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Traumatic, pericardio-diaphragmatic rupture: An extremely rare cause of pericarditis
The Journal of Emergency Medicine, Vol. 30, No. 2, pp. 141–145, 2006 Copyright © 2006 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/06 $–see front matter
doi:10.1016/j.jemermed.2005.04.017
Clinical Communications
TRAUMATIC, PERICARDIO-DIAPHRAGMATIC RUPTURE: AN EXTREMELY RARE CAUSE OF PERICARDITIS Jeffrey Barrett,
MD, FAAEM
and Wayne Satz,
MD, FAAEM
Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania Reprint Address: Jeffrey Barrett, MD, FAAEM, 14 Wicklow Court, Cherry Hill, NJ 08003
e Abstract—A 54-year-old man with a recent history of blunt abdominal trauma presented to the Emergency Department with severe pain in the chest and abdomen. He was tachycardic, tacypneic, and hypoxic. An electrocardiogram (EKG) at that time showed ST elevation and PR depression consistent with acute pericarditis, and a computed tomography (CT) scan subsequently showed herniation of abdominal contents into the pericardium and left hemithorax. After surgical repair of the diaphragmatic defect and intrapericardial hernia, the EKG findings resolved. He recovered over the course of several weeks and was subsequently discharged home. © 2006 Elsevier Inc.
an even more unusual way with the delayed onset of pericarditis.
CASE REPORT A 54-year-old man presented to the Emergency Department (ED) via ambulance after being struck by an automobile while crossing the street. He reported being hit by the automobile on the left side of his body. He was thrown on impact, but denied any head injury or loss of consciousness. His chief complaint at that time was severe left flank and thigh pain. He did not ambulate after the accident, as he was immediately transported to the hospital by Emergency Medical Services (EMS). Upon arrival in the ED, the patient was seen and examined by the senior Emergency Medicine resident and attending physician on duty. His past medical history was significant only for asthma, for which he occasionally used an albuterol inhaler. He denied any previous surgeries, as well as any alcohol, tobacco, or drug use. He was allergic to penicillin, which caused a rash. His temperature was 36.9°C (98.4°F), pulse 55 beats/min, respiratory rate 28 breaths/min, blood pressure 147/89 torr, and the pulse oximeter reading was 100% on room air. On physical examination there was no evidence of head trauma, the pupils were equal and reactive to light, and the neck was without any cervical spine tenderness. The trachea was midline and breath sounds were clear
e Keywords— blunt abdominal trauma; diaphragmatic rupture; diaphragmatic hernia; pericarditis; ST elevation
INTRODUCTION Traumatic rupture of the diaphragm is a rare but serious consequence of blunt abdominal trauma. The diagnosis can be difficult to make in the acute setting, particularly if herniation of the abdominal contents through the defect has not yet occurred. Herniation can occur in a delayed fashion and manifest in a variety of ways, further confounding the diagnosis. In this case report a rare type of diaphragmatic rupture, pericardiodiaphragmatic rupture, is described that presented in
RECEIVED: 8 September 2004; FINAL ACCEPTED: 1 April 2005
SUBMISSION RECEIVED:
28 February 2005; 141
142
and equal bilaterally. The heart was regular without any murmurs, gallops, or rubs. The abdomen was soft and non-tender and there was no spinal tenderness or stepoff. The pelvis was stable, but point tender anteriorly. There was no blood at the urethral meatus nor any “High-riding” prostate on rectal examination. The extremities were without gross deformity, the peripheral pulses were all present and equal, and the neurologic examination was normal. At that visit plain films were obtained of the pelvis and the left femur, but no laboratory tests were ordered. The films demonstrated a fracture of the left superior pubic ramus. This fracture and the flank pain prompted the treating physicians to order an enhanced computed tomography (CT) scan of the abdomen and pelvis. This CT scan confirmed the left superior pubic ramus fracture, but more importantly did not reveal any solid organ injury or free intra-peritoneal fluid. On repeat examination the patient was comfortable, and his vital signs had normalized, so at that point the patient was given a prescription