Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan

Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan Takafumi Shinjo, Yoshimitsu Izawa, Chikara Yonekawa, Tomohiro Matsumura, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5296552/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Feb, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted 12 You are reading this latest preprint version Abstract Background Traumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. Our purposes were to describe the characteristics of TDI patients, to compare penetrating TDI with blunt TDI, and to identify risk factors for mortality in Japan. Methods We retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating TDI and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression analysis was performed to identify risk factors for mortality. Results A total of 1147 patients (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Blunt TDI represented 70% and penetrating TDI 30%. In penetrating TDI, the most common cause was self-inflicted (49%), and compared to blunt TDI, males were 69% of patients (vs. 66%; P = 0.50) and the mortality rate was 8.3% (vs. 26%; P < 0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.04), Injury Severity Score (OR 1.03, 95%CI 1.006–1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45–0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32–4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24–9.17), computed tomography (CT) (OR 0.32, 95%CI 0.15–0.69), and diaphragm repair (OR 0.44, 95%CI 0.25–0.78) were independent predictors of mortality. Conclusions In Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma. traumatic diaphragmatic injury (TDI) penetrating TDI (PTDI) blunt TDI (BTDI) Japan Trauma Data Bank (JTDB) associated injury severe concomitant injury independent predictor of mortality epidemiology Figures Figure 1 Background Traumatic diaphragmatic injury (TDI) is rare but frequently fatal [1–3]. In the United States, significant differences have been reported between penetrating TDI (PTDI) and blunt TDI (BTDI) in terms of demographics, injury patterns, complications, prognosis, and mortality [1,4]. PTDI also shows different characteristics from BTDI regarding diagnosis, treatment, and other aspects of practice management [5–7]. The incidence of penetrating trauma varies from country to country. Countries in which penetrating trauma is less common include Japan (2.4% incidence of penetrating trauma among all trauma patients) [8], the United Kingdom (4.8%) [9], Germany (3.6%) [10], and Australia and New Zealand (3.8%) [11], while countries in which penetrating trauma is more common include the United States (8.9%) [12], South Africa (40.7%) [13], and Israel (7.4%) [10]. In countries where penetrating trauma is less common, opportunities to treat PTDI are obviously reduced, so familiarity with characteristics of PTDI that differ from those of BTDI is warranted. However, in Japan as well as in other countries with less penetrating trauma, large-scale nationwide studies of all TDI have been lacking, even though large-scale nationwide studies limited to BTDI have been conducted [14–18]. The epidemiology, clinical practice, and prognosis of all TDI in Japan therefore remain unknown. Differences may exist in the clinical characteristics of TDI in Japan compared to countries where penetrating trauma is more common, such as the United States. The purposes of this study were to elucidate the characteristics of PTDI and BTDI patients in Japan, to compare PTDI with BTDI, and to identify risk factors for mortality using a nationwide trauma database in Japan. Methods [Ethics Approval] This study was approved by the institutional review board at Jichi Medical University. The need to obtain informed consent was waived because all analyses used anonymized data (approval no. RINDAI 21-079). [Study design and Setting] This multicenter observational retrospective cohort study was conducted using data from patients registered to the Japan Trauma Data Bank (JTDB) between 2004 and 2019. Our findings were reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for Observational Studies [19]. [Japan Trauma Data Bank] The JTDB is a nationwide hospital-based trauma registry in Japan, established in 2003 by the Japanese Association for the Surgery of Trauma (Trauma Registry Committee) and the Japanese Association for Acute Medicine (Committee for Clinical Care Evaluations). The JTDB is also managed by the Japan Trauma Care and Research (JTCR). As of March 2019, 280 emergency medical institutions across Japan participated in the registry [8]. The JTDB collected 92 data elements relating to trauma patients such as age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) code (AIS90 update98), Injury Severity Score (ISS), vital signs on hospital arrival, Revised Trauma Score (RTS), medical management, surgical operations, computed tomography (CT), and mortality at discharge. [Participants] Among all patients recorded in the JTDB between 2004 and 2019, those with an AIS code (AIS90 update98) indicating diaphragmatic injury (440699.2, 440602.2, 440604.3, and 440606.4) were included in this study. If a patient had more than one AIS code indicating diaphragmatic injury, the most severe AIS code was adopted. Patients with unknown outcomes, those with AIS code 440699.2, meaning TDI of unknown detail, those with unknown mechanism of injury, and those in cardiac arrest (systolic blood pressure = 0 mmHg and/or