A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room, he is awake and ale and appears frightened but in no distress. The chest radiograph suggests an airfluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. The next best step in management is
Correct Answer: Immediate celiotomy
Description: The finding of an airfluid level in the left lower chest with a nasogastric tube entering it after blunt trauma to the abdomen is diagnostic of diaphragmatic rupture with gastric herniation into the chest. This lesion needs to be fixed immediately.With continuing negative pressure in the chest, each breath sucks more of the abdominal contents into the chest and increases the likelihood of vascular compromise of the herniated viscera. While the diaphragm is easily fixed from the left chest, this injury should be approached from the abdomen. The possibility of injury below the diaphragm after sufficient blunt injury to rupture the diaphragm mandates examination of the intra-abdominal solid and hollow viscera; adequate exposure of the diaphragm to allow secure repair is possible from this approach.
Category:
Surgery
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