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tachycardia, or dyspnea. A CXR may show a pneumothorax,
pneumomediastinum, subcutaneous emphysema in the neck, a left pleural
effusion, or an air–fluid level in the mediastinum. Perforation of the intraabdominal esophagus may cause retrosternal, epigastric, or shoulder pain.
Patients with suspected esophageal perforation should be adequately volume
resuscitated and receive antibiotics covering gram-positive, gram-negative, and
anaerobic organisms. The diagnosis of an esophageal perforation can be made by
either an esophagram, esophagoscopy, or both. In one study, flexible
esophagoscopy had a sensitivity of 100% and specificity of 96%. Depending on
the expertise at each institution and the stability of the patient, these studies may
be paired to lessen the chance of a misdiagnosis. Once the diagnosis is made, if
the leak is large and not contained, prompt surgical correction is mandatory.
Smaller, contained leaks may be successfully managed nonoperatively. If the
diagnosis is made within 24 hours, mortality rate is approximately 5%. Delayed
diagnosis for more than 24 hours after injury is associated with a mortality rate of
70%.

DIAPHRAGMATIC INJURIES
A crushing abdominal force will produce a sudden increase in intrathoracic and
intra-abdominal pressure against the fixed diaphragm. A diaphragmatic injury
should also be suspected in any thoracic or upper abdominal penetrating injury.
The level of the diaphragm fluctuates greatly with respirations, and injuries of the
diaphragm have been reported with penetrating wounds as high as the third rib
and as low as the 12th rib. Blunt traumatic diaphragmatic rupture is more
commonly left sided (80%) because the left diaphragm is relatively unprotected
compared to the right, though right and bilateral diaphragmatic injuries have been
reported ( Fig. 115.11 ). Right-sided diaphragmatic injuries are associated with
increased mortality rate as these patients usually have a greater physiologic insult
and associated injuries.