for a narcotic analgesic and discharged home. Two days later he returned to the ED via EMS due to intractable pain in the anterior thoracoabdominal region that radiated to the back. This pain was not present on the first ED visit, but developed over the ensuing 2 days. He could not describe the quality of this pain, only that its intensity was severe, and that there was a respirophasic quality to it. The pain was associated with shortness of breath and not relieved by the acetaminophen and oxycodone he was prescribed on the previous visit. He could not relate if the pain was affected by position as he stated he had been recumbent in bed since his discharge. His vital signs were as follows: temperature 36.3°C (97.3°F), pulse 113 beats/min, respiratory rate 22 breaths/min, blood pressure 130/90 torr, pulse oximetry 90% on room air. On physical examination there was a regular tachycardia without any murmurs, gallops, or rubs, and decreased breath sounds with crackles at the left lung base. The abdomen was diffusely tender to mild palpation with voluntary guarding throughout, and no peritoneal signs. At that point, intravenous (iv) access was obtained, the patient was placed on supplemental oxygen and a cardiac monitor, and an AP chest X-ray (CXR) (Figure 1) as well as an electrocardiogram (EKG) (Figure 2) was obtained. On review of the CXR, there was no pneumothorax or rib fractures, but the mediastinum appeared to be unusually wide and the left hemidiaphragm was elevated. There was also what appeared to be a gas shadow overlying the heart. The trauma surgery service was then consulted for suspicion of a traumatic diaphragmatic rupture. A CT scan of the chest and abdomen was subsequently obtained that demonstrated transdiaphragmatic bowel herniation into the pericardium and left hemitho-
J. Barrett and W. Satz
Figure 1. AP CXR showing a widened mediastinum, elevated left hemidiaphragm, and gas shadows overlying the heart.
rax (Figure 3). The patient was immediately taken to the operating room for repair of the defect and subsequently admitted to the surgical intensive care unit (ICU). While in the surgical ICU, cardiology was consulted due to the ST elevation noted on the patient’s EKG. Serial CK-MB and Troponin-I measurements performed at that time were negative. An echocardiogram subsequently showed a normal ejection fraction and a small pericardial effusion with no wall motion abnormalities. It was concluded that these electrocardiographic findings were most consistent with pericarditis and no treatment was necessary other than observation with serial electrocardiograms, which showed resolution of these ST segment changes over the course of several days (Figure 4).
DISCUSSION This case illustrates a rare presentation of an uncommon complication of blunt abdominal trauma: pericarditis as a manifestation of pericardio-diaphragmatic rupture with intra-pericardial herniation of bowel. Diaphragmatic rupture is a relatively uncommon injury, as well as one frequently overlooked (1). There are probably several reasons for this. First, the clinical presentation of the acutely and multiply injured trauma patient is often overshadowed by signs and symptoms of other more obvious or potentially life-threatening injuries (2). Second, the more serious clinical manifestations of this disorder may be latent until herniation or strangulation of abdominal contents occurs (3). Lastly, the diagnostic modality most commonly relied upon by emergency physicians in the setting of acute blunt abdominal trauma, the CT scan, is somewhat limited in its ability to diagnose this problem (4).
Traumatic Pericardio-Diaphragmatic Rupture
143
Figure 2. EKG obtained at presentation on the second emergency department visit. There is concave ST segment elevation with a height more than 25% of the T wave in the inferior and lateral leads. There is also PR depression in those leads, best seen in lead II.
Diaphragmatic rupture can occur in the setting of either penetrating or blunt abdominal trauma, but is three times more common after blunt trauma (2). In blunt abdominal trauma the sudden rise in intra-abdominal pressure can cause the diaphragm to rupture in several places: the right
Figure 3. An enhanced CT scan demonstrating bowel in the pericardium and left hemithorax (white arrow). Also noted in this image is a left-sided pleural effusion (black arrow).
