Approximately The location of damage is predominantly on the left side in both blunt and penetrating injuries [ 14 ], because the perpetrators of penetrating injuries are usually right-handed. Furthermore, the left side is structurally weaker in cases of blunt injuries, because it is the site of embryological coalescence. The right diaphragm is less prone to damage, as it is protected by the liver and its ligaments are connected to the adjacent organs, as well as due to the plugging effect [ 14 , 15 ].
This is probably due to the increased incidence of severe blunt trauma associated with road traffic accidents, with a resultant increase in right-sided injuries despite the greater structural strength of the right side, as well as due to the higher survival rate of multiple trauma patients resulting from advances in the emergency medicine system, medical technology, and diagnostic accuracy [ 15 , 17 ].
However, the proportion of right-sided injuries was also fairly high, at In contrast, in —, 22 of 51 patients had a right-sided injury The symptoms of TDI vary greatly, and it is affected more strongly than other types of diaphragmatic injuries by other accompanying injuries. Although TDI has no distinctive diagnosable symptoms or signs, failure to detect damage caused by TDI can cause severe complications [ 7 , 13 ]. Therefore, even if a diaphragmatic injury is not diagnosed radiologically, an active investigation and surveillance for damage is necessary, if suspected based on the mechanism of injury.
No standard test exists for diagnosing diaphragmatic injuries, and the preoperative diagnosis rate is low despite the use of multiple modalities such as chest X-rays, chest CT, and focused abdominal sonography for trauma. Simple chest X-rays are the most common differential diagnostic technique, but have low sensitivity and specificity [ 19 ]. On the contrary, high-resolution, multi-slice CT of the chest has recently shown a higher accuracy in the diagnosis of TDI and is performed routinely in blunt trauma patients.
However, despite the increasingly widespread use of CT, many patients with TDI are not diagnosed at the initial evaluation [ 20 ]. In this study, preoperative diagnoses using chest X-rays and chest CT were more commonly performed in patients with blunt injuries This was probably because patients with penetrating injuries tend to undergo emergency surgery without preoperative investigations. In contrast, as blunt injuries tend to be accompanied by multiple areas of complex damage, patients tend to undergo a radiological evaluation prior to surgery, resulting in a higher preoperative diagnosis rate.
For this reason, the time to surgery in cases of blunt injuries is likely to be longer, as confirmed by the finding that the proportion of patients who underwent emergency surgery within 6 hours of injury was lower in patients with blunt injuries TDI manifests along a spectrum based on the mechanism of injury.
Penetrating injuries can cause small defects that may not result in organ herniation or defects large enough to cause abdominal organs to herniate into the thoracic cavity.
However, the rapid increase in intra-abdominal pressure in blunt injuries tends to cause large tears along the central tendon of the diaphragm, and organ herniation occurs more easily [ 21 — 23 ]. A previous study reported that the right side of the diaphragm is protected by buffering organs such as the liver and heart, and is therefore less prone to damage than the left side [ 24 , 25 ].
In this study, the incidence of organ herniation was significantly higher in patients with blunt injuries, with An interesting finding in this study was liver herniation in three patients, all of whom showed left-sided herniation due to blunt injury. This finding provides empirical support for the proposal that in order for a large organ such as the liver to be herniated, a large tear caused by a blunt injury must occur, and this mechanism is more likely to cause herniation on the left side, which is weaker.
Ebert et al. Furthermore, thoracic injury was the most common accompanying injury hemothorax, rib fracture, pneumothorax, pulmonary contusion, pericardial tear, and thoracic aorta injury. Other accompanying injuries included abdominal organ injury liver tearing and spleen, colon, small intestine, abdominal aorta, and kidney damage , limb fracture, hip fracture, head trauma, and spine injury.
Karmy-Jones and Jurkovich [ 27 ] reported that diaphragmatic injuries in severe blunt trauma were often accompanied by damage to the thoracoabdominal cavity, most often caused by rib fracture and hemopneumothorax, followed by spleen rupture, liver rupture, intestinal rupture, brain damage, and other fractures. In this study, these injuries occurred more frequently in blunt injuries, with the exception of thoracic aorta, liver, and adrenal injuries.
Dunham et al. In this study, 45 patients This value is higher than the previously reported rate of intubation. In 29 of these 45 patients, intubation was performed due to changes in mental status, and 26 of those patients sustained blunt injuries. This is probably associated with the fact that blunt injuries are often accompanied by other types of organ injuries, including brain injury. This finding is consistent with our hypothesis, according to which patients with TDI due to a blunt injury would have a poorer prognosis than those with TDI due to a penetrating injury.
Jung et al. In this study, In a multivariate analysis, Watkins et al. In our multivariate logistic regression analysis Table 7 , the severity of TDI was higher 3. Furthermore, the risk of severe TDI was about fold higher in patients with respiratory compromise OR: In contrast, sex, size of the damaged area, and the initial GCS had no impact on severity. The limitations of this study include its small sample size, as it targeted TDI patients from a single emergency medical center.
Although Gachon University Gil Medical Center is a trauma center, the number of patients over the past 19 years was relatively small. Moreover, this study is retrospective in nature, which is an especially relevant limitation considering the missing paper records from before the implementation of an electronic medical record system. With advances in society and improvements in the health-care environment, the incidence of TDI and its diagnosis are increasing.
