Management of Diaphragmatic Trauma: Huge Hole or Chest Wall Avulsion?

Educational Objectives

The goal of this program is to improve the surgical treatment of diaphragmatic injuries and vascular injuries of the extremities, and clinical approaches to the mangled extremity. After hearing and assimilating this program, the clinician will be better able to:

1. Choose an appropriate technique for repair of diaphragmatic injuries.

Summary

Diagnosis: typically, initial finding inability to define left hemidiaphragm; less experienced practitioners may believe diaphragm elevated when herniation into left chest has actually occurred; computed tomography (CT) — usually demonstrates associated injuries, eg, splenic injury, multiple rib fractures, fluid in abdomen and chest, and herniation of intraabdominal contents into pleural space; contrast studies — depending on type of injury (eg, frontal blow to abdomen vs lateral blow to chest wall), herniation may appear more lateral or medial

Left vs right diaphragmatic injuries: autopsy studies show incidence of right and left injuries similar; clinically, left-sided injuries much more common, particularly with history of blunt trauma; discrepancy in incidence most likely due to death at scene in victims of right-sided injuries (associated with injuries of greater magnitude and liver); in data from Crash Injury Research Engineering Network (CIREN) project, diaphragmatic injuries left-sided in 71% of cases, right-sided in 24%, and bilateral in 5%

Associated injuries: diaphragmatic injuries do not occur in isolation; rib fractures most commonly associated injury (bilateral in 30%, right- or left-sided in 40%); aortic or cardiac injuries seen with 40%; other injuries — pulmonary (mostly contusions); intraabdominal; 70% of left-sided injuries associated with injury to spleen; nearly all cases of right-sided injuries associated with liver injury

Repair in acute setting: tissue usually normal and without retraction, so primary repair possible; repair with interrupted nonabsorbable figure-of-8 or horizontal mattress sutures possible in most cases; incorporate both fascial leaflets in full-thickness bite; laparoscopic repair — alternative for diagnosis and repair if surgeon has adequate skills; intraabdominal pressure must be decreased to reduce abdominal contents from chest and perform repair; primarily applicable to smaller lacerations

Large defects: may be seen with acute injury, but more likely encountered in chronic setting when patient presents with enlarging hernia; use of prosthetic materials may be necessary if approximation of edges not possible; data sparse, but generally, defects >20 cm2 considered to require mesh; surgeon may attempt to primarily approximate defect, but if sutures under tension or if repair causes flattening of diaphragm, addition of prosthetic mesh should be considered; for laparoscopic repairs of chronic herniation, bolster repair with onlay mesh

Diaphragmatic avulsion: very rare; usually associated with motor vehicle accidents, multiple rib fractures, and significant hematoma of thoracoabdominal region; may be accompanied by injury to chest wall, with herniation through chest wall; in such cases, repair of ribs required first to allow repair of herniation, after which diaphragm anchored to ribs; avulsion requires suture to remaining muscle on chest wall (if present); if no rim of muscle remains, suture diaphragm to rib by encircling rib and anchoring diaphragm with polypropylene suture; use mesh if primary repair creates tension

Early Control of Vascular Injury in the Extremities

Kenji Inaba, MD, Associate Professor of Surgery and Medical Director of the Surgical Intensive Care Unit, Division of Trauma and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles

Diagnosis of vascular injuries: level of suspicion depends on physical examination; “hard” signs — significant bleeding, hematoma, bruit, thrill, pulselessness, and/or shock; hematoma most common sign after gunshot wound; presence of hard sign mandates exploration in operating room (OR); exceptions to direct transfer to OR include shotgun wound, multilevel gunshot wound, or blunt injury with uncertainty about appropriate site of incision; observation appropriate — in absence of signs, or with normal ankle-brachial index (ABI) or brachial-brachial index (BBI; >0.9); “soft” signs — minimal bleeding; small hematoma; slightly abnormal ABI or BBI; injuries (even complete transections), often present with vasospasm and no active bleeding; imaging needed to detect injuries

Vascular imaging: catheter-based angiography (CBA) traditionally performed; CT angiography (CTA) now used; advantages of CTA — rapid (2 min for both extremities); available 24 hr/day, 7 days/wk; does not require interventional radiology (IR) team; uses all preexisting hardware, software, and contrast injectors; requires only peripheral venous puncture, rather than central arterial puncture; amounts of contrast and radiation exposure similar to those with CBA; interpretation and planning for operative procedures simple; even smallest vessels can be discriminated; allows rotation of images and view of injury in multiple dimensions

Sensitivity of CTA: Inaba et al prospectively studied 635 consecutive patients with extremity injuries; ≈6% presented with hard signs and went directly to OR; 83% completely asymptomatic and safely observed; 10% to 12% had soft signs; 89 underwent CTA; investigators concluded that categorizing patients into hard, soft, and no signs effective; all patients with hard signs went to OR and 97% had clinically significant injuries which required some type of procedure; in group with no signs, no injuries missed by time of discharge; in group with soft signs, injury detected on CTA in ≈25%; CTA indeterminate in 10% because of fragmentation; shotgun injuries may obscure vascular defect behind scatter (may require CBA); in patients with no artifact, sensitivity of CTA 100% and specificity high

Nerves, soft tissue, and bone: documentation of preoperative examination crucial; orthopedic injuries — should be imaged preoperatively to determine orthopedic plan; if orthopedic intervention necessary, isolation of vascular injury and reperfusion of extremity with shunt may be best first actions; if patient stable, orthopedist can stabilize leg and definitive vascular repair can be performed; if patient not stable, leave shunt in place