side, the left side, or into the pericardium. This had been thought to occur with a higher frequency on the left, but some more recent case series have shown it to occur with equal frequency on the right (5,6). The diagnosis of diaphragmatic rupture can sometimes be made with a screening chest X-ray, particularly if herniation of abdominal contents has occurred. Plain films, however, are not a sensitive diagnostic modality. One case series from a major trauma center showed the initial chest X-ray to be diagnostic of diaphragmatic rupture only 46% of the time (7). Findings on the chest X-ray that would suggest the diagnosis include air shadows in the chest or a nasogastric tube seen above the diaphragm. Gastrograffin and barium contrast also have been utilized in an attempt to increase the yield of plain films, as they make herniation of the stomach easily visible as an abrupt constriction as it passes through the diaphragmatic defect (8). This has been referred to as the “Collar sign” and also has been described with respect to CT scan images (9). Diagnostic peritoneal lavage is not much better than the chest X-ray in diagnosing this condition, and has been shown to be falsely negative about 25% of the time (10). Recently there has been interest in using bedside ultrasound to make this diagnosis in the ED, but much study is still needed before this can be deemed an acceptable diagnostic technique (11). Although the CT scan performed on the patient’s first visit did not show any evidence of diaphragmatic injury, the defect most likely was present at that time. The CT
144
J. Barrett and W. Satz
This is thought to occur because an intact diaphragm is no longer there to support these structures. In one reported series this finding was found in 90% of diaphragmatic ruptures (15). Pericardio-diaphragmatic rupture is the rarest type of diaphragmatic injury, occurring in less than 1% of cases of diaphragmatic ruptures (2). This entity can be a diagnostic challenge, as the presentation can be somewhat variable both in terms of the temporal relation to the trauma and its clinical features. Herniation of abdominal contents causing acute symptoms has been described occurring as long as 15 years after the traumatic event, and the clinical manifestations have varied from intestinal obstruction to acute cardiac tamponade (16,17). In this case report we describe acute pericarditis as a manifestation occurring several days after the traumatic event. The patient’s initial electrocardiogram is a good example of the changes typically seen in acute pericarditis. The ST elevation seen is concave, not convex as one would expect with ischemia. There are no Q-waves or loss of R-waves in the leads where the ST elevation is most pronounced, which one might also expect if ischemia were the etiology of these changes. The height of the ST elevation is also more than 25% of the height of the T-wave, as expected with pericarditis, but not more than 5 mm, which would suggest ischemia (18). It is seen prominently in lead V6, where benign early repolarization, another potential cause of ST elevation, is infrequent (19). PR depression is also noted in the leads with the ST segment elevation, with the reciprocal changes of PR elevation and ST depression in lead aVR, a finding that is characteristically seen in pericarditis (20). Figure 4. Serial electrocardiograms obtained during recovery in the ICU that show resolution of the PR and ST segment abnormalities noted previously.
scan is excellent at excluding injuries to solid organs in the setting of blunt abdominal trauma, but is less sensitive for injuries to the small bowel, pancreas, and diaphragm (12). Previous reports have estimated the sensitivity of the CT scan for detecting acute diaphragmatic rupture to be around 61% (13). Newer, helical CT scanners that employ the ability to reconstruct images in different planes have been shown to have a higher sensitivity (78% for left sided defects), but are still far from perfect (14). Signs evident on the CT scan that would suggest diaphragmatic injury include the previously mentioned “Collar sign.” Although relatively specific, this finding has been estimated to have a sensitivity of less than 50%. Another more sensitive but subtle CT finding is the “Dependent viscera” sign, in which the liver, stomach, or bowel directly abuts the posterior ribs.
CONCLUSION Acute traumatic rupture of the diaphragm is a rare consequence of blunt abdominal trauma. Even today this diagnosis is often missed as the tool most often relied upon in the setting of blunt abdominal trauma, the CT scan, is somewhat limited in its ability to accurately visualize diaphragmatic defects. The clinical manifestations of this condition can also vary wildly, as can the temporal relationship to the acute traumatic event. Emergency physicians should keep this diagnosis in mind not only when seeing a patient after an acute traumatic event, but also when seeing a patient with a history of blunt abdominal trauma. REFERENCES 1. McCune RP. Rupture of the diaphragm caused by blunt trauma. J Trauma 1976;16:531–7.