heart rate = 0 beats/min) on arrival at the hospital were excluded from analyses of in-hospital mortality and its predictive factors. In the multivariable regression analysis, patients who had one or more missing values among the explanatory variables were also excluded. [Variables] The following data from the JTDB were analyzed in this study: age, sex, type of trauma (penetrating or blunt), cause of trauma (accident, self-injury, assault, or work-related), etiology of trauma (traffic accident, fall, stabbing, or gunshot), prehospital blood pressure, prehospital heart rate, blood pressure on hospital arrival, heart rate on hospital arrival, ISS, RTS, severe (AIS ³3) concomitant non-thoracic injury (head, face, neck, abdomen, vertebra, upper extremity, lower extremity including pelvis), any concomitant abdominal injury, associated injury (hemothorax/ pneumothorax, tension pneumothorax, massive hemothorax, flail chest, thoracic aorta injury, cardiac injury, pulmonary injury, trachea/main stem bronchus injury, rib injury, sternum injury, esophagus injury, colon injury, intestine injury, kidney injury, liver injury, mesentery injury, pancreas injury, spleen injury, stomach injury, or duodenum injury), CT of the chest/abdomen, initial therapeutic management (thoracotomy, laparotomy, endoscopic surgery, or non-operative management), performance of diaphragm repair, blood transfusion within 24 h, and mortality. Hypotension was defined as a systolic blood pressure <90 mmHg. The Shock Index (SI) was the heart rate divided by the systolic blood pressure, with an SI ³1 denoting a state of shock. Severe concomitant injury was defined as an injury with a maximum AIS ³3. [Outcome Measures] The primary outcome measure was in-hospital mortality. [Statistical Analysis] Continuous variables were presented as median with interquartile range (IQR), while categorical variables were presented as frequency and percentage. Baseline demographic characteristics, clinical findings, management, and outcomes were analyzed according to the mechanism (penetrating vs. blunt) of diaphragmatic injury. Between-group comparisons were performed using the chi-squared or Fisher’s exact test for categorical data and the Wilcoxon test for continuous data. Multivariable logistic regression analysis was performed with a forced entry procedure to identify factors independently associated with in-hospital mortality. The explanatory variables were selected based on previous studies and according to whether they were considered clinically relevant to diaphragmatic injury. The variables selected were age, type of trauma (blunt, penetrating), ISS, RTS, hypotension on hospital arrival, severe concomitant head injury, severe concomitant abdominal injury, severe concomitant upper extremity injury, severe concomitant lower extremity injury including pelvis, flail chest, thoracic aortic injury, cardiac injury, CT of the chest/abdomen, thoracotomy/laparotomy as initial management, diaphragm repair, and blood transfusion within 24 h. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. All tests were two-tailed, and values of P< 0.05 were considered statistically significant. All statistical analyses were conducted using JMP Pro 17 software (SAS Institute Japan Co., Minato-ku, Tokyo). Results Figure 1 shows patient flow in this study. Of all patients registered in the JTDB during the study period, 11,426 (3.4%) were due to penetrating injury and 311,712 (92%) were due to blunt injury. Of all patients, 1,147 (0.3%) had TDI and 771 of these patients were enrolled in this study. Of the excluded patients, 308 were in cardiac arrest on arrival. Table 1 shows the baseline characteristics, clinical findings, management, and outcomes of all patients with TDI. Comparisons between PTDI and BTDI are also shown. Patients with PTDI were younger, and suicide was the most common cause of injury, followed by assault. Patients with prehospital hypotension and SI ≥1 were significantly more common in PTDI, while the frequency of patients with hypotension and SI ≥1 on hospital arrival did not differ significantly between PTDI and BTDI. The abdomen was the most common region of severe concomitant injury in PTDI, while the lower extremity including the pelvis was the most common region of severe concomitant injury in BTDI. Any concomitant abdominal injury was significantly more common in PTDI. In PTDI, liver injury was the most common associated injury, followed by hemothorax/pneumothorax. In BTDI, the most common associated injuries were rib fracture, followed by hemothorax/pneumothorax, lung injury, and spleen injury. CT of the chest and/or abdomen was performed in more than 80% of both PTDI and BTDI. Thoracotomy/laparotomy as initial therapeutic management was significantly more common in PTDI, while NOM was significantly more common in BTDI. Diaphragm repair was significantly more common following PTDI. The mortality rate was significantly lower for PTDI than for BTDI. Table 1 Characteristics of patients with traumatic diaphragm injury eligible for analysis and their comparisons based on penetrating and blunt injury mechanisms Variables overall n = 771 Penetrating n = 230 (30%) Blunt n = 541 (70%) p value Age, years 56 [39–70] 49 [36–64] 59 [41–72] < 0.001 Male sex 515 (67%) 158 (69%) 357 (66%) 0.50 Cause of trauma Accident 482 (63%) 19 (8.3%) 463 (86%) Self-injury, suicide 138 (18%) 112 (49%) 26 (4.8%) Assault 91 (12%) 89 (39%) 2 (0.4%) Work-related 45 (5.8%) 5 (2.2%) 40 (7.4%) TDI