Of the 3.003 reviewed patients, 425 had TDI (14.1%). A diagnosis of TDH was established in 55 cases (1.8%). All further analyses were performed in theses 55 cases. TDH was predominant in males with 46 cases (83%).
BT was most common with 40 cases (72.7%). MVC was the most common blunt mechanism (26 cases, 65%), followed by pedestrian-hit-by-car (11 cases, 27.5%), assault (5%), and falls (2.5%). Among the 15 cases of penetrating trauma (27.3%), stab wounds (SW) were present in 9 (60%), and GSW in 6 (40%) (Figure 1).
Diagnosis was mostly performed by chest radiography (CXR) in 31 cases (56%).
The administration of a water-soluble contrast by nasogastric tube was performed in 2 cases, supporting the diagnosis of TDH.
Since 2008, at HC-Unicamp, hemodynamically stable trauma patients had access to a multi-slice CT scan, which was used to diagnose 7 cases (12%) (Figure 2 and 3). TDH was observed intraoperatively in 17 cases (32%); 14 of these were diagnosed by laparotomy and had associated intra-abdominal injury or hemodynamically unstable (Figure 4); and 3 by laparoscopy.
Diagnostic peritoneal lavage (DPL) was performed in 5 cases, 3 were positive for intra-abdominal injury, 2 negative, and all cases of DPL were subjected to exploratory laparotomy. In the 2 negative cases of DPL, laparotomy was performed due to the suggestive herniation image in CXR and worsening of the patient’s hemodynamics. Surgical procedures were performed within 24 hours in 42 cases (76%), between 24-72 h in 8 (14%), and 72-96 h in 3 cases (5%) Two cases were diagnosed and treated 60 and 180 days after the trauma, respectively.
Laparotomy was the most performed procedure (49 cases, 89%), followed by thoracolaparotomy (5 cases, 9%) and laparoscopy (1 case, 2%).
Left side hernia was the most common (44 cases, 80%), followed by right side (10 cases, 18%), and bilateral (1 case, 2%). Right side most common mechanism was MVC (6 cases).
Diaphragmatic grade III injury occurred in 21 patients (38%), grade IV in 19 (34%), grade V in 9 (17%), and grade II in 6 (11%) (Figure 5). In SW, grade III injury was the most common, followed by grade II. In GSW, grades II, III, and IV had proportionally equal cases. In BT, grade IV was most common followed by grade III.
The stomach was the most common herniated organ (38 cases), followed by the spleen (18 cases), colon (15 cases), small bowel (6 cases), and liver (5 cases). Twenty-five (45.5%) cases had more than one herniated abdominal structure.
Associated intra-abdominal injuries were found in 37 patients (67.3%). Spleen was the most injured (19 cases), followed by the liver (16 cases), stomach (8 cases), colon (6 cases), small bowel and urinary bladder (3 cases each), kidney (2 cases), and pancreas (1 case).
Associated extra-abdominal injuries were found in 35 cases (63.6%). The most common was pelvic fracture (14 cases), and others included long bone fractures (12 cases), traumatic brain injury (TBI) and face trauma (5 cases each), and spinal cord trauma (3 cases). Associated intrathoracic injuries were identified in 13 cases (23.6%). The most common injury was hemopneumothorax and fracture of the ribs (6 cases), followed by lung contusion (4 cases), cardiac injury (2 cases), and thoracic aorta injury (1 case).
About the trauma scores, the maximum RTS was 7.84 (38 cases) and the minimum was 3.26. ISS > 15 was found in 43 cases (78.2%) and > 25 in 21 (38.2%). In cases of ISS > 25, the most prevalent trauma mechanism was BT with 20 cases (95.2%) and 1 case (4.8%) had GSW. Of the 37 patients (67.3%) with systolic blood pressure (SBP) > 90 mmHg, 11 (29.7%) had ISS > 25. Of the 18 patients with hemodynamic instability (SBP < 90 mmHg) in the trauma bay, 11 (61.1%) had ISS > 25. In 21 cases with ISS > 25, the grade of diaphragmatic injury in most was IV (8 cases, 38.1%), followed by grade III (7 cases, 33.3%), and grade V (6 cases, 28.6%).
Seven cases (12.7%) had TRISS < 0.50, and 48 (87.3%) had TRISS > 0.50.
Related to morbidity, 32 cases (58.2%) had postoperative complications. Of these, 71% with ISS > 25 had complications during hospitalization, and 45% with ISS < 25 had complications. Pneumonia was the most frequent complication (15 cases), followed by empyema and acute coagulopathy associated with trauma (7 cases each), and atelectasis (3 cases).
The length of stay included a maximum of 61 days, and the average was 14 days.
The mortality rate was 20% (11 cases), and the most common cause was the lethal triad (coagulopathy, hypothermia, and acidosis) in 6 cases (54.5%), followed by multiple organ failure syndrome in 3 (27.3%), TBI and pulmonary embolism (1 case each). Mortality was observed in 10 cases (25%) with BT and 1 case (15%) with penetrating trauma. Overall mortality was 20%.