Diaphragmatic Injury
                        ====================

þ General
 - Rate of 0.8% at MIEMSS [J Trauma]
 - more on left than on right (liver protects right diaphragm)
 - many associated injuries that may mask (rib fractures, etc.) and many
   pelvic fractures associated with diaphragm rupture (similar mechanism of
   injury).
 - 26.7% mortality
 - 60% of acute eventration of diaphragm will have associated intraperitoneal
   injury; acute eventration is indication for immediate laparotomy.

þ Diagnostic Clues in stable patients
 - abdominal pain
 - respiratory distress
 - mechanisme
 - upright CXR.

þ Workup if suspect:
 - CXR (30-50% suggestive or diagnostic)
 - NG tube
 - gastrograffin (can get false negative)
 - serial CXRs
 - BE to look for "double beak" sign with two narrowings of large bowel as
   going through diaphragm.
 - CT: can see easier on left side
 - 20% false negative of DPL with 100,000 rbc as criteria
 - liver-spleen scan to check for liver location
 - ultrasound:  not very useful.
 - thoracoscopy (at Mercy)

þ Latent Phase
 - days to years later
 - pain/n/v
 - referred pain to L shoulder
 - obstruction
 - dyspnea
 - orthopnea
 - atypical chest pain