that must be answered before routine laparoscopic evaluation for patients such as those described by Murray et al can be recommended is how many of these injuries will eventuate in a hernia. The paper by Reber et al was reviewed to approach this question. Because these injuries are so common, more than 10 hernias should have been discovered in a 16-year period at a university center. This paper is not ideal because the reviewer does not know how many trauma patients are seen in that center annually. Further, the incidence of penetrating injuries in Switzerland is small. A better paper is that of Feliciano et al,1 who located only 16 patients with a delay in diagnosis of an injury to the diaphragm in 9 years. (This paper was not
reviewed in detail because it was outside the time limits suggested by the Editor.) Nevertheless, it was from the Baylor Trauma Center, which treats a large number of patients with penetrating injuries. Surely, if 24% of patients with penetrating injuries of this anatomic region have injuries to the diaphragm, and if a large number of them progressed to significant hernia, more would be seen with this condition. This question should be susceptible to experimental study. It should be possible to determine in the experiment a relationship between the size of an injury and the occurrence of a hernia. Unfortunately, the reviewer has not been able to find any such published data. Therefore, we are left with the knowledge that patients with penetrating injury to the thoracoabdominal area have a substantial incidence of diaphragmatic injury, but do not have sufficient evidence of the consequence of the injuries to make a scientific recommendation as to how much effort and expense is appropriate to make the diagnosis. JOHN C. McDONALD, MD Department of Surgery LSU Medical Center Shreveport, Louisiana
Reference 1. Feliciano DV, Cruse PA, Mattox KL, et al. Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 1988; 28:1135–1144.
Trauma
Blunt Carotid Injury Guest Reviewer: William C. Mackey, MD BLUNT CAROTID INJURY: A REVIEW.
Mulloy JP, Flick PA, Gold RE. Radiology 1998;207:571–585. Objective
Design Conclusions
280
To review the incidence, pathogenesis, clinical presentation, evaluation, and management of blunt carotid injuries (BCI). In addition, the importance of screening blunt trauma patients at high risk for BCI is discussed. Literature review. Significant blunt carotid injury is diagnosed in approximately 0.4% of all blunt trauma patients and in up to 0.67% of patients with significant blunt injuries from motor vehicle accidents. The real incidence of this injury may be higher. Because BCI often accompany major head injuries, the signs and symptoms of carotid-injury–related cerebral ischemia may be masked by the signs and symptoms of the closed head injury. In fact, only about 6% of BCI are diagnosed appropriately at presentation, because of the characteristic interval of hours to days between the time of carotid injury and the onset of ischemia-related symptoms. Four distinct mechanisms of injury account for most BCI. Type I injuries result from a direct blow to the anterior or anterolateral neck. These injuries are uncommon and account for less than 5% of BCI. Type II injuries are by far the most common (⬎90% of BCI) and result from hyperextension and contralateral rotation of the neck, with resultant stretching of the distal internal carotid over the lateral masses of the first and second cervical vertebrae. Type III injuries are the rarest and result from intraoral injuries, such as children falling with a toothbrush or pencil in their mouths. Type IV injuries occur in association with basilar CURRENT SURGERY
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Volume 56 / Number 6 • July/August 1999