classification Contusion (OIS I) 53 (6.9%) 13 (5.7%) 40 (7.4%) 0.43 Laceration (OIS II-IV) 370 (48%) 193 (84%) 177 (33%) < 0.001 Rupture with herniation 348 (45%) 24 (10%) 324 (60%) < 0.001 On-scene cardiac arrest 6 (0.8%) 0 (0%) 6 (1.1%) 0.18 On-scene hypotension* 101 (13%) 47 (20%) 54 (10%) < 0.001 On-scene Shock Index ≥ 1** 174 (23%) 63 (27%) 111 (21%) 0.038 Hypotension on hospital arrival* 206 (27%) 66 (29%) 140 (26%) 0.42 Shock Index ≥ 1 on hospital arrival** 292 (38%) 83 (36%) 209 (39%) 0.51 ISS 26 [18–38] 18 [13–25] 32 [22–42] < 0.001 RTS 7.6 [6.0-7.8] 7.6 [6.6–7.8] 7.1 [5.7–7.8] < 0.001 TRISS Ps, % 88 [55–96] 95 [89–97] 80 [42–93] < 0.001 Isolated TDI 19 (2.5%) 6 (2.6%) 13 (2.4%) 0.80 Body region of severe† concomitant injury Head 159 (21%) 3 (1.3%) 156 (29%) < 0.001 Abdomen 324 (42%) 116 (50%) 208 (38%) 0.002 Vertebra 36 (4.7%) 2 (0.9%) 34 (6.3%) < 0.001 Upper extremity 41 (5.3%) 3 (1.3%) 38 (7.0%) < 0.001 Lower extremity including pelvis 185 (24%) 1 (0.4%) 184 (34%) < 0.001 Any concomitant abdominal injury 525 (68%) 179 (78%) 346 (64%) < 0.001 Associated injury Hemothorax or pneumothorax 321 (42%) 78 (34%) 243 (45%) 0.005 Tension pneumothorax 16 (2.1%) 4 (1.7%) 12 (2.2%) 0.78 Massive hemothorax 21 (2.7%) 11 (4.8%) 10 (1.9%) 0.029 Flail chest 36 (4.7%) 0 (0%) 36 (6.7%) < 0.001 Thoracic aorta 40 (5.2%) 1 (0.4%) 39 (7.2%) < 0.001 Heart 28 (3.6%) 15 (6.5%) 13 (2.4%) 0.009 Lung 284 (37%) 64 (28%) 220 (41%) < 0.001 Trachea/main stem bronchus 3 (0.4%) 2 (0.9%) 1 (0.2%) 0.21 Rib 358 (46%) 31 (13%) 327 (60%) < 0.001 Sternum 18 (2.3%) 2 (0.9%) 16 (3.0%) 0.11 Esophagus 2 (0.3%) 2 (0.9%) 0 (0%) 0.088 Colon 55 (7.1%) 16 (7.0%) 39 (7.2%) 1.00 Intestine 59 (7.7%) 17 (7.4%) 42 (7.8%) 1.00 Kidney 74 (9.6%) 10 (4.4%) 64 (12%) < 0.001 Liver 248 (32%) 93 (40%) 155 (29%) 0.001 Mesentery 84 (11%) 14 (6.1%) 70 (13%) 0.005 Pancreas 30 (3.9%) 8 (3.5%) 22 (4.1%) 0.83 Spleen 155 (20%) 25 (11%) 130 (24%) < 0.001 Stomach 66 (8.6%) 42 (18%) 24 (4.4%) < 0.001 Duodenum 8 (1.0%) 2 (0.9%) 6 (1.1%) 1.00 CT of chest/abdomen 656 (85%) 187 (81%) 469 (87%) 0.060 Initial therapeutic management Thoracotomy/laparotomy 549 (71%) 187 (81%) 362 (67%) < 0.001 Thoracotomy alone 99 (13%) 36 (16%) 63 (12%) 0.12 Laparotomy alone 314 (41%) 86 (37%) 228 (42%) 0.23 Endoscopic surgery alone 30 (3.9%) 9 (3.9%) 21 (3.9%) 1.00 Non-operative management 192 (25%) 34 (15%) 158 (29%) < 0.001 Diaphragm repair 392 (51%) 133 (58%) 259 (48%) 0.011 Blood transfusion within 24 h 535 (71%) 156 (69%) 379 (71%) 0.60 Mortality 162 (21%) 19 (8.3%) 143 (26%) < 0.001 Data are presented as number (percentage) or median [IQR] TDI, traumatic diaphragmatic injury; OIS, organ injury scale; ISS, injury severity score; RTS, revised trauma score; TRISS, trauma-injury severity score; Ps, probability of survival. *Systolic blood pressure < 90 mmHg, excluding cardiac arrest **Excluding cardiac arrest †maximum Abbreviated Injury Scale ≥ 3 Table 2 shows the ORs of each variable for in-hospital mortality following TDI. Univariable analysis for in-hospital mortality was conducted. Twenty-one percent of patients died in the hospital. Age, hypotension on hospital arrival, SI ≥1 on hospital arrival, ISS, severe concomitant head injury, severe concomitant abdominal injury, severe concomitant upper extremity injury, severe concomitant lower extremity injury including pelvis, flail chest, thoracic aortic injury, cardiac injury, rib injury, NOM, and blood transfusion within 24 h were all significantly associated with higher mortality. Penetrating injury, RTS, CT of the chest and/or abdomen, thoracotomy and/or laparotomy as initial management, and diaphragm repair were significantly associated with lower mortality. TDI classification, presence of any concomitant abdominal injury, and associated injury to each abdominal organ were not significantly associated with in-hospital mortality. Table 2 Odds ratios of in-hospital mortality following TDI according to patient characteristics Variables Death n = 162 (21%) Survived n = 609 (79%) OR (95%CI) P value Age, years 62 [44–75] 54 [38–68] 1.02 (1.01–1.03) < 0.001 Sex, Male 104 (64%) 411 (67%) 0.86 (0.60–1.24) 0.45 Female 58 (36%) 198 (33%) 1 (reference) - Type of trauma Penetrating injury 19 (12%) 211 (35%) 0.25 (0.15–0.41) < 0.001 Blunt injury 143 (88%) 398 (65%) 1 (reference) - TDI classification Contusion (OIS I) 12 (7.4%) 41 (6.7%) 1 (reference) - Laceration (OIS II-IV) 75 (46%) 295 (48%) 0.86 (0.43–1.73) 0.71 Rupture with herniation 75 (46%) 273 (45%) 0.93 (0.46–1.87) 0.85 Hypotension on hospital arrival* (+) (-) 85 (52%) 77 (48%) 121 (20%) 488 (80%) 4.45 (3.08–6.42) 1 (reference) < 0.001 - Shock Index ≥ 1 on hospital arrival** (+) (-) 92 (57%) 70 (43%) 200 (33%) 409 (67%) 2.68 (1.88–3.82) 1 (reference) < 0.001 - ISS 41 [28–50] 25 [18–34] 1.07 (1.06–1.09) < 0.001 RTS 5.1 [2.8–6.6] 7.6 [6.6–7.8] 0.48 (0.42–0.55) < 0.001 Body region of severe concomitant injury Head (+) (-) 56 (35%) 106 (65%) 103 (17%) 506 (83%) 2.59 (1.76–3.82) 1 (reference) < 0.001 - Abdomen (+) (-) 87 (54%) 75 (46%) 237 (39%) 372 (61%) 1.82 (1.28–2.58) 1 (reference) < 0.001 - Vertebra (+) (-) 8 (4.9%) 154 (95%) 28 (4.6%) 581 (95%) 1.07 (0.48–2.41) 1 (reference) 0.83 - Upper extremity (+) (-) 18 (11%) 144 (89%) 23 (3.8%) 586 (96%) 3.18 (1.67–6.05) 1 (reference) < 0.001 - Lower extremity including pelvis (+) (-) 73 (45%) 89 (55%) 112 (18%) 497 (82%) 3.63 (2.51–5.27) 1 (reference) < 0.001 - Associated injury Hemothorax or pneumothorax (+) (-) 68 (42%) 94 (58%) 253 (42%) 356 (58%) 1.01 (0.71–1.44) 1 (reference) 0.92 - Tension pneumothorax (+) (-) 4 (2.5%) 158 (98%) 12 (2.0%) 597 (98%) 1.25 (0.40–3.95) 1 (reference) 0.75 - Massive hemothorax (+) (-) 6 (3.7%) 156 (96%) 15 (2.5%) 594 (98%) 1.52 (0.58–3.98) 1 (reference) 0.41 - Flail chest (+) (-) 14 (8.6%) 148 (91%) 22 (3.6%) 587 (96%) 2.52 (1.26–5.05) 1 (reference) 0.011 - Thoracic aorta (+) (-) 14 (8.6%) 148 (91%) 26 (4.3%) 583 (96%) 2.12 (1.08–4.16) 1 (reference) 0.043 - Heart (+) (-) 12 (7.4%) 150 (93%) 16 (2.6%) 593 (97%) 2.96 (1.37–6.40) 1 (reference) 0.007 - Lung (+) (-) 60 (37%) 102 (63%) 224 (37%) 385 (63%) 1.01 (0.70–1.44) 1 (reference) 1.00 - Rib (+) (-) 90 (56%) 72 (44%) 268 (44%) 341 (56%) 1.59 (1.12–2.25) 1 (reference) 0.010 - Sternum (+) (-) 6 (3.7%) 156 (96%) 12 (2.0%) 597 (98%) 1.91 (0.70–5.17) 1 (reference) 0.23 - Colon (+) (-) 12 (7.4%) 150 (93%) 43 (7.1%) 566 (93%) 1.05 (0.54–2.04) 1 (reference) 0.86 - Intestine (+) (-) 10 (6.2%) 152 (94%) 49 (8.1%) 560 (92%) 0.75 (0.37–1.51) 1 (reference) 0.50 - Kidney (+) (-) 19 (12%) 143 (88%) 55 (9.0%) 554 (91%) 1.33 (0.76–2.32) 1 (reference) 0.29 - Liver (+) (-) 61 (38%) 101 (62%) 187 (31%) 422 (69%) 1.36 (0.94–1.95) 1 (reference) 0.10 - Mesentery (+) (-) 22 (14%) 140 (86%) 62 (10%) 547 (90%) 1.38 (0.82–2.33) 1 (reference) 0.25 - Pancreas (+) (-) 7 (4.3%) 155 (96%) 23 (3.8%) 586 (96%) 1.15 (0.48–2.73) 1 (reference) 0.81 - Spleen (+) (-) 35 (22%) 127 (78%) 120 (20%) 489 (80%) 1.12 (0.73–1.71) 1 (reference) 0.58 - Stomach (+) (-) 8 (4.9%) 154 (95%) 58 (9.5%) 551 (90%) 0.49 (0.23–1.05) 1 (reference) 0.080 - CT of chest/abdomen (+) (-) 112 (69%) 50 (31%) 544 (89%) 65 (11%) 0.26 (0.17–0.40) 1 (reference) < 0.001 - Initial therapeutic management Thoracotomy/laparotomy (+) (-) 96 (59%) 66 (41%) 453 (74%) 156 (26%) 0.50 (0.34–0.71) 1 (reference) < 0.001 - Endoscopic surgery alone (+) (-) 1 (0.6%) 161 (99%) 29 (4.8%) 580 (95%) 0.12 (0.01–0.91) 1 (reference) 0.010 - Non-operative management (+) (-) 65 (40%) 97 (60%) 127 (21%) 482 (79%) 2.54 (1.75–3.68) 1 (reference) < 0.001 - Diaphragm repair (+) (-) 37 (23%) 125 (77%) 355 (58%) 254 (42%) 0.21 (0.14–0.31) 1 (reference) < 0.001 - Blood transfusion within 24 h (+) (-) 134 (85%) 24 (15%) 401 (67%) 197 (33%) 2.74 (1.72–4.37) 1 (reference) < 0.001 - Crude odds ratios were calculated for 771 patients. Data are presented as number (percentage) or median [IQR]. TDI, traumatic diaphragmatic injury; OIS, organ injury scale; ISS, injury severity score; RTS, revised trauma score; IQR, interquartile range; OR, odds ratio; CI, confidence interval. *Systolic blood pressure < 90 mmHg, excluding cardiac arrest **Excluding cardiac arrest †maximum Abbreviated Injury Scale ≥ 3 Table 3 shows the multivariate logistic regression analysis for predictors of mortality following TDI. In the multivariable logistic regression analysis, 16 independent variables were used. Age, ISS, RTS, severe concomitant abdominal injury, and severe concomitant upper extremity injury were independent predictors for mortality, whereas CT of the chest and/or abdomen and diaphragm repair were independent predictors for survival. Hypotension on hospital arrival was not an independent predictor of mortality. Table 3 Multivariate logistic regression analysis for predictors of mortality Variables OR 95%CI P value Age, years 1.03 1.01–1.04 < 0.001 Type of trauma (penetrating vs. blunt) 0.44 0.19–1.007 0.052 ISS 1.03 1.006–1.06 0.017 RTS 0.55 0.45–0.67 < 0.001 Hypotension on hospital arrival* 1.13 0.57–2.22 0.71 Body region of severe† concomitant injury Head 0.62 0.29–1.30 0.20 Abdomen 2.45 1.32–4.56 0.004 Upper extremity 3.38 1.24–9.17 0.016 Lower extremity including pelvis 1.25 0.64–2.41 0.50 Associated injury Flail chest 0.73 0.27–1.95 0.53 Thoracic aorta 0.94 0.34–2.56 0.90 Heart 2.28 0.47-11.0 0.30 CT of chest/abdomen 0.32 0.15–0.69 0.003 Thoracotomy/laparotomy as initial management 0.56 0.30–1.03 0.066 Diaphragm repair 0.44 0.25–0.78 0.004 Blood transfusion within 24 h 1.83 0.77–4.31 0.16 OR, odds ratio; CI, confidence interval; ISS, injury severity score; RTS, revised trauma score. *Systolic blood pressure < 90 mmHg, excluding cardiac arrest †maximum Abbreviated Injury Scale ≥ 3 Discussion The aims of the present study were to describe the clinical characteristics of PTDI and BTDI in Japan, to compare PTDI with BTDI, and to identify risk factors for mortality. We found three important clinical issues for TDI in Japan. First, PTDI differed significantly from BTDI in many respects: cause of trauma, type of injury, on-scene hemodynamics, severity, body region of severe concomitant injury, associated injuries, initial treatment management, and mortality. Second, TDI was rare but frequently fatal even in Japan, mainly due to blunt injury mechanisms, often with severe concomitant injuries to the abdomen, lower extremities including the pelvis, and head. Third, younger age, CT of the chest/abdomen, and diaphragm repair were associated with favorable outcomes following TDI, while higher ISS, lower RTS, concomitant severe abdominal injury, and concomitant severe upper extremity injury were independent predictors of death. First, PTDI differed significantly from BTDI in many ways. Sadly, the most common cause of PTDI in Japan was self-injury or suicide attempt (accounting for half), not assault as in other countries [20,21]. In Japan, where gunshot wounds are extremely rare, penetrating trauma is almost always from a stab wound, and over 70% of abdominal stab wounds are reportedly self-inflicted, with TDI