Traumatic Pericardio-Diaphragmatic Rupture 2. Shah R. Traumatic rupture of diaphragm. Ann Thorac Surg 1995; 60:1444 –9. 3. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston textbook of surgery, 16th Ed. Phila: 2001. WB Saunders 2001. 4. Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002;22:S103–18. 5. Waldschmidt ML, Laws, HL. Injuries of the diaphragm. J Trauma 1980;20:587–91. 6. De la Rocha AG, Creel RJ, Mulligan GW, Burns CM. Diaphragmatic rupture due to blunt abdominal trauma. Surg Gynecol Obstet 1982;154:175– 80. 7. Gelman R. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. Am J Roentgenol 1991;156:51–7. 8. Sharma OP. Pericardio-diaphragmatic rupture: five new cases and literature review. J Emerg Med 1999;17:963– 8. 9. Agrawal KB, Kamble RT, Sundarum P, et al. The collar sign. Postgrad Med J 2000;76:53–5. 10. Freeman T, Fischer RP. The inadequacy of peritoneal lavage in diagnosing diaphragmatic rupture. J Trauma 1976;16:538 – 42. 11. Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 2004;22:601– 4. 12. ACEP Board of Directors. Clinical policy: critical issues in the
145
13.
14. 15. 16.
17.
18. 19.
20.
evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med 2004;43:278 –90. Murray JG. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of the CT. AJR Am J Roentgenol 1996;166:1035–9. Kileen KL. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol 1999;173:1611– 6. Bergin D, Ennis R, Keough C, et al. The dependent viscera sign. Am J Roentgenol 2001;177:1137– 40. Girzadas DV. Delayed traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. Ann Emerg Med 1991; 20:1246 –7. Beless DJ. Delayed presentation of intrapericardial diaphragmatic hernia, an unusual cause of colon obstruction. Ann Emerg Med 1991;20:415–7. Troughton RW, Asher CR, Klein AL, et al. Pericarditis. Lancet 2004;363:717–27. Wang, K. Asinger RW, Marriott HJ, et al. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003;349:2128 –35. Spodick DH. Acute pericarditis— current concepts and practice. JAMA 2003;289:1150 –3.
doi:10.1016/j.jemermed.2005.04.017
Clinical Communications
TRAUMATIC, PERICARDIO-DIAPHRAGMATIC RUPTURE: AN EXTREMELY RARE CAUSE OF PERICARDITIS Jeffrey Barrett,
MD, FAAEM
and Wayne Satz,
MD, FAAEM
Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania Reprint Address: Jeffrey Barrett, MD, FAAEM, 14 Wicklow Court, Cherry Hill, NJ 08003
e Abstract—A 54-year-old man with a recent history of blunt abdominal trauma presented to the Emergency Department with severe pain in the chest and abdomen. He was tachycardic, tacypneic, and hypoxic. An electrocardiogram (EKG) at that time showed ST elevation and PR depression consistent with acute pericarditis, and a computed tomography (CT) scan subsequently showed herniation of abdominal contents into the pericardium and left hemithorax. After surgical repair of the diaphragmatic defect and intrapericardial hernia, the EKG findings resolved. He recovered over the course of several weeks and was subsequently discharged home. © 2006 Elsevier Inc.
an even more unusual way with the delayed onset of pericarditis.
