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Abstract: Traumatic diaphragmatic hernia is a disease in which a thoracic or abdominal injury occurs, the diaphragm ruptures, and intra-abdominal organs protrude into the thoracic cavity through the diaphragmatic wound to form a type of diaphragmatic hernia. In this case, after the violent impact of a car accident, the patient developed chest tightness and chest pain, dyspnea, nausea and vomiting. Combining with the history of trauma and emergency CT, the patient was clearly diagnosed as pneumothorax and traumatic diaphragmatic hernia. After thoracentesis and repair of the ruptured diaphragmatic hernia, together with drug treatment, the patient’s symptoms improved significantly.
Basic information】Male, 35 years old
Disease Type】Traumatic diaphragmatic hernia, pneumothorax
Hospital】The First Affiliated Hospital of Kunming Medical University
Date of consultation】November 2021
Treatment plan】Surgery (diaphragm rupture repair) + medication (fentanyl citrate injection, amoxicillin capsule)
Treatment period】10 days of hospitalization and 2 months of follow-up
Effectiveness】Symptom relief, good postoperative healing
I. Initial consultation
The patient was a 35-year-old Mr. Zhang, who was transferred to our department from the emergency room. According to his family, the patient was involved in a traffic accident on the road 2 hours ago, and after the emergency braking, his chest and abdomen were violently impacted by the seat belt, and he immediately felt chest tightness and chest pain, difficulty in breathing, accompanied by nausea and vomiting symptoms. His family quickly called 120 to our hospital for emergency treatment. The emergency CT showed that the left side of the chest cavity showed gastric cavity and intestinal tube shadow, and the left diaphragm was not clear; the mediastinal window of the upper lung field showed left pleural effusion and left pulmonary solid change; the lung window showed bilateral pneumothorax. In order to quickly relieve the patient’s dyspnea, thoracentesis was performed in the emergency room, and the patient was then admitted to our department with “traumatic diaphragmatic hernia”.
(Gastric cavity and intestinal canal were seen in the left thoracic cavity, and the left diaphragm was not clear)
II. Treatment process
After seeking the consent of the family, the patient underwent routine examination of blood, urine, liver and kidney function, coagulation function, C-reactive protein, cardiac function, etc., and no significant abnormalities were found. The patient’s dyspnea was controlled after emergency thoracentesis and aspiration treatment. After excluding contraindications to surgery, it was decided to arrange diaphragmatic rupture repair for the patient. Postoperatively, a nasogastric tube was placed for gastrointestinal decompression, and amoxicillin capsules were used for anti-infection and fentanyl citrate injection for analgesia, and the patient was monitored for electrolyte disturbances. For the small amount of pleural effusion, it was decided not to deal with it for the time being and to observe whether it could be absorbed by itself after standardized medication.
III. Treatment effect
After positive symptomatic treatment, the patient’s dyspnea symptoms were significantly relieved, the postoperative abdominal organs were successfully reset, the symptoms of chest tightness and chest pain were gradually reduced, and the surgical wound healed well without signs of infection, and the pleural effusion was slowly absorbed on its own. On the third postoperative day, the patient’s gastrointestinal and digestive tract power was restored and a liquid diet was started. After 10 days of treatment, the patient’s symptoms of dyspnea disappeared, the symptoms of chest tightness and chest pain improved significantly, the surgical wound healed well, and the CT and various indexes tended to be normal on re-examination, so the patient was discharged from the hospital. During the follow-up 2 months after discharge, the patient did not complain of chest tightness and chest pain, nausea and vomiting, and was very satisfied with the treatment effect.
IV. Precautions
We are glad that the patient recovered from the disease, but we still need to advise the patient to prevent infection after discharge, pay attention to the cleanliness and dryness of the wound, and use anti-infective drugs as prescribed by the doctor. In daily life, you can get out of bed moderately and gradually, which is good for increasing lung capacity and reducing pulmonary complications, as well as improving blood circulation, promoting incision healing, and facilitating the recovery of intestinal motility function. Quit smoking and limit alcohol, and perform training of breathing and coughing up sputum. The first step is a semi-liquid diet, such as meat porridge, vegetable porridge, fruit puree, vegetable puree and rotten noodles, etc. After the recovery of gastrointestinal function, a normal diet will be considered. At the same time, the family members were instructed to monitor their condition daily and to communicate with the doctor in a timely manner if blood vomiting, blood in stool, palpitations, dizziness, abdominal pain, fever, etc. occur.
V. Personal insight
Traumatic diaphragmatic hernia can sometimes be combined with fracture and shock, or even with heart contusion and intestinal obstruction. The patient in this article is still lucky to have no history of open trauma, relatively mild symptoms, and very timely consultation, which creates conditions for a good prognosis. Therefore, when we suffer serious trauma to the chest in our daily life, it is wise to call 120 for medical assistance in time when we have symptoms such as pain and difficulty in breathing; in addition, traumatic diaphragmatic hernia requires early surgery to repair the diaphragmatic defect, and the earlier the surgery is performed, the better the result will be, and complications can be effectively avoided; when the disease is combined with shock, symptomatic priority should be given to hemostasis and blood transfusion to correct shock and reduce mortality. When the disease is combined with shock, hemostasis and transfusion are needed to reduce the mortality rate.