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Tension Gastrothorax Causing Hemodynamic Instability in a Traumatic Diaphragm Rupture

A 64-year-old female with a history of atrial fibrillation and diabetes mellitus presented to the emergency department as a Level I trauma activation after a motor vehicle accident. On arrival, the patient had a GCS of 15 and was transiently hypotensive with a systolic blood pressure of 90, which responded to fluid resuscitation. She had an obvious deformity to her left lower extremity and had been needle-decompressed in her left chest by EMS for decreased breath sounds. A chest X-ray in the emergency room was consistent with a left diaphragm rupture, but given her clinical stability, she underwent CT imaging (Fig. 1). This showed an acute left diaphragm rupture with herniation of the stomach and intra-abdominal fat into the left hemithorax. Her other injuries consisted of a C7 transverse process fracture, left rib 6 to 11 fractures, left pulmonary contusion, and a grade 1 renal laceration. She was then taken to the operating room for exploration. On induction, the patient became hypotensive with tachycardia to 130 and systolic blood pressures in the 30’s. She was immediately explored and with manual reduction of her stomach back into her abdomen, her tension physiology resolved. The remainder of her case was uneventful. She underwent diaphragm repair with a running 0 Prolene suture and a left chest tube placement. Her postoperative course was uneventful other than initial postoperative respiratory failure. Diaphragmatic rupture and herniation is uncommon, and when it occurs, it is usually due to a congenital defect in the diaphragm. Trauma is a rare cause of diaphragmatic rupture with occurrence in 0.8 to 1.6 per cent of blunt force traumas due to a sudden rise in intra-abdominal pressure that overcomes the strength of the diaphragm.1 Rupture typically occurs on the left side, likely because of the protective effects of the liver.2 The defects in the diaphragm created during the trauma are usually asymptomatic, and imaging is not sensitive for defects until there has been herniation of abdominal contents. For this reason, the defects are not typically identified during initial trauma workup and can even present years after the trauma. When contents eventually herniate, serious complications can ensue, such as incarceration of the stomach and other organs, or in this patient’s case, obstructive shock. Tension gastrothorax is a type of obstructive shock caused by prolapse and distention of the stomach into the thoracic cavity. Air, fluid, and gastric content builds up in the herniated stomach within the thoracic cavity, this can subsequently lead to an increase in intrathoracic pressure because the abnormally positioned and angulated gastroesophageal junction functions as a one-way valve.2 Increasing gastric expansion leads to deviation of the mediastinum, reduced venous return due to a crushed inferior vena cava, decreased preload and eventually, diminished cardiac output, and cardiac arrest. In the setting of tension gastrothorax, relieving the obstructive shock is the first priority and can be followed later by definitive repair. This can be accomplished by nasogastric tube decompression, endoscopy,