Bullets which cross the anatomical boundary of the diaphragm (fourth intercostal space anteriorly, the sixth space in the mid-axillary line, or the eighth space posteriorly) mandate abdominal evaluation and probably celiotomy. Physical examination is unreliable in the presence of thoracic trauma. Assessment requires surgical exploration, diagnostic peritoneal lavage, laparoscopy, ultrasound, and/or thoracoscopy. Abdominal exploration is appropriate for patients with hemodynamic instability without an obvious thoracic source of hemorrhage, if investigations or examination suggest injury. Opening a second body cavity adds to surgical stress, hypothermia, and anesthesia time (Hirshberg.etal 1995). Diagnostic peritoneal lavage is the most commonly performed procedure in thoracoabdominal injuries but has a limited ability to detect diaphragmatic and retroperitoneal injuries. In penetrating trauma, the red blood cell count criterion for a positive diagnostic peritoneal lavage may be reduced to as low as 1000/mm3. Laparoscopy is useful in identifying peritoneal violation but remains unproven in assessing visceral injury. Ultrasound may detect intra-abdominal fluid. A 30° thoracoscope placed through the chest tube site can effectively evaluate the diaphragm for penetration without adding major surgical incisions.
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