伊澤 祥光

BACKGROUND: Traumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. We aimed to describe the characteristics of TDI patients, compare penetrating TDI with blunt TDI, and identify mortality risk factors in Japan. METHODS: We retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression was performed to identify mortality risk factors. RESULTS: Of the 338,744 patients, 1,147 (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Penetrating TDI represented 29.8% and blunt TDI 70.2%, and comparing penetrating and blunt TDI, the most common cause was self-inflicted (48.7%) vs. accident (85.6%), males were 68.7% vs. 66.0% of the patients (P = 0.50), and the mortality rate was 8.3% vs. 26.4% (P < 0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.04), Injury Severity Score (OR 1.03, 95%CI 1.006-1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45-0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32-4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24-9.17) were independent predictors of mortality, and computed tomography (CT) (OR 0.32, 95%CI 0.15-0.69) and diaphragm repair (OR 0.44, 95%CI 0.25-0.78) were protective factors. CONCLUSIONS: In Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma.

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Introduction: Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy. Presentation of case: A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures. Discussion: Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest. Conclusion: When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.