Ruptured diaphragm

Nursing, Feb 1999 by Day, Michael W

JANE HARRISON, 36, ARRIVES IN YOUR EMERGENCY DEPARTment after the car she was driving struck a garbage truck from the rear at high speed. She complains of abdominal pain, difficulty breathing, and pain radiating to her left shoulder. The paramedics have started an intravenous (I.V) line with 0.9% sodium chloride solution and 100% oxygen via non-rebreather mask.

What's the situation?

Ms. Harrison wasn't wearing a seat belt, and her car doesn't have air bags. The impact of the crash threw her into the steering wheel, bending the wheel down.

You take Ms. Harrison's vital signs: BP, 112/80; heart rate, 132; respirations, 38 and shallow. You put a pulse oximetry sensor on her index finger; her Spo^ sub 2^ is 78%. A colleague attaches Ms. Harrison to a cardiac monitor, which shows sinus tachycardia. Her breath sounds are decreased on the left side, and you note jugular vein distension and an upward-sweeping crescent-shaped bruise across her lower abdomen.

What's you assessment?

Based on Ms. Harrison's history and signs and symptoms, you suspect a ruptured diaphragm. Any injury below the nipple line or in the flanks or lateral chest wall should be evaluated for trauma to the diaphragm and abdomen.

In Ms. Harrison's case, sudden and rapid deceleration against the steering wheel created an increase in abdominal pressure that literally popped a tear in the diaphragm. Other possible causes include a fall in which the abdomen strikes a blunt object, or a penetrating injury, such as a knife or gunshot wound. Ruptures-particularly those caused by blunt trauma-are more common on the left side of the diaphragm because the left side is embryonically weak and the right side is somewhat protected by the liver.

A tear in the diaphragm may allow abdominal organs to move into the chest cavity. Shifting organs displace the lung on the injured side and may also cause a mediastinal shift that can compress the lung opposite the injury.

Injury also decreases the diaphragm's effectiveness as a major respiratory muscle. Because a ruptured diaphragm can lead to life-threatening respiratory distress and circulatory changes, quick diagnosis and treatment are crucial.

Signs and symptoms of a ruptured diaphragm include dyspnea, dysphagia, abdominal pain, sharp epigastric or chest pain that radiates to the left shoulder (a result of injury to the phrenic nerve), bowel sounds in the lower to middle chest, and decreased breath sounds on the injured side. Jugular vein distension may be caused by a mediastinal shift.

What must you do immediately?

Notify the physician of Ms. Harrison's condition. Establish a second I.V. line with lactated Ringer's solution and insert a nasogastric (NG) tube to decompress the stomach. Obtain a portable chest X-ray. The X-ray shows the tip of the NG tube above the level of the diaphragm, a hollow mass above the left diaphragm, and a potential mediastinal shift to the right. In up to 30% of patients with ruptured diaphragms but no displaced abdominal organs, however, the chest X-ray appears normal.

Ms. Harrison has a computed tomography (CT) scan of the chest and abdomen, which confirms that about 60% of the stomach is above the diaphragm. The physician diagnoses a ruptured left diaphragm, and you prepare Ms. Harrison for immediate surgery.

What should be done later?

After surgery, Ms. Harrison will be admitted to the intensive care unit, where she'll be mechanically ventilated for several days. She'll have repeated chest X-rays and CT scans to make sure the diaphragm repair remains intact and her abdominal contents don't shift into the chest. She'll receive opioids for pain relief.

After about a 2-week hospital stay, Ms. Harrison is discharged home. She plans to buy a newer car with lap and shoulder belts and a driver's-side air bag.

BY MICHAEL W. DAY, RN, CCRN, MSN

Outreach Educator and Staff-Development Coordinator Northwest MedStar Spokane, Wash.