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Phrenic Nerve Injury Following Blunt Trauma J Accid Emerg Med 2000;17:419–428 419 J Accid Emerg Med: first published as 10.1136/emj.17.6.426 on 1 November 2000. Downloaded from CASE REPORTS Phrenic nerve injury following blunt trauma David Bell, Ajith Siriwardena Abstract Phrenic nerve trauma in the absence of direct injury is unusual and may present diagnostic diYculty. Diaphragmatic pa- ralysis resulting from phrenic nerve injury may closely mimic diaphragmatic rupture. This case highlights the value of magnetic resonance imaging in establishing dia- phragmatic integrity and of ultrasono- graphic assessment during respiratory excursion in confirming diaphragmatic paralysis. In cases of non-contact injury involving torsional injury to the neck, an index of clinical awareness may help to establish the diagnosis of phrenic nerve trauma. Figure 1 Posteroanterior chest radiograph taken after (J Accid Emerg Med 2000;17:419–420) injury showing elevated right hemi-diaphragm. Keywords: phrenic nerve injury; blunt trauma diaphragmatic rupture was made. Computed tomography demonstrated mild rotation of the axis of the liver (anti-clockwise rotation Case report through the plane of the middle hepatic vein) A 36 year old man was admitted to the compatible with diaphragmatic rupture. How- accident and emergency department two hours ever, a magnetic resonance scan confirmed Y after a road tra c accident. The patient was that the diaphragm was intact but elevated. driving a car that had been struck on the near- Ultrasound scan with respiratory excursion http://emj.bmj.com/ side by another vehicle. The patient’s vehicle demonstrated paralysis of the right hemi- had been stationary at the time of impact. The diaphragm. patient was wearing a seatbelt and reported A diagnosis of right hemi-diaphragmatic that he had not struck his head. There was no paralysis secondary to phrenic nerve damage history of loss of consciousness. He com- plained of pain in the head, neck and back. He had also briefly experienced paraesthesiae in the right hand but this had resolved by the time on September 30, 2021 by guest. Protected copyright. of arrival in the department. At primary survey his neck was immobilised in a hard collar. He was maintaining his airway, self ventilating with a respiratory rate of 20/minute and there was decreased air entry to the right lower zone. The trachea was central. Cardiovascular examination was normal. Oxy- gen saturation was 97% on air and an electro- cardiograph was normal. Secondary survey demonstrated severe lumbar spine tenderness over T12 and L1 vertebrae but no obvious University Department of neurological deficit. Physical examination was Surgery, Royal otherwise normal. His past medical history was Infirmary of significant for a myocardial infarction one year Edinburgh, Edinburgh previously. Radiographs of the cervical spine were nor- Correspondence to: Mr Siriwardena, Department mal. Lumbar spine films demonstrated a of Surgery, Manchester stable anterior wedge compression fracture of Royal Infirmary, Manchester T12. Chest radiograph showed an elevated M13 9WL right hemi-diaphragm (fig 1). This was not ([email protected]) Figure 2 Posteroanterior chest radiograph taken 12 evident on a chest film taken 12 months previ- months before injury showing normal position of right Accepted 29 February 2000 ously (fig 2). A provisional diagnosis of hemi-diaphragm. www.jnlaem.com 420 Bell, Siriwardena J Accid Emerg Med: first published as 10.1136/emj.17.6.426 on 1 November 2000. Downloaded from was made. The injury was treated conserva- and confirmed by fluoroscopy or ultrasonogra- tively with non-opioid analgesia for the phy with respiratory excursion. An important lumbar spine injury. The patient remains well practical consideration is that the clinical find- six months after injury with no clinical ings and radiological appearances on plain evidence of respiratory compromise. He has radiographs and computed tomography may declined further assessment of diaphragmatic mimic diaphragmatic rupture. function. In summary, this case highlights a rare cause of phrenic nerve injury in the absence of direct Discussion trauma. The clinical presentation may closely Traumatic phrenic nerve injury is well recog- resemble diaphragmatic rupture. nised after both penetrating and blunt trauma 12 Contributors to the neck. In contrast, injury as a result of David Bell initiated the writing of the report and the distraction or stretching of the nerve is rare.3 MEDLINE search. Ajith Siriwardena supervised the writing of the report and the phrasing of the final draft and reviewed the In several of these previous reports, a compo- adequacy of the literature search and review of relevant publica- nent of nerve damage may have been as a tions. result of blunt trauma. There was no evidence Funding: none. of blunt trauma in this case with the Conflicts of interest: none. mechanism of injury thought to be lateral hyperextension of the neck. There are no pre- 1 Iverson LI, Mittal A, Dugan DJ, et al. Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special ref- vious reports of phrenic nerve palsy by this erence to stretch trauma. Am J Surg 1976;132:263–9. mechanism. 2 Dalshaug GB, Rothwell BC. Diaphragmatic paralysis following minor blunt trauma. Journal of Trauma, Injury, Clinical manifestations of this injury include Infection and Critical Care 1999;47:413–15. breathlessness, orthopnoea and respiratory 3 Snyder RW, Kukora SJ, Bothwell WN, et al. Phrenic nerve 4 injury following stretch trauma. J Trauma 1994.36:734–6. distress. The diagnosis may be suspected on 4 Carter RE. Unilateral diaphragmatic paralysis in spinal cord chest radiography and computed tomography injury. Paraplegia 1980;18:267–74. http://emj.bmj.com/ on September 30, 2021 by guest. Protected copyright. www.jnlaem.com Non-penetrating chest blows and sudden death in the young 421 J Accid Emerg Med: first published as 10.1136/emj.17.6.426 on 1 November 2000. Downloaded from Non-penetrating chest blows and sudden death in the young S Thakore, M Johnston, E Rogena, Z Peng, D Sadler Abstract right and left lower lung lobes. There was a 15 Sudden death in the young after low mm long and 8 mm deep laceration within the energy anterior chest wall impact is an left ventricular myocardium at the apex. There under-recognised phenomenon in this was no natural disease and toxicological analy- country. Review of the literature yields ses were negative. Death was attributed to several American references to commotio blunt force chest trauma. cordis, mainly in the context of sporting events. Two cases are reported of sudden Case report 2 death in young men as a result of blunt A 19 year old man was playing in goal in a five a impact anterior chest wall trauma. It is side football game when he was struck in the suggested that these cases draw attention central chest by a leather football, kicked with to a lethal condition of which many considerable force from a range of only a few practitioners are unaware. yards. Although initially in obvious discomfort (J Accid Emerg Med 2000;17:421–422) and “winded”, he continued to stand in goal for Keywords: chest blows; sudden death an estimated 5–10 minutes before crying out and collapsing. Bystander cardiopulmonary re- Case report 1 suscitation was started promptly by a doctor The deceased was a 15 year old boy who participating in a neighbouring game. Ambu- collapsed to the ground immediately after lance paramedics performed advanced life being struck centrally in the chest with a 500 g support, including repeated administration of stone, thrown from a distance of 8 to 10 feet epinephrine and attempts at electrical cardiover- during a gang fight. Upon collapse he was said sion. On arrival in the A&E department to have suVered a fit and was carried bodily a approximately 70 minutes after the collapse he short distance by friends and laid on the was in asystole. Further attempts at resuscita- ground. There was no basic life support until tion, including pericardiocentesis and external ambulance paramedics arrived, five minutes pacing, were performed but unfortunately failed after receiving the emergency call. to achieve return of spontaneous circulation. The cardiac rhythm at the scene was pulseless electrical activity, which degenerated NECROPSY FINDINGS to ventricular fibrillation resistant to electrical There were signs of medical intervention in the cardioversion. Appropriate advanced life sup- form of electode pads, endotracheal intubation http://emj.bmj.com/ port continued and he arrived at the accident and a needle puncture mark in the left cubital and emergency (A&E) department 27 minutes fossa. Marked upper anterior mediastinal after the emergency call. His pupils were fixed bruising was present in relation to right subcla- and dilated and he had an agonal rhythm, inter- vian cannulation. There was 350 ml of blood rupted by runs of ventricular tachycardia and within the pericardial sac and a small puncture episodes of ventricular fibrillation. Right needle mark over the lower sternum entering the right ventricular apex, representing the attempt at thoracocentesis was performed because of on September 30, 2021 by guest. Protected copyright. reduced air entry on auscultation but no air was pericardiocentesis. There was no other myo- aspirated. Internal jugular and femoral venous cardial abnormality and no injury to the chest lines were inserted and a crystalloid bolus was wall. There was no natural disease but infused. Ventricular fibrillation developed, but toxicological analyses were not performed. electrical cardioversion proved unsuccessful. Death was attributed to blunt force chest Accident and His rhythm degenerated into asystole and trauma resulting from being struck on the Emergency resuscitation attempts were stopped. chest by the football. Department, Ninewells Hospital, Dundee, DD1 9SY, Scotland NECROPSY FINDINGS Discussion S Thakore There were signs of medical intervention in the We suggest that the above cases illustrate death M Johnston form of needle puncture marks in the cubital attributable to primary arrhythmia occurring fossae, right lower neck, right groin and right after blunt chest trauma.
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