CASE REPORT A 54-year-old man presented to the Emergency Department (ED) via ambulance after being struck by an automobile while crossing the street. He reported being hit by the automobile on the left side of his body. He was thrown on impact, but denied any head injury or loss of consciousness. His chief complaint at that time was severe left flank and thigh pain. He did not ambulate after the accident, as he was immediately transported to the hospital by Emergency Medical Services (EMS). Upon arrival in the ED, the patient was seen and examined by the senior Emergency Medicine resident and attending physician on duty. His past medical history was significant only for asthma, for which he occasionally used an albuterol inhaler. He denied any previous surgeries, as well as any alcohol, tobacco, or drug use. He was allergic to penicillin, which caused a rash. His temperature was 36.9°C (98.4°F), pulse 55 beats/min, respiratory rate 28 breaths/min, blood pressure 147/89 torr, and the pulse oximeter reading was 100% on room air. On physical examination there was no evidence of head trauma, the pupils were equal and reactive to light, and the neck was without any cervical spine tenderness. The trachea was midline and breath sounds were clear
e Keywords— blunt abdominal trauma; diaphragmatic rupture; diaphragmatic hernia; pericarditis; ST elevation
INTRODUCTION Traumatic rupture of the diaphragm is a rare but serious consequence of blunt abdominal trauma. The diagnosis can be difficult to make in the acute setting, particularly if herniation of the abdominal contents through the defect has not yet occurred. Herniation can occur in a delayed fashion and manifest in a variety of ways, further confounding the diagnosis. In this case report a rare type of diaphragmatic rupture, pericardiodiaphragmatic rupture, is described that presented in
RECEIVED: 8 September 2004; FINAL ACCEPTED: 1 April 2005
SUBMISSION RECEIVED:
28 February 2005; 141
142
and equal bilaterally. The heart was regular without any murmurs, gallops, or rubs. The abdomen was soft and non-tender and there was no spinal tenderness or stepoff. The pelvis was stable, but point tender anteriorly. There was no blood at the urethral meatus nor any “High-riding” prostate on rectal examination. The extremities were without gross deformity, the peripheral pulses were all present and equal, and the neurologic examination was normal. At that visit plain films were obtained of the pelvis and the left femur, but no laboratory tests were ordered. The films demonstrated a fracture of the left superior pubic ramus. This fracture and the flank pain prompted the treating physicians to order an enhanced computed tomography (CT) scan of the abdomen and pelvis. This CT scan confirmed the left superior pubic ramus fracture, but more importantly did not reveal any solid organ injury or free intra-peritoneal fluid. On repeat examination the patient was comfortable, and his vital signs had normalized, so at that point the patient was given a prescription for a narcotic analgesic and discharged home. Two days later he returned to the ED via EMS due to intractable pain in the anterior thoracoabdominal region that radiated to the back. This pain was not present on the first ED visit, but developed over the ensuing 2 days. He could not describe the quality of this pain, only that its intensity was severe, and that there was a respirophasic quality to it. The pain was associated with shortness of breath and not relieved by the acetaminophen and oxycodone he was prescribed on the previous visit. He could not relate if the pain was affected by position as he stated he had been recumbent in bed since his discharge. His vital signs were as follows: temperature 36.3°C (97.3°F), pulse 113 beats/min, respiratory rate 22 breaths/min, blood pressure 130/90 torr, pulse oximetry 90% on room air. On physical examination there was a regular tachycardia without any murmurs, gallops, or rubs, and decreased breath sounds with crackles at the left lung base. The abdomen was diffusely tender to mild palpation with voluntary guarding throughout, and no peritoneal signs. At that point, intravenous (iv) access was obtained, the patient was placed on supplemental oxygen and a cardiac monitor, and an AP chest X-ray (CXR) (Figure 1) as well as an electrocardiogram (EKG) (Figure 2) was obtained. On review of the CXR, there was no pneumothorax or rib fractures, but the mediastinum appeared to be unusually wide and the left hemidiaphragm was elevated. There was also what appeared to be a gas shadow overlying the heart. The trauma surgery service was then consulted for suspicion of a traumatic diaphragmatic rupture. A CT scan of the chest and abdomen was subsequently obtained that demonstrated transdiaphragmatic bowel herniation into the pericardium and left hemitho-
J. Barrett and W. Satz
Figure 1. AP CXR showing a widened mediastinum, elevated left hemidiaphragm, and gas shadows overlying the heart.
rax (Figure 3). The patient was immediately taken to the operating room for repair of the defect and subsequently admitted to the surgical intensive care unit (ICU). While in the surgical ICU, cardiology was consulted due to the ST elevation noted on the patient’s EKG. Serial CK-MB and Troponin-I measurements performed at that time were negative. An echocardiogram subsequently showed a normal ejection fraction and a small pericardial effusion with no wall motion abnormalities. It was concluded that these electrocardiographic findings were most consistent with pericarditis and no treatment was necessary other than observation with serial electrocardiograms, which showed resolution of these ST segment changes over the course of several days (Figure 4).