A future multi-center, prospective study is warranted to determine the survival rate and neurological outcome of patients with TDI. Table 1 Clinical characteristics of patients with TDI. Table 2 Initial hemodynamic, respiratory, and physiological variables of TDI patients. Table 3 Accompanying injuries in TDI patients. Table 4 Procedures performed in TDI patients in the emergency department. Table 5 Herniated structures in TDI patients. Table 6 Operative approach, time, and method in TDI patients.
Table 7 Risk factors for severe injury in univariate and multivariate analyses. Rosati C. Acute traumatic injury of the diaphragm. Chest Surg Clin N Am ;—9. Traumatic diaphragmatic injuries. Thorac Surg Clin ;—5. Traumatic diaphragmatic hernia.
Coma is a word used to describe a person who is unconscious, or a state where the person is unable to respond to the spoken word or to a stimulus such as a pinch to the shoulder or on the chest.
Sometimes the person may be able to move and open their eyes, but they are unable to obey commands semi-conscious or semi-comatose. When the brain injury is severe, the person may be so deeply comatose that they can no longer cough or swallow properly. This means they could inhale their own saliva. To protect the airway and lungs, the person will need a tube placed into their throat and be connected to a breathing machine ventilator to help them breathe properly.
After a severe brain injury, the brain may start to swell and the patient's condition may deteriorate as the hours go by. People injured away from a major trauma centre will need to be transferred. At first, if the injury can be treated with an operation, this will happen as soon as possible.
Other treatment may include:. One of the most frustrating things for families is the difficulty to predict how the person will be after suffering a severe trauma, especially when it involves a brain injury. It may be a struggle in the first few days to keep the person alive, and it is only after this that the extent of the damage may be known. If the patient wakes up regains consciousness , they may behave differently to how they would have before their injury.
This may be very uncomfortable and confronting for the person and their relatives and friends. Regaining control of the body and being able to live in society are challenges for the person who survives a major injury. Trauma, version 2. The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one.
This is a typical fracture in cases when pedestrians are run over by cars. Skull fractures can also be divided into bending and bursting fractures. Bending fractures result from direct localized trauma. They include:. Bursting fractures, however, result from indirect, transferred trauma.
The results are deformations of the skull and extensive compressions with fractures due to tensile force. These fractures are mainly found at the base of the skull.
Transversal pressure leads to transverse fractures and longitudinal pressure to oblique fractures. So-called hinge fractures transverse fracture of the base of the skull can be found when kicks are carried out against a head that is fixed to the floor, the so-called curb-stomping. A globular fracture is a special form of the bending and bursting fractures. The impaction of the spine into the inside of the skull results in basilar skull ring fractures.
They are the typical evidence of a jump from a great height, because, as opposed to someone falling or being thrown, this injury mechanism requires the person to land on his feet. Clinical signs of skull fractures are monocle or glasses hematomas, bleedings, or cerebrospinal fluid outflow out of the auditory canal. Epidural hematomas originate between the skull bone and the dura mater. The underlying cause is an injury of the meningeal artery which is often seen in the course of skull fractures.
This results in bleedings with protrusion of the dura mater with increasing compression of the brain. Typically, an interval free of symptoms minutes to hours occurs before the onset of the symptoms due to the increased intracranial pressure. There is a risk of misinterpreting this as an alcoholic stupor. The convex space-consuming lesion is typical in the computed tomography CT scan. The free blood volume of more than mL is lethal.
When there are lesions of the bridging veins, bleedings between the dura mater and the arachnoid mater occur. Normally, this occurs traumatically in cases of acceleration-deceleration traumas, e. There is a long interval free of symptoms, and the formation of a chronic subdural hematoma due to bloody oozing is possible. The typical concave shape can be seen in the CT scan.
In this case, bleedings occur under the arachnoid mater as contusion bleedings due to skull traumas or rupture of an aneurysm. The bursting into the subdural space is possible. Clinical symptoms are unconsciousness, headache, vertigo, nausea, and retrograde amnesia. There is no traceable defect of brain substance. The contrecoup is mostly more distinct than the coup due to suction effects or superposition of pressure waves.
Morphologically, there is bruising, bleedings, and edemas. After re-absorption, a plaque jaune develops as a late sequela. Fluid retention makes the brain swell. There is the risk of constriction in the foramen magnum malignant brain edema with central death. Blunt-mechanic trauma that does not cause death directly but immediately. The injured organ, referred to as reflectogenic zone, is not identical to the target organ, but the stimulus is transferred to the target organ via the brain stem, mostly through the heart-circulation-system.
Carotid sinus reflex: The carotid sinus is a small expulsion of the internal carotid artery, just after the bifurcation of the common carotid artery. Here we find baroreceptors regulating blood pressure by decreasing the heart rate. The exogenous pressure on the carotid sinus — like a karate chop against 1 or both sides of the neck, or impaction on the neck after falling or at a traffic accident — results in continuous bradycardia with circulatory collapse. Typical findings are traumatic changes at the carotid sinus like bleedings or rupture of the inner layer and slightly extended signs of vital reaction.
Solar plexus reflex: The solar plexus is a part of the vegetative nervous system. It lies in front of the aorta around the branching of the superior mesenteric artery. Here, the stimulation of the plexus also leads to a reflective decrease in heart and circulatory activity with possible death. Penetrating trauma is defined as the mechanic impact of sharp, semi-sharp, or pointy objects like knives, hatchets, scissors, or glass fragments. The lethal cause is mostly a lesion of vessels, especially in the area of the neck and the clavicle.
Stab wounds are the consequence of tissue disruption with pointy instruments which are mainly held perpendicular to the body surface and create a deep canal so that the wound is more deep than wide.
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