A 4-year-old boy is brought to the emergency department with vague chest discomfort. Two months ago, the patient was involved in a high-speed motor vehicle collision but sustained only minor injuries. He was observed in the emergency department overnight and discharged home. Medical history is otherwise unremarkable. Vital signs are normal. Auscultation of the lungs shows decreased air entry into the left lower base. An x-ray of the chest is shown below. Which of the following is the best next step in management of this patient?

Question

A 4-year-old boy is brought to the emergency department with vague chest discomfort.  Two months ago, the patient was involved in a high-speed motor vehicle collision but sustained only minor injuries.  He was observed in the emergency department overnight and discharged home.  Medical history is otherwise unremarkable.  Vital signs are normal.  Auscultation of the lungs shows decreased air entry into the left lower base.  An x-ray of the chest is shown below.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d943_0e44_bc81_792790400a9f_MD0003_00 This patient has a diaphragmatic rupture with herniation of abdominal contents into the thoracic cavity. Diaphragmatic rupture can occur after blunt thoracoabdominal trauma (eg, motor vehicle collision) due to a sudden and unequal increase in thoracoabdominal pressure, resulting in tears or avulsion. The left diaphragm is more prone to injury than the right due to congenital weakness in the diaphragm's left posterolateral region and the liver's protective effects on the right side. Some patients (especially children) with traumatic diaphragmatic injury may initially have no symptoms and can present months to years later after progressive expansion of the diaphragmatic defect. Due to the mass effect of the abdominal organs in the thorax, symptoms may be related to lung compression (eg, chest discomfort, dyspnea), and chest x-ray may show bowel loops within the thoracic cavity and mediastinal shift. Delayed diagnosis is also associated with increased risk of hernia formation and bowel strangulation, which can be fatal (Choice E). Although this patient's x-ray findings suggest diaphragmatic injury, CT scan of the chest and abdomen is performed because it is more sensitive and is the definitive diagnostic modality. Surgical repair is indicated after the diagnosis is confirmed, and CT scan aids in planning of operative approach (eg, thoracotomy vs laparotomy). (Choice A) Chest tube insertion is appropriate for patients with a large fluid collection such as hemothorax (which would appear as a homogenous consolidation) or pneumothorax (which would appear as a single air-filled pocket outside of the visceral pleural line). This patient has multiple air-filled loops, suggestive of bowel. (Choice C) Flexible bronchoscopy visualizes the proximal airway lumen and mucosa to assess airway patency and continuity. In the trauma setting, it may be used to diagnose tracheobronchial injury. Although blunt trauma increases the risk of tracheobronchial injury, this patient has no respiratory distress or associated x-ray findings (eg, pneumomediastinum, pneumothorax, subcutaneous emphysema). (Choice D) Pneumonia is unlikely in the absence of fever and with a chest x-ray showing no infiltrates; therefore, intravenous antibiotics are not required. Educational objective: Diaphragmatic rupture should be suspected in patients with prior blunt thoracoabdominal trauma and abnormal chest x-ray findings (eg, bowel loops in the thorax, mediastinal shift). Delayed presentations can occur after progressive expansion of the diaphragmatic defect and abdominal organ herniation. CT scan of the chest and abdomen confirms the diagnosis. References: Acute traumatic diaphragmatic injury. (http://www.ncbi.nlm.nih.gov/pubmed/20112631) Blunt traumatic diaphragmatic injuries in children. (http://www.ncbi.nlm.nih.gov/pubmed/15589913)

A 4-Year-Old Boy Is Brought to the Emergency Department with Vague