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Unstable VS,
peritonitis, or Laparotomy
Yes
evisceration?
No
STAT
Trauma Labs
CXR / FAST
DO NOT perform local wound exploration
Hemo/pneumothorax?
Yes
Chest tube. Negative
No
Yes
Yes No
Observe in
Abdominal hospital
exploration and
diaphragm repair
* Consider IV/Oral/Rectal contrast
Page 1 of 3
Rational: Penetrating wounds to the thoracoabdominal region may injure both intra-thoracic and
intra-abdominal structures, as well as the diaphragm between these two body cavities.
Delayed diagnosis of diaphragm injuries can be associated with a 25% incidence of
significant morbidity or mortality, compared to 3% risk with injuries identified and
managed in the acute period.2
Page 2 of 3
Protocol11:
A. Inclusion Criteria:
These guidelines apply only to those patients with penetrating injury in the
thoracoabdominal region, and who meet all four of the following criteria:
The presence of any one or more of the above mandates immediate abdominal or
thoracic exploration - without delay for further investigative maneuvers or x-rays.
B. Protocol: (From the Alameda County Medical Center/Highland General Hospital, Trauma Service
Manual)
1. Local Wound Exploration is not performed. Inserting fingers, probes, q-tips and
other objects into the wound in an attempt to determine depth of penetration risks
causing an iatrogenic pneumothorax and will not help diagnose a diaphragmatic
injury.
3. Definitive Evaluation consists in ruling out an injury to the left diaphragm and
other adjacent intra-abdominal organs (stomach, colon, pancreas, spleen).
Therefore, asymptomatic patients with Penetrating wounds to the left thoraco-
abdominal region should undergo either a diagnostic laparoscopy or, if a chest
tube has been inserted, thoracoscopy. This is performed under general anesthesia
with the understanding that should peritoneal violation be found, a formal
exploration (via midline abdominal incision) is warranted to fully appreciate
and repair any occult hollow viscus injuries.
G:\Performance Improvement\Guidelines & Protocols\Thoracoabdominal Wounds
Initiated: 02/25/13
Reviewed / Revised: 09/08/14
Renown Regional Medical Center
Trauma / Critical Care Guideline
Page 3 of 3
Right diaphragmatic injuries caused by knives are probably much less clinically
significant (the liver is thought to prevent bowel herniation through the defect)
and may be left untreated. Thus, asymptomatic patients (i.e. - no peritonitis, no
shock, etc.) with isolated stab wounds to the right thoracoabdominal region may
be observed for presence of hollow visceral injury without the need to perform
diagnostic laparoscopy or thoracoscopy.
References:
1. Wilson, Grande and Hoyt. Trauma, Emergency Resuscitation, Perioperative Anesthesia and Surgical
Management. Pp 482-483. 2007 Informa Healthcare USA, New York, NY
2. Jay Menaker and Thomas M. Scalea. Penetrating Thoraco-abdominal Injury. Trauma Reports. 2010 Nov/Dec;
11(6)
3. Nagy KK, Barrett J. Diaphragm. In: Ivatury RR, Cayten CG, eds. The Textbook of Penetrating Trauma.
Baltimore: Williams & Wilkins, 1996:564570.
4. Murray JA, Demetriades D, Asencio JA, et al. Occult injuries to the diaphragm: prospective evaluation of
laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg. 1998 Dec;187(6):626-630.
5. Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal
trauma: a multicenter experience. J Trauma. 1997 May;42(5):825-829
6. Ortega AE, Tang E, Froes ET, et al. Laparoscopic evaluation of penetrating thoracoabdominal traumatic
injuries. Surg Endosc. 1996 Jan;10(1):19-22.
7. Renz BM, Feliciano DV. Gunshot wounds to the right thoracoabdomen: a prospective study of nonoperative
management. J Trauma 1994; 37:737744.
8. Murray JA, Demetriates D Cornwell EE, et al. Penetrating left thoracoabdominal trauma: the incidence and
clinical presentation of diaphragm injuries. J trauma 1997; 43:824.
9. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after
abdominal penetrating trauma. J Trauma 2005; 58:789.
10. Ochsner MG, Rozycki GS, Lucente F, Wherry DC, et al. Prospective evaluation of thoracoscopy for diagnosing
diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma. 1993 May;34(5):704-709
11. http://eastbay.surgery.ucsf.edu/eastbaytrauma/Protocols/ER%20protocol%20pages/thoracoabdom-stab.htm