McElwee et al developed an algorithm to help diagnose rupture of the diaphragm in a trauma patient. The authors are from Wake Forrest University in Winston-Salem, North Carolina.


Clinical findings that may suggest diaphragmatic rupture:

(1) decreased breath sounds over one hemithorax

(2) bowel sounds in chest

(3) trauma to lower chest or upper abdomen

(4) fractures to ribs or other bones

(5) abnormal chest X-ray suggesting diaphragmatic hernia


Initial diagnostic activities:

(1) Place a nasogastric tube and demonstrate stomach in chest:

(2) Positive peritoneal lavage (or FAST screen).

(3) Pneumoperitoneum (after exclusion of pneumothorax, 500 mL of air are injected through the peritoneal lavage catheter and an X-ray is taken 5-10 minutes later to demonstrate air in the pleural space)


If any of these findings are positive, then a laparotomy is performed.


If the initial diagnostic tests are negative, but there is still clinical suspicion of a diaphragmatic rupture, then additional testing needs to be pursued:

(1) CT scan (most likely to be used today)

(2) upper GI or barium enema

(3) liver spleen scan

(4) laparoscopy



• The FAST protocol were not available at the time the algorithm was formulated..


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