present in just under 4% of these [22]. Further, while the proportion of male patients with PTDI has been reported as around 90% in other countries [1,2,23], no sex difference was evident in Japan. A strong correlation has been reported between assault as a cause of penetrating injury and male patients [24]. As with other organ injuries, a clear difference was noted between most PTDIs resulting from self-injury, suicide, or assault and most BTDI resulting from accidents. These findings have not been well described in previous studies of TDI. The mortality rate of PTDI was significantly lower than that of BTDI in Japan, similar to countries like the United States [1,2,4]. In the present study, despite worse prehospital hemodynamics than BTDI, PTDI showed a higher RTS (better physiological severity) on hospital arrival and consequently a lower mortality rate. This would indicate that PTDI is evaluated as more severe than BTDI in the prehospital setting, but actually has a good prognosis. More thoracotomy and/or laparotomy and less NOM as initial therapeutic management and more diaphragm repair may be associated with lower mortality in PTDI than in BTDI. In principle, all diaphragmatic injuries require surgical repair, but NOM is only acceptable under certain conditions for PTDI [5,6]. Thoracoabdominal stab wounds are suspected to result in PTDI and NOM may be recommended as initial management of the injury in the United States and elsewhere. In Japan, however, poor experience with penetrating trauma may make the decision for NOM difficult, and laparotomy or thoracotomy may be performed more often. PTDI was associated with a significantly higher prevalence of concomitant severe abdominal injury than BTDI. Associated injuries to abdominal organs were most common in the order of liver, stomach and spleen, similar to the study using the National Trauma Data Bank (NTDB) by Fair et al.[1]. Second, TDI was rare but fatal even in Japan, mainly due to blunt trauma mechanisms and often accompanied by severe injuries to the abdomen, lower extremities including the pelvis, and head. Previous reports have shown that the incidence of TDI is less than 0.5% of all trauma [1,25], with a mortality rate of 7–21% [1,2,4,25,26], and the results of the present study were almost the same. In this study, the in-hospital mortality rate was 21%, but 27% (308/1,147) of patients with cardiac arrest on hospital arrival were excluded from the study. The "true mortality" of all cases of TDI, including cardiac arrest on hospital arrival, would therefore certainly be higher. The fact that more than a quarter of the patients with TDI in this study were in cardiac arrest on hospital arrival may mean that TDI itself is extremely lethal, as suggested by several case reports [27–29]. However, no previous investigations have reported that such a high proportion of TDI cases were in cardiac arrest on hospital arrival. Excluding those in cardiac arrest on hospital arrival, just under 30% of TDI patients showed hypotension and just under 40% had an SI ≥ 1 in this study. This also suggests that TDI is likely to be severe. In two cohort studies limited to BTDI using the JTDB [14,15], the proportion of shock was calculated without excluding cardiac arrest on arrival, so the proportion of shock included cardiac arrest. Such a methodology does not accurately represent the rate of shock. The present study revealed that in Japan, patients with PTDI accounted for only 30% of TDI, relatively similar to the situations in Australia (37.5%) [16] and Germany (8.6%) [30], but the exact opposite of the United States (67–75%) [1,2,4] and South Africa (94%) [26], where penetrating trauma is more common [9–13]. The PTDI proportion may offer a direct reflection of the incidence of penetrating trauma in a country or region. Regarding concomitant injuries, very few cases showed isolated TDI, and the most common regions of severe concomitant injury were the abdomen, lower extremities including the pelvis, and head, in that order, and most TDIs involved some concomitant injury to the abdomen. The results were similar to findings from previous studies [2,25,31,32]. Third, in our multivariate logistic analysis, independent predictors of TDI survival were younger age, CT of the chest/abdomen, and diaphragm repair, while independent predictors of death were higher ISS, lower RTS, concomitant severe abdominal injury, and concomitant severe upper extremity injury. Previous studies have also reported similar independent predictors to this study [2,16,23,25,33]. Penetrating injury was not a significant independent predictor of TDI survival. The unique independent predictors in the present study were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. Severe upper extremity injuries suggest that a strong external force may also have been applied to the trunk. As long as permitted by the general condition of the patient, CT is recommended to carefully explore for diaphragmatic injuries and any diaphragmatic injuries identified should be surgically repaired. The significance of the present study lies in its position as the only nationwide study of PTDI and BTDI from a country with a relatively low incidence of penetrating trauma, and this study was second in size only to the nationwide cohort study by Fair et al. [1] using the NTDB. We expect that the present results will contribute to trauma care worldwide, particularly in countries with low rates of penetrating trauma. [Limitations] We