oa Diaphragmatic Paralysis in Trauma patient and bedside Ultrasound – A Case Report

Background: The diaphragm is a musculotendinous structure providing a significant drive for respiration and lung expansion during inspiration. The other muscles aiding in ventilation are intercostal, abdominal, and accessory muscles, including sternocleidomastoid and scalene.¹ Direct neck trauma, either blunt or penetrating, potentially can contribute to diaphragmatic paralysis related to phrenic nerve palsy.² The use of ultrasound to confirm diaphragmatic paralysis is growing and becoming an alternative to conventional investigations, including fluoroscopy which is a gold standard.³Case presentation: A middle-aged man was found lying on the road with neck and upper back pain following a frontal collision with a bus. He was a restrained car driver at the time of the impact and was eventually brought by ambulance to the Emergency Department (ED). He had no breathing difficulty although, in the chest x-ray, the right hemidiaphragm was found to be raised (Figure 1). Bedside ultrasound showed no right hemidiaphragm movement assessed in B-Mode (Figure 2). In M-Mode, it showed a flat excursion and minimal change in thickness of the right hemidiaphragm compared to the left. He was managed conservatively with a cervical collar, analgesia, and admitted to the trauma ward for observation and discharged on day 5 with the diagnosis of transient right-sided diaphragmatic paralysis recovered fully as evident with reduced height differential between hemidiaphragm on repeat chest x-ray done one day before discharge, and C1 transverse process and C7 right lamina fracture. Recommendations: The use of bedside ultrasound is critical in suspected traumatic diaphragmatic paralysis during a secondary or tertiary survey to avoid high-risk transfers and the prevention of secondary injuries. Conclusion: Bedside ultrasound has characteristics that make it an ideal tool to use in ED to improve patient safety and optimize resource utilization. Hence; its use is highly recommended. However, further research is needed to determine its effectiveness in traumatic patients for diaphragm paralysis.