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