DISCUSSION This case illustrates a rare presentation of an uncommon complication of blunt abdominal trauma: pericarditis as a manifestation of pericardio-diaphragmatic rupture with intra-pericardial herniation of bowel. Diaphragmatic rupture is a relatively uncommon injury, as well as one frequently overlooked (1). There are probably several reasons for this. First, the clinical presentation of the acutely and multiply injured trauma patient is often overshadowed by signs and symptoms of other more obvious or potentially life-threatening injuries (2). Second, the more serious clinical manifestations of this disorder may be latent until herniation or strangulation of abdominal contents occurs (3). Lastly, the diagnostic modality most commonly relied upon by emergency physicians in the setting of acute blunt abdominal trauma, the CT scan, is somewhat limited in its ability to diagnose this problem (4).
Traumatic Pericardio-Diaphragmatic Rupture
143
Figure 2. EKG obtained at presentation on the second emergency department visit. There is concave ST segment elevation with a height more than 25% of the T wave in the inferior and lateral leads. There is also PR depression in those leads, best seen in lead II.
Diaphragmatic rupture can occur in the setting of either penetrating or blunt abdominal trauma, but is three times more common after blunt trauma (2). In blunt abdominal trauma the sudden rise in intra-abdominal pressure can cause the diaphragm to rupture in several places: the right
Figure 3. An enhanced CT scan demonstrating bowel in the pericardium and left hemithorax (white arrow). Also noted in this image is a left-sided pleural effusion (black arrow).
side, the left side, or into the pericardium. This had been thought to occur with a higher frequency on the left, but some more recent case series have shown it to occur with equal frequency on the right (5,6). The diagnosis of diaphragmatic rupture can sometimes be made with a screening chest X-ray, particularly if herniation of abdominal contents has occurred. Plain films, however, are not a sensitive diagnostic modality. One case series from a major trauma center showed the initial chest X-ray to be diagnostic of diaphragmatic rupture only 46% of the time (7). Findings on the chest X-ray that would suggest the diagnosis include air shadows in the chest or a nasogastric tube seen above the diaphragm. Gastrograffin and barium contrast also have been utilized in an attempt to increase the yield of plain films, as they make herniation of the stomach easily visible as an abrupt constriction as it passes through the diaphragmatic defect (8). This has been referred to as the “Collar sign” and also has been described with respect to CT scan images (9). Diagnostic peritoneal lavage is not much better than the chest X-ray in diagnosing this condition, and has been shown to be falsely negative about 25% of the time (10). Recently there has been interest in using bedside ultrasound to make this diagnosis in the ED, but much study is still needed before this can be deemed an acceptable diagnostic technique (11). Although the CT scan performed on the patient’s first visit did not show any evidence of diaphragmatic injury, the defect most likely was present at that time. The CT
144
J. Barrett and W. Satz
This is thought to occur because an intact diaphragm is no longer there to support these structures. In one reported series this finding was found in 90% of diaphragmatic ruptures (15). Pericardio-diaphragmatic rupture is the rarest type of diaphragmatic injury, occurring in less than 1% of cases of diaphragmatic ruptures (2). This entity can be a diagnostic challenge, as the presentation can be somewhat variable both in terms of the temporal relation to the trauma and its clinical features. Herniation of abdominal contents causing acute symptoms has been described occurring as long as 15 years after the traumatic event, and the clinical manifestations have varied from intestinal obstruction to acute cardiac tamponade (16,17). In this case report we describe acute pericarditis as a manifestation occurring several days after the traumatic event. The patient’s initial electrocardiogram is a good example of the changes typically seen in acute pericarditis. The ST elevation seen is concave, not convex as one would expect with ischemia. There are no Q-waves or loss of R-waves in the leads where the ST elevation is most pronounced, which one might also expect if ischemia were the etiology of these changes. The height of the ST elevation is also more than 25% of the height of the T-wave, as expected with pericarditis, but not more than 5 mm, which would suggest ischemia (18). It is seen prominently in lead V6, where benign early repolarization, another potential cause of ST elevation, is infrequent (19). PR depression is also noted in the leads with the ST segment elevation, with the reciprocal changes of PR elevation and ST depression in lead aVR, a finding that is characteristically seen in pericarditis (20). Figure 4. Serial electrocardiograms obtained during recovery in the ICU that show resolution of the PR and ST segment abnormalities noted previously.