acknowledge that there are several limitations in this study. First, the present study was limited by the inherent constraints of the JTDB. Because the JTDB is a hospital-based registry, not a population-based registry, selection bias is present in that only patients who visited and were admitted to JTDB-registered facilities are registered in the JTDB. The use of registries such as the JTDB also allows only retrospective analysis. Second, the JTDB data did not allow us to determine how or when the TDI was diagnosed. We could not evaluate whether surgery was performed after obtaining a radiographic or CT imaging diagnosis, or whether the diagnosis was made intraoperatively rather than preoperatively. One issue for future investigation may be to consider the factors that led to a higher-than-expected rate of NOM for TDI, since surgical repair is supposed to be the principle of treatment. Third, during the observation period of this study, the JTDB did not register whether the diaphragmatic injury was on the left or right side as a variable, and no data were available on any organs that prolapsed in diaphragmatic hernia. The characteristics of TDI reportedly differ significantly between the left and right sides, and differences also exist in the recommendations for therapeutic management [2,6,7]. With data on whether TDI is left, right, or bilateral available in the revised JTDB from 2019, future studies will now be able to compare left- and right-sided TDI in Japan. In addition, in the case of diaphragmatic hernia, the prolapsed organs are also now being registered in the revised JTDB. We would like to conduct further research on TDI using the revised JTDB in the future. Conclusion The present study revealed the clinical characteristics and prognosis of PTDI and BTDI in Japan. PTDI in Japan showed no difference in the ratio of male and female patients, displayed a population characteristic of self-injury as the most common cause of trauma, and had worse prehospital hemodynamics but lower physiological severity on hospital arrival and better prognosis compared with BTDI. TDI in Japan was also very rare but frequently fatal, mostly caused by blunt trauma mechanisms and often accompanied by severe injuries to the abdomen, lower extremities including the pelvis, and head. For penetrating and blunt TDI, factors associated with favorable outcomes were younger age, CT of the chest/abdomen, and diaphragm repair, while independent predictors of death were higher ISS, lower RTS, concomitant severe abdominal injury, and concomitant severe upper extremity injury. These findings may be helpful in the diagnosis and management of TDI not only in Japan, but also in other countries with less penetrating trauma. Abbreviations TDI traumatic diaphragmatic injury PTDI penetrating traumatic diaphragmatic injury BTDI blunt traumatic diaphragmatic injury JTDB Japan Trauma Data Bank STROBE Strengthening the Reporting of Observational Studies in Epidemiology JTCR Japan Trauma Care and Research AIS Abbreviated Injury Scale ISS Injury Severity Score RTS Revised Trauma Score TRISS Trauma-Injury Severity Score Ps probability of survival OIS Organ Injury Scale CT computed tomography SI Shock Index IQR interquartile range OR odds ratio CI confidence interval NOM non-operative management NTDB National Trauma Data Bank Declarations [Ethics approval and consent to participate] This study was approved by the institutional review board of Jichi Medical University. The need to obtain informed consent was waived because all analyses used anonymized data (approval no. RINDAI 21-079). [Consent for publication] Not applicable. [Availability of data and materials] The data that support the findings of this study are available from the Japan Trauma Care and Research (JTCR) but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. [Competing interests] The authors declare that they have no competing interests. [Funding] This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. [Authors’ contributions] All authors contributed to the study conception and design. TS drafted and wrote the manuscript. YI substantively revised the manuscript. TS, YI, CY, and Tomohiro, M interpreted the data. Takashi, M supervised the study. All authors read and approved the final manuscript. [Acknowledgements] We thank Shizukiyo Ishikawa, Professor at the Center for Information of Jichi Medical University, for advice on study design and handling of real-world data. We also thank FORTE Science Communications (https://www.forte-science.co.jp/) for English language editing. References Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015;209: 864–8; discussion 868-9. Zarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC. Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg. 2013;74: 1392–8; quiz 1611. David V. Feliciano, Kenneth L. Mattox, Ernest E. Moore. Trauma, Ninth Edition. McGraw Hill; 2021. Ties JS, Peschman JR, Moreno A, Mathiason MA, Kallies KJ, Martin RF, et al. Evolution in the management of traumatic diaphragmatic injuries: a multicenter review. J Trauma Acute Care Surg. 2014;76: 1024–1028. McDonald AA, Robinson BRH, Alarcon L, Bosarge PL, Dorion H, Haut ER, et al. 