Kearney P A, Rouhana S W, Burney R E
Department of Surgery, University of Kentucky, Lexington.
Ann Emerg Med. 1989 Dec;18(12):1326-30. doi: 10.1016/s0196-0644(89)80270-7.
In the absence of respiratory distress and massive visceral herniation, the diagnosis of blunt diaphragmatic disruption can be difficult. This is particularly true for diaphragmatic injuries confined to the right hemidiaphragm. Because diagnostic delay and strangulation are associated with notable increases in mortality and morbidity, it is important to identify the injury as early as possible. Victims of lateral impact motor vehicle collisions are more likely to experience rupture of the diaphragm than victims of frontal collisions. Occupants exposed to left lateral impacts are at greatest risk. The side of diaphragmatic rupture correlates with the direction of impact. The right hemidiaphragm is more resistant to rupture. Deformation shear is a more plausible mechanism for diaphragmatic rupture after lateral impacts. Knowledge of the mechanisms that produce this injury combined with information regarding the victim's seat position and direction of the impacting force should lead to a high index of clinical suspicion for diaphragmatic rupture. Chest radiography and diagnostic peritoneal lavage will establish the correct diagnosis in almost 90% of the patients with acute diaphragmatic disruption. Additional diagnostic studies are reserved for the remaining 10% of patients. Due to the pressure differential between abdomen and thorax, the natural history of these injuries is one of enlargement, and none can be expected to heal spontaneously. Once the diagnosis has been established, the treatment of every diaphragmatic disruption is surgical repair.
在没有呼吸窘迫和大量内脏疝出的情况下，钝性膈肌破裂的诊断可能会很困难。对于局限于右半膈肌的损伤尤其如此。由于诊断延迟和绞窄与死亡率和发病率的显著增加相关，尽早识别损伤很重要。侧面撞击机动车碰撞的受害者比正面碰撞的受害者更有可能发生膈肌破裂。遭受左侧撞击的乘客风险最大。膈肌破裂的一侧与撞击方向相关。右半膈肌更不易破裂。变形剪切是侧面撞击后膈肌破裂更合理的机制。了解造成这种损伤的机制并结合受害者的座位位置和撞击力方向的信息，应该会导致对膈肌破裂有较高的临床怀疑指数。胸部X线摄影和诊断性腹腔灌洗将在几乎90%的急性膈肌破裂患者中确立正确诊断。其余10%的患者则需进行额外的诊断研究。由于腹部和胸部之间的压力差，这些损伤的自然病程是扩大，没有一例有望自愈。一旦确诊，所有膈肌破裂的治疗方法都是手术修复。