scan is excellent at excluding injuries to solid organs in the setting of blunt abdominal trauma, but is less sensitive for injuries to the small bowel, pancreas, and diaphragm (12). Previous reports have estimated the sensitivity of the CT scan for detecting acute diaphragmatic rupture to be around 61% (13). Newer, helical CT scanners that employ the ability to reconstruct images in different planes have been shown to have a higher sensitivity (78% for left sided defects), but are still far from perfect (14). Signs evident on the CT scan that would suggest diaphragmatic injury include the previously mentioned “Collar sign.” Although relatively specific, this finding has been estimated to have a sensitivity of less than 50%. Another more sensitive but subtle CT finding is the “Dependent viscera” sign, in which the liver, stomach, or bowel directly abuts the posterior ribs.
CONCLUSION Acute traumatic rupture of the diaphragm is a rare consequence of blunt abdominal trauma. Even today this diagnosis is often missed as the tool most often relied upon in the setting of blunt abdominal trauma, the CT scan, is somewhat limited in its ability to accurately visualize diaphragmatic defects. The clinical manifestations of this condition can also vary wildly, as can the temporal relationship to the acute traumatic event. Emergency physicians should keep this diagnosis in mind not only when seeing a patient after an acute traumatic event, but also when seeing a patient with a history of blunt abdominal trauma. REFERENCES 1. McCune RP. Rupture of the diaphragm caused by blunt trauma. J Trauma 1976;16:531–7.
Traumatic Pericardio-Diaphragmatic Rupture 2. Shah R. Traumatic rupture of diaphragm. Ann Thorac Surg 1995; 60:1444 –9. 3. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston textbook of surgery, 16th Ed. Phila: 2001. WB Saunders 2001. 4. Iochum S, Ludig T, Walter F, et al. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics 2002;22:S103–18. 5. Waldschmidt ML, Laws, HL. Injuries of the diaphragm. J Trauma 1980;20:587–91. 6. De la Rocha AG, Creel RJ, Mulligan GW, Burns CM. Diaphragmatic rupture due to blunt abdominal trauma. Surg Gynecol Obstet 1982;154:175– 80. 7. Gelman R. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. Am J Roentgenol 1991;156:51–7. 8. Sharma OP. Pericardio-diaphragmatic rupture: five new cases and literature review. J Emerg Med 1999;17:963– 8. 9. Agrawal KB, Kamble RT, Sundarum P, et al. The collar sign. Postgrad Med J 2000;76:53–5. 10. Freeman T, Fischer RP. The inadequacy of peritoneal lavage in diagnosing diaphragmatic rupture. J Trauma 1976;16:538 – 42. 11. Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med 2004;22:601– 4. 12. ACEP Board of Directors. Clinical policy: critical issues in the
145
13.
14. 15. 16.
17.
18. 19.
20.
evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med 2004;43:278 –90. Murray JG. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of the CT. AJR Am J Roentgenol 1996;166:1035–9. Kileen KL. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR Am J Roentgenol 1999;173:1611– 6. Bergin D, Ennis R, Keough C, et al. The dependent viscera sign. Am J Roentgenol 2001;177:1137– 40. Girzadas DV. Delayed traumatic intrapericardial diaphragmatic hernia associated with cardiac tamponade. Ann Emerg Med 1991; 20:1246 –7. Beless DJ. Delayed presentation of intrapericardial diaphragmatic hernia, an unusual cause of colon obstruction. Ann Emerg Med 1991;20:415–7. Troughton RW, Asher CR, Klein AL, et al. Pericarditis. Lancet 2004;363:717–27. Wang, K. Asinger RW, Marriott HJ, et al. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003;349:2128 –35. Spodick DH. Acute pericarditis— current concepts and practice. JAMA 2003;289:1150 –3.