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Int J Emerg Med. 2017;10: 4. Paramasivam SJ, Purushothaman S, Al Bshabshe A, Eltaher Osman MJ, Alwadai NM, Sulaiman N, et al. An unusual presentation of acute diaphragmatic hernia complicated by tension gastrothorax an under-recognized cause of cardiac arrest due to a fall from a height: A case report and literature review. SAGE Open Med Case Rep. 2022;10: 2050313X221140241. Schurr LA, Thiedemann C, Alt V, Schlitt HJ, Götz M, Riedl M, et al. Diaphragmatic Injuries among Severely Injured Patients (ISS ≥ 16)-An Indicator of Injury Pattern and Severity of Abdominal Trauma. Medicina . 2022;58. doi:10.3390/medicina58111596 Dirican A, Yilmaz M, Unal B, Piskin T, Ersan V, Yilmaz S. Acute traumatic diaphragmatic ruptures: A retrospective study of 48 cases. Surg Today. 2011;41: 1352–1356. Okada M, Adachi H, Kamesaki M, Mikami M, Ookura Y, Yamakawa J, et al. Traumatic diaphragmatic injury: experience from a tertiary emergency medical center. Gen Thorac Cardiovasc Surg. 2012;60: 649–654. Williams M, Carlin AM, Tyburski JG, Blocksom JM, Harvey EH, Steffes CP, et al. Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries. Am Surg. 2004;70: 157–62; discussion 162-3. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 16 Nov, 2024 Reviews received at journal 14 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviewers agreed at journal 13 Nov, 2024 Reviews received at journal 06 Nov, 2024 Reviewers agreed at journal 03 Nov, 2024 Reviewers agreed at journal 30 Oct, 2024 Reviewers agreed at journal 29 Oct, 2024 Reviewers invited by journal 29 Oct, 2024 Editor assigned by journal 25 Oct, 2024 Submission checks completed at journal 25 Oct, 2024 First submitted to journal 19 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5296552","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":373505503,"identity":"bd370ee1-c503-4710-bc09-9978c724b062","order_by":0,"name":"Takafumi Shinjo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIie3RvQrCMBDA8SuBukRcTxTrIyQIdhGf5UTQRZ0FoVYKugiufZxCBpfq7FgQnB0dHIwfdGzjJpj/VEJ/NHcFsNl+McZUdgVoORG4QK+jpIRU1iMZE3S+IDxtNzjBIARNjPLjCYjqLRhHG3bJMuh74ByKP9M8TZMMSU1XkesLgqEM4UiFBHFGQlCiCXeRgOnXU1FCJgKJgrHzJksDwlOBCTH6EGVAnksOR0rqWbpIYi/XpbPoX3m+9wJP7tSlfpsvvBqWbCxPb0qnr+RiaibAy59qW0Nis9ls/9IDS6tBqt0liFEAAAAASUVORK5CYII=","orcid":"","institution":"Department of Emergency and Critical Care Medicine, Jichi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Takafumi","middleName":"","lastName":"Shinjo","suffix":""},{"id":373505504,"identity":"417e9334-1bf0-467e-a6c8-55c486458a0e","order_by":1,"name":"Yoshimitsu Izawa","email":"","orcid":"","institution":"Department of Emergency and Critical Care Medicine, Jichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yoshimitsu","middleName":"","lastName":"Izawa","suffix":""},{"id":373505505,"identity":"9fa638c2-4cbf-4f15-9ad2-766657285a4a","order_by":2,"name":"Chikara Yonekawa","email":"","orcid":"","institution":"Department of Emergency and Critical Care Medicine, Jichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chikara","middleName":"","lastName":"Yonekawa","suffix":""},{"id":373505506,"identity":"dffc38a3-a13f-4d1f-a7be-8226d493f626","order_by":3,"name":"Tomohiro Matsumura","email":"","orcid":"","institution":"Department of Emergency and Critical Care Medicine, Jichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Matsumura","suffix":""},{"id":373505507,"identity":"f0e8f1a3-71df-42ae-a2ea-e2bb8b97ce85","order_by":4,"name":"Takashi Mato","email":"","orcid":"","institution":"Department of Emergency and Critical Care Medicine, Jichi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Mato","suffix":""}],"badges":[],"createdAt":"2024-10-20 03:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5296552/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5296552/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-025-00826-2","type":"published","date":"2025-02-11T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68699169,"identity":"77ae499a-81d0-43d1-8abb-59c65fa1ffb6","added_by":"auto","created_at":"2024-11-11 07:10:04","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":400310,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patient selection\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5296552/v1/5ca094aa83b9d237abd3ad25.jpeg"},{"id":76488231,"identity":"33e1b838-e4dc-40d6-b462-1200c8e44b19","added_by":"auto","created_at":"2025-02-17 16:13:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1546606,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5296552/v1/c7bb7880-2cb1-4b1d-af86-935495473d0d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan","fulltext":[{"header":"Background","content":"\u003cp\u003eTraumatic diaphragmatic injury (TDI) is rare but frequently fatal [1\u0026ndash;3]. In the United States, significant differences have been reported between penetrating TDI (PTDI) and blunt TDI (BTDI) in terms of demographics, injury patterns, complications, prognosis, and mortality [1,4]. PTDI also shows different characteristics from BTDI regarding diagnosis, treatment, and other aspects of practice management [5\u0026ndash;7]. The incidence of penetrating trauma varies from country to country. Countries in which penetrating trauma is less common include Japan (2.4% incidence of penetrating trauma among all trauma patients) [8], the United Kingdom (4.8%) [9], Germany (3.6%) [10], and Australia and New Zealand (3.8%) [11], while countries in which penetrating trauma is more common include the United States (8.9%) [12], South Africa (40.7%) [13], and Israel (7.4%) [10]. In countries where penetrating trauma is less common, opportunities to treat PTDI are obviously reduced, so familiarity with characteristics of PTDI that differ from those of BTDI is