Logic, Timing, and Techniques for Staged Amputations

Dr. Inaba

Traumatic amputations: associated with high injury burden; decision to amputate one of most difficult clinical decisions (must be done quickly, often in middle of night); National Trauma Databank — majority of amputations due to trauma involve fingers or toes, but limb amputation required in 25%; 83% associated with blunt trauma; co-occurring injuries seen in almost all cases; 20% of patients presented with hypotension; 20% had traumatic brain injury; 40% involved upper extremities; 7.3% of civilian injuries involved bilateral amputations; 4% had amputations of 3 limbs

Frequency of major amputations in descending order: below-knee; below-elbow; above-knee; above-elbow

Morbidity and mortality: significantly increases chance of dying and length of hospital stay; one-quarter of patients have some type of major in-hospital complication; one-quarter not discharged home; because cohort young, probability of lifelong impact on psychologic status and quality of life high

Determining need for amputation: in patients presenting with near-complete amputations which cannot be reconstructed, decision to amputate straightforward; challenge presented by patient with complicated extremity and uncertainty about whether limb can be restored to functional viability; scoring systems — Hanover fracture scale; Nerve Injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of Patient (NISSSA) score; Mangled Extremity Severity Score (MESS); all have inadequate sensitivity and specificity for determining which patients need amputation; Lower Extremity Assessment Project Study Group — investigated 556 patients with high-energy lower extremity injuries; analyzed 5 scoring systems and concluded that high scores did not predict need for amputation

Clinical factors in scoring systems: all scoring systems use same factors; 1) can leg be revascularized? 2) can skeletal system be reconstructed? 3) is there sufficient soft tissue, or can flap be mobilized to cover skeletal reconstruction? 4) is the limb functional (ie, is there nerve supply to limb)? all 4 must be true to achieve good result

Damage control for extremity injury: if unsure whether patient fulfills criteria, or if patient unstable, subsequent return to OR can be considered; amputation not considered damage ­control for patient with complicated limb injury; damage control includes vascular shunt; as torso and brain top priorities in management of trauma, laparotomy and thoracotomy must precede treatment of extremity; initial bleeding from extremity may be controlled by tourniquet above injury; if source of bleeding from junctional area in which tourniquet cannot be applied, insertion of Foley catheter or other external pressure device may control hemorrhage of extremity while control of bleeding from thorax and abdomen achieved

Informed consent: if considering amputation preoperatively and patient able to talk, discussion with patient one of most important aspects of care; if patient unable to talk (due to, eg, traumatic brain injury), obtain second opinion before performing amputation in acute setting

Issues in traumatic amputations: for upper extremity trauma, “everything possible” to save limb generally done, but not at expense of brain or torso; dictum of “less is always more” should be applied (ie, if unsure, amputate less; nonviable tissue should be removed, but otherwise, preservation of tissue favored); when amputations performed in acute setting, decision usually obvious and surgeon performing only completion amputation; technique for amputation — amputation must be optimized; consider need for load-bearing by lower extremity stump; poorly performed amputation can be extremely problematic; to avoid neuroma, cutting of nerve should be high and away from end of bone; hemostasis should be meticulous to prevent hematoma; if leaving bone with fracture, consult with orthopedic surgeon; ensure that length of bone correct; use all available instruments to create ideal bone end

Staged amputation: traditional approach to traumatic amputation included initial amputation with packing, followed by return to OR for washout; no class 1 evidence supports this approach; in healthy patient, if clean tissue available, good soft-tissue coverage possible, and no proximal fracture present, primary amputation acceptable option; Los Angeles County + USC Medical Center series — among 106 acute limb amputations, approximately one-third had traditional staged amputation and about two-thirds underwent primary reconstruction; scores for severity of injuries of torso and limb well matched in these 2 groups; no difference seen in complications overall; rate of deep infection much lower in immediate reconstruction group; need for revision 30% in staged group vs 15% in immediate reconstruction group

Readings

Ball CJ et al: Hydrogen sulfide reduces neutrophil recruitment in hind-limb ischemia-reperfusion injury in an L-selectin and ADAM-17-dependent manner. Plast Reconstr Surg 2013 Mar;131(3):487-97; Barmparas G et al: Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis. Am Surg 2010 Nov;76(11):1214-22; Bosse MJ et al: A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2011 Jan;83-A(1):3-14; Dwivedi S et al: Treating traumatic injuries of the diaphragm. J Emerg Trauma Shock 2010 Apr-Jun;3(2):173-6; Inaba K et al: Computed tomographic angiography in the initial assessment of penetrating extremity injuries. J Trauma 2007 Feb;62(2):520-2; Inaba K et al: Prospective evaluation of multidetector computed tomography for extremity vascular trauma. J Trauma 2011 Apr;70(4):808-15; Johansen K et al: Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990 May;30(5):568-72; Kobayashi L et al: Traumatic limb amputations at a level I trauma center. Eur J Trauma Emerg Surg 2011 Feb;37(1):67-72; Ly TV et al: Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am 2008 Aug;90(8):1738-43; Thuan VL et al: Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am 2008 Aug;90(8):1738-43; Zarour AM et al: Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg 2013 Jun;74(6):1392-8.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Coimbra spoke at Trauma, Critical Care, and Acute Care Surgery Conference 2014, held March 31 to April 2, 2014, in Las Vegas, NV. For information about 2015 Trauma, Critical Care, and Acute Care Surgery Conference, please go to trauma-criticalcare.com. or visit our website, Audio-Digest.org and click on “Upcoming Meetings.” The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS620401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.