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An Unusual Diving Accident: A Case of Delayed Presentation of Traumatic Diaphragmatic Rupture
The Journal of Emergency Medicine, Vol. 45, No. 3, pp. e81–e82, 2013 Copyright Ó 2013 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.03.028
Visual Diagnosis in Emergency Medicine AN UNUSUAL DIVING ACCIDENT: A CASE OF DELAYED PRESENTATION OF TRAUMATIC DIAPHRAGMATIC RUPTURE Yoann Baudoin, MD,* Guillaume Lacroix, MD,† Pierre Louge, MD,‡ and Jean Philippe Platel, MD* *Department of Abdominal and Emergency Surgery, †Intensive Care Unit, and ‡Hyperbaric Medicine, Military Teaching Hospital Sainte Anne, Toulon, France Reprint Address: Yoann Baudoin, MD, Department of Abdominal and Emergency Surgery, Military Teaching Hospital Sainte Anne, Boulevard Sainte Anne, BP 20545, 83000 Toulon Cedex 09, France
CASE REPORT A 40-year-old male scuba diver presented with severe thoracic and abdominal pain and dyspnea that occurred during the ascent phase of a 50-m dive. He was evacuated to the Hyperbaric Medicine Department for decompressionsickness management. Blood pressure was 100/70 mm Hg, pulse was 120 beats/min, respiratory rate was 35 breaths/min, and oximeter was 95% on 12 L/min of oxygen. On physical examination, he presented with decreased breath sounds over the left hemithorax and global abdominal tenderness. A thoracic and abdominal computed tomography (CT) scan was performed urgently before blood tests results were received (Figure 1A and 1B). Firstly, a tension pneumothorax was excluded with the chest x-ray (CT scout view; Figure 2). The patient’s only medical history was a chest trauma due to traffic accident, treated by thoracic drainage 6 years before. CT scan showed a rupture of the diaphragm associated with a major thoracic hernia. The patient underwent urgent surgery; reduction of the strangled hernia and repair of the diaphragmatic defect were performed laparoscopically. Hernia contents were transverse colon, small bowel, and omentum. The patient was discharged after 1 week and recovered his diving aptitude after 3 months.
Figure 1. (A) Digestive structure in a thoracic position. (B) Coronal view of the thoracic hernia.
RECEIVED: 28 August 2012; FINAL SUBMISSION RECEIVED: 1 February 2013; ACCEPTED: 15 March 2013 e81
e82
Y. Baudoin et al.
scan or chest x-ray study can diagnose ruptures either fortuitously or in cases of nonspecific epigastric or chest pain. Rarely, ruptures are discovered during thoracic hernia strangulation (1–3). In 70 90% of cases, rupture of the diaphragmatic dome is located on the left, given the protective role of the liver on the right. Hernia contents can be variable (4). The mechanism of intestinal gas volume variation, change in lung volume during the different phases of diving, and an unrecognized diaphragmatic rupture could be the explanation for this unusual diving accident. Figure 2. Chest x-ray.
REFERENCES DISCUSSION
Ten to 20% of diaphragm ruptures are not diagnosed during the initial trauma. Defects that are too small to be detected at the early phase get gradually bigger and become eventually symptomatic, sometimes after a few years. CT
1. Cameron EW, Mirvis SE. Ruptured hemidiaphragm: unusual late presentation. J Emerg Med 1996;14:53–8. 2. Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995;170:5–9. 3. Maddox R, Mansel RE, Butchart EG. Traumatic rupture of the diaphragm: a difficult diagnosis. Injury 1991;22:299–302. 4. Nursal TZ, Ugurlu M, Kologlu M, Hamaloglu E. Traumatic diaphragmatic hernias: a report of 26 cases. Hernia 2001;5:25–9.
http://dx.doi.org/10.1016/j.jemermed.2013.03.028
Visual Diagnosis in Emergency Medicine AN UNUSUAL DIVING ACCIDENT: A CASE OF DELAYED PRESENTATION OF TRAUMATIC DIAPHRAGMATIC RUPTURE Yoann Baudoin, MD,* Guillaume Lacroix, MD,† Pierre Louge, MD,‡ and Jean Philippe Platel, MD* *Department of Abdominal and Emergency Surgery, †Intensive Care Unit, and ‡Hyperbaric Medicine, Military Teaching Hospital Sainte Anne, Toulon, France Reprint Address: Yoann Baudoin, MD, Department of Abdominal and Emergency Surgery, Military Teaching Hospital Sainte Anne, Boulevard Sainte Anne, BP 20545, 83000 Toulon Cedex 09, France
CASE REPORT A 40-year-old male scuba diver presented with severe thoracic and abdominal pain and dyspnea that occurred during the ascent phase of a 50-m dive. He was evacuated to the Hyperbaric Medicine Department for decompressionsickness management. Blood pressure was 100/70 mm Hg, pulse was 120 beats/min, respiratory rate was 35 breaths/min, and oximeter was 95% on 12 L/min of oxygen. On physical examination, he presented with decreased breath sounds over the left hemithorax and global abdominal tenderness. A thoracic and abdominal computed tomography (CT) scan was performed urgently before blood tests results were received (Figure 1A and 1B). Firstly, a tension pneumothorax was excluded with the chest x-ray (CT scout view; Figure 2). The patient’s only medical history was a chest trauma due to traffic accident, treated by thoracic drainage 6 years before. CT scan showed a rupture of the diaphragm associated with a major thoracic hernia. The patient underwent urgent surgery; reduction of the strangled hernia and repair of the diaphragmatic defect were performed laparoscopically. Hernia contents were transverse colon, small bowel, and omentum. The patient was discharged after 1 week and recovered his diving aptitude after 3 months.
Figure 1. (A) Digestive structure in a thoracic position. (B) Coronal view of the thoracic hernia.
RECEIVED: 28 August 2012; FINAL SUBMISSION RECEIVED: 1 February 2013; ACCEPTED: 15 March 2013 e81
e82
Y. Baudoin et al.
scan or chest x-ray study can diagnose ruptures either fortuitously or in cases of nonspecific epigastric or chest pain. Rarely, ruptures are discovered during thoracic hernia strangulation (1–3). In 70 90% of cases, rupture of the diaphragmatic dome is located on the left, given the protective role of the liver on the right. Hernia contents can be variable (4). The mechanism of intestinal gas volume variation, change in lung volume during the different phases of diving, and an unrecognized diaphragmatic rupture could be the explanation for this unusual diving accident. Figure 2. Chest x-ray.
REFERENCES DISCUSSION
Ten to 20% of diaphragm ruptures are not diagnosed during the initial trauma. Defects that are too small to be detected at the early phase get gradually bigger and become eventually symptomatic, sometimes after a few years. CT
1. Cameron EW, Mirvis SE. Ruptured hemidiaphragm: unusual late presentation. J Emerg Med 1996;14:53–8. 2. Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg 1995;170:5–9. 3. Maddox R, Mansel RE, Butchart EG. Traumatic rupture of the diaphragm: a difficult diagnosis. Injury 1991;22:299–302. 4. Nursal TZ, Ugurlu M, Kologlu M, Hamaloglu E. Traumatic diaphragmatic hernias: a report of 26 cases. Hernia 2001;5:25–9.