Voeller G R, Reisser J R, Fabian T C, Kudsk K, Mangiante E C
Department of Surgery, University of Tennessee, Memphis.
Am Surg. 1990 Jan;56(1):28-31.
Between 1983 and 1988, 33 (21 men, 12 women) patients were treated for blunt diaphragmatic injuries following motor-vehicle (90%) or auto-pedestrian (10%) accidents at the Presley Trauma Center. Thirteen patients (39%) were right sided and 19 (56%) were left sided. One patient sustained bilateral ruptures. The mean Injury Severity Score (ISS) in both those that lived and those that died was not significantly different when right- and left-sided injuries were compared. Admission chest films were abnormal in 28 patients and diagnostic in nine patients (27%). The chest x ray was abnormal in 10 (78%) of those with right-sided injury. Twenty-three patients had diagnostic peritoneal lavage (DPL); 19 were initially positive, two were initially negative but became positive on relavage. There were two false-negative lavages. CT scan (4 patients) and barium enema (1 patient) were nondiagnostic. Diagnosis was delayed in four patients, two were diagnosed by repeat chest x ray and two by repeat lavage. All patients had multiple associated injuries, with 82 per cent having concomitant intra-abdominal injuries. All patients were explored via the transabdominal route. Complications occurred in 55 per cent and there were eight deaths (24%), all unrelated to the diaphragmatic injury. There was no relationship to mortality and hemidiaphragm injured. Chest x ray remains the single most beneficial diagnostic test for diaphragmatic injury. DPL is an insensitive test for isolated diaphragm injuries; however, the combination of CXR and DPL will lead to the diagnosis in the majority of cases. Ancillary radiologic tests are not beneficial. An elevated or obscured right hemidiaphragm should raise suspicion for blunt rupture.(ABSTRACT TRUNCATED AT 250 WORDS)
1983年至1988年间，普雷斯利创伤中心收治了33例（21名男性，12名女性）因机动车事故（90%）或汽车与行人碰撞事故（10%）导致的钝性膈肌损伤患者。13例患者（39%）为右侧膈肌损伤，19例（56%）为左侧膈肌损伤。1例患者双侧膈肌破裂。比较左右侧损伤患者时，存活者和死亡者的平均损伤严重度评分（ISS）无显著差异。28例患者入院时胸部X线片异常，9例患者（27%）的胸部X线片具有诊断价值。右侧膈肌损伤患者中10例（78%）胸部X线片异常。23例患者接受了诊断性腹腔灌洗（DPL）；19例最初呈阳性，2例最初呈阴性但再次灌洗时转为阳性。有2例假阴性灌洗结果。CT扫描（4例患者）和钡灌肠（1例患者）无诊断价值。4例患者诊断延迟，2例通过重复胸部X线片诊断，2例通过重复灌洗诊断。所有患者均有多处合并伤，82%伴有腹腔内损伤。所有患者均经腹部途径进行探查。55%的患者出现并发症，8例死亡（24%），均与膈肌损伤无关。死亡率与膈肌损伤侧别无关。胸部X线片仍然是诊断膈肌损伤最有益的单项检查。DPL对孤立性膈肌损伤检查不敏感；然而，胸部X线片和DPL联合应用可在大多数病例中确诊。辅助性影像学检查无诊断价值。右侧膈肌抬高或模糊应怀疑钝性破裂。（摘要截短至250字）
