Rupture of diaphragm: Nursing

Diaphragm rupture refers to tears of the diaphragm, mostly caused by blunt or penetrating trauma to the abdomen.

Now, let’s quickly recap the anatomy and physiology of the diaphragm, which is a dome-shaped sheet of skeletal muscle that divides the thoracic cavity from the abdominal cavity. It curves superiorly into right and left domes, or hemidiaphragms, with the liver lying just beneath the right dome. It has a mobile, central portion known as the central tendon and a peripheral muscular portion that is fixed to the bones, cartilages, and ligaments of the thoracic cage.

Now, the diaphragm is the chief muscle for inspiration; meaning that when it contracts, it helps us breathe in. During contraction, the central portion of the diaphragm depresses, increasing the volume of the thoracic cavity, which, in turn, increases the volume in the lungs. This makes the intrapulmonary pressure fall below the atmospheric pressure, creating a partial vacuum that allows fresh air to be sucked in! The diaphragm also helps with circulation. During contraction, the increased intra-abdominal pressure and decreased intrathoracic pressure help with the venous return of blood towards the heart through the inferior vena cava.

Now, the most common cause of diaphragm rupture is penetrating injury to the thorax or the abdomen, like a knife or gunshot wound, which can pierce through the diaphragm.

Less commonly, diaphragm rupture can be caused by blunt abdominal trauma, such as a motor vehicle crash, which causes a sudden increase in intra-abdominal pressure, causing the diaphragm to rupture. This rupture is far more common on the left hemidiaphragm compared to the right hemidiaphragm, which is protected by the liver.

Okay, let’s look at what happens when there’s a tear in the diaphragm. First, abdominal organs, like the stomach or bowel, may herniate or pass through the diaphragm tear. These abdominal organs increase the intrathoracic pressure and push against the lung, which decreases respiratory function. They can also compress blood vessels supplying the lungs, causing pulmonary hypertension. Now an interesting fact is that herniation is mainly a complication of larger diaphragm tears, which are most often caused by blunt abdominal trauma.