CASE PRESENTATION

DR TEJAS KAKKAD, MD.

HISTORY

• 54 YEAR FEMALE• OTHERWISE HEALTHY• H/0 ROAD TRAFFIC ACCIDENT• CHEST TRAUAMA• FALL IN BLOOD PRESSURE• FALL IN HB

CONT…..

• TACHYPNEA• TACHYCARDIA• MILD RESPIRATORY DISTRESS

XRAY CHEST

DIAGNOSIS

• IT SEEMS TO BE A LEFT SIDED MODERATE PLEURAL EFFUSION

• WITH MEDIASTINAL SHIFT TO THE OPPOSITE SIDE

• MOST LIKELY DIAGNOSIS WITH PRESENT HISTORY IS LEFT HEAMOTHORAX

TREATMENT

• NEXT STEP WOULD BE ICD INSERTION • ISNT IT????????????

USG THORAX

• DUE TO AVAILABILITY OF BED SIDE USG WE DID USG THORAX TO CONFIRM THE BEST SITE FOR ICD INSERTION.

• BUT SURPRISINGLY THERE WAS NO FLUID IN PLEURAL CAVITY

• ANY GUESS WHAT IT COULD BE?• WITH THIS XRAY, USG THORAX FINDINGS AND

HISTORY ANY DIFFERENTIAL??

NO CLUE

• NO CLUE• SO WE DECIDED TO GO FOR CT THORAX

HERNIATION OF INTESTINE

CT THORAX

• IT WAS DIAPHRAGMATIC RUPTURE WITH TRANS DIAPHRAGMATIC HERNIATION OF INTESTINAL STRUCTURE.

• ICD insertion would have been definitely DISASTROUS !!!!!!!!!!!!

THORACOTOMY WITH SURGICAL REPAIR

• Finally patient went for thoracotomy and surgical repair of diaphragm and reposition of intestinal structure.

FOLLOW UP

• Post operatively pt did well.• ICD kept for some days post operatively.• Patient had other multiple trauma also which

recovered gradually.• Ultimately patient was discharged after

removing ICD after 4 weeks of hospitalization.

DIAPHRAGMATIC RUPTURE

• Diaphragmatic rupture (also called diaphragmatic injury or tear) is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in respiration. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma[2] and occurs in about 5% of cases of severe blunt trauma to the trunk.[3]

DIAPHRAGMATIC RUPTURE

• Diagnostic techniques include X-ray, computed tomography, and surgical techniques such as laprotomy. Diagnosis is often difficult because signs may not show up on X-ray, or signs that do show up appear similar to other conditions. Signs and symptoms included chest and abdominal pain, difficulty breathing, and decreased lung sounds. When a tear is discovered, surgery is needed to repair it.

DIAPHRAGMATIC RUPTURE

• Injuries to the diaphragm are usually accompanied by other injuries. Since the pressure is higher in the abdominal cavity than the chest cavity, rupture of the diaphragm is almost always associated with herniation of abdominal organs into the chest cavity, called traumatic diaphragmatic hernia. This herniation can interfere with breathing, and blood supply can be cut off to organs that herniated through the diaphragm, damaging them.

TAKE HOME MESSAGE

• CT thorax has definitely a role in certain patients of chest trauma.

• ICD should be inserted only after confirmation of presence of air, fluid, pus or blood at the site.

• Diaphragmatic rupture is one of differentials in a patient of chest trauma.

• Diaphragmatic rupture is rare entity and its repair would be challenging.

THANK YOU