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pain or ipsilateral shoulder pain. The presence of bowel sounds within the
thoracic cavity is nonspecific because bowel sounds can be transmitted from the
abdominal cavity in children. More commonly, bowel sounds are absent because
of the ileus that is typically associated with the injury. A nasogastric tube may be
difficult to pass in patients with a diaphragmatic injury and gastric herniation. In
left-sided diaphragmatic tears, the tip of the nasogastric tube may be seen looping
into the chest. Even though the diagnosis of diaphragmatic injury is usually made
upon initial review of the CXR, some series have reported that up to 30% to 50%
of initial films are normal. Right-sided diaphragmatic injury and herniation is
more difficult to diagnose because the herniated organs are more likely to be
solid. The chest x-ray may just show opacification of the right lung fields. This
emphasizes the importance of serial evaluations and CXRs in patients suspected
of having a diaphragmatic injury. Other diagnostic studies such as chest and
abdominal CT scan with contrast or upper and lower gastrointestinal tract series
can help confirm the diagnosis.
Before performing a tube thoracostomy for a pneumothorax or hemothorax,
diaphragmatic injury should be considered to avoid injury to herniated intraabdominal organs. In patients who clinically appear to have a diaphragmatic
injury (scaphoid abdomen, bowel sounds auscultated in the thoracic cavity), a
finger should be inserted in the thoracostomy incision site and the diaphragm
should be palpated before placing a chest tube.
Herniation and strangulation of bowel may result from a delayed diagnosis.
Diaphragmatic defects will not spontaneously heal because of motion associated
with respirations and cyclical tension. Exploratory laparotomy or laparoscopy
should be performed in cases where a diaphragmatic hernia is strongly suspected.

TRAUMATIC ASPHYXIA
Traumatic asphyxia results from direct compression of the chest or abdomen. The
most common mechanism is a child run over by a slowly moving motor vehicle
or pinned underneath a heavy object. In anticipation of impending injury, the
child may inspire, tensing the thoracoabdominal muscles and closing the glottis.
Traumatic asphyxia also occurs in patients with asthma, seizures, persistent

vomiting, and pertussis.
Positive pressure is transmitted to the mediastinum, and blood is forced out of
the right atrium into the valveless venous and capillary systems. The clinical
manifestations occur because the increase in pressure dilates the capillary and
venous systems. Areas drained by the superior vena cava are particularly affected,
explaining the marked difference between the patient’s head and neck as opposed