Acute injuries of the diaphragm. An analysis of 165 cases

The records of 165 patients with diaphragmatic injuries seen at Detroit Receiving Hospital from July 1980 through June 1985 were reviewed. Causes included gunshot wounds in 89 patients, stab wounds in 65, and blunt trauma in 11. Mortality rates were 18%, 5%, and 27%, respectively, deaths being caused primarily by bleeding from associated injuries. Operations on these patients included laparotomy in 123 (75%), thoracotomy in four (2%), and both in 38 (23%). The mortality rates for these operations were 0%, 50%, and 53%, respectively. A presumptive preoperative diagnosis of diaphragmatic injury from chest x-ray findings was possible in only 24 (15%) patients. Of 42 thoracotomies, five were performed in the emergency department for cardiac arrest, with three (60%) deaths. Of 37 thoracotomies performed in the operating room, 17 were for thoracic injuries with six (35%) deaths and 20 were for resuscitation for abdominal injuries with 13 (65%) deaths. In most patients, the diaphragmatic injury was critical only in warning the surgeon that severe injuries might be present in both the chest and abdomen. Of 43 patients admitted with a blood pressure of less than 70 mm Hg or four or more associated injuries, 22 died. However, even in these high-risk patients, if resuscitation raised the initial operating room blood pressure to more than 70 mm Hg, reduced the shock time to less than 30 minutes, and kept blood loss below 10 units, the mortality was only 8% (1/12). In contrast, if none of these conditions could be met, the mortality in this high-risk group was 100% (16/16). Thus more aggressive resuscitative efforts and earlier control of bleeding seem to provide the best chance for improved survival.