warranted. However, in Japan as well as in other countries with less penetrating trauma, large-scale nationwide studies of all TDI have been lacking, even though large-scale nationwide studies limited to BTDI have been conducted [14\u0026ndash;18]. The epidemiology, clinical practice, and prognosis of all TDI in Japan therefore remain unknown. Differences may exist in the clinical characteristics of TDI in Japan compared to countries where penetrating trauma is more common, such as the United States. The purposes of this study were to elucidate the characteristics of PTDI and BTDI patients in Japan, to compare PTDI with BTDI, and to identify risk factors for mortality using a nationwide trauma database in Japan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Ethics Approval]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board at Jichi Medical University. The need to obtain informed consent was waived because all analyses used anonymized data (approval no. RINDAI 21-079).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Study design and Setting]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis multicenter observational retrospective cohort study was conducted using data from patients registered to the Japan Trauma Data Bank (JTDB)\u0026nbsp;between 2004 and 2019. Our findings were reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for Observational Studies\u0026nbsp;[19].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Japan Trauma Data Bank]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe JTDB is a nationwide hospital-based trauma registry in Japan, established in 2003 by the Japanese Association for the Surgery of Trauma (Trauma Registry Committee) and the Japanese Association for Acute Medicine (Committee for Clinical Care Evaluations). The JTDB is also managed by the Japan Trauma Care and Research (JTCR). As of March 2019, 280 emergency medical institutions across Japan participated in the registry\u0026nbsp;[8]. The JTDB collected 92 data elements relating to trauma patients such as age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) code (AIS90 update98), Injury Severity Score (ISS), vital signs on hospital arrival, Revised Trauma Score (RTS), medical management, surgical operations, computed tomography (CT), and mortality at discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Participants]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong all patients recorded in the JTDB between 2004 and 2019, those with an AIS code\u0026nbsp;(AIS90 update98) indicating diaphragmatic injury (440699.2, 440602.2, 440604.3, and 440606.4) were included in this study. If a patient had more than one AIS code indicating diaphragmatic injury, the most severe AIS code was adopted. Patients with unknown outcomes, those with AIS code 440699.2, meaning TDI of unknown detail, those with unknown mechanism of injury, and those in cardiac arrest (systolic blood pressure = 0 mmHg and/or heart rate = 0 beats/min) on arrival at the hospital were excluded from analyses of in-hospital mortality and its predictive factors. In the multivariable regression analysis, patients who had one or more missing values among the explanatory variables were also excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Variables]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following data from the JTDB were analyzed in this study: age, sex, type of trauma (penetrating or blunt), cause of trauma (accident, self-injury, assault, or work-related), etiology of trauma (traffic accident, fall, stabbing, or gunshot), prehospital blood pressure, prehospital heart rate, blood pressure on hospital arrival, heart rate on hospital arrival, ISS, RTS, severe (AIS\u0026nbsp;³3) concomitant non-thoracic injury (head, face, neck, abdomen, vertebra, upper extremity, lower extremity including pelvis), any concomitant abdominal injury, associated injury (hemothorax/ pneumothorax, tension pneumothorax, massive hemothorax, flail chest, thoracic aorta injury, cardiac injury, pulmonary injury, trachea/main stem bronchus injury, rib injury, sternum injury, esophagus injury, colon injury, intestine injury, kidney injury, liver injury, mesentery injury, pancreas injury, spleen injury, stomach injury, or duodenum injury), CT of the chest/abdomen, initial therapeutic management (thoracotomy, laparotomy, endoscopic surgery, or non-operative management), performance of diaphragm repair, blood transfusion within 24 h, and mortality. Hypotension was defined as a systolic blood pressure \u0026lt;90 mmHg. The Shock Index (SI) was the heart rate divided by the systolic blood pressure, with an SI\u0026nbsp;³1 denoting a state of shock. Severe concomitant injury was defined as an injury with a maximum AIS\u0026nbsp;³3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Outcome Measures]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome measure was in-hospital mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e[Statistical Analysis]\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables were presented as median with interquartile range (IQR), while categorical variables were presented as frequency and percentage. Baseline demographic characteristics, clinical findings, management, and outcomes were analyzed according to the mechanism (penetrating vs. blunt) of diaphragmatic injury. Between-group comparisons were performed using the chi-squared or Fisher’s exact test for categorical data and the Wilcoxon test for continuous data.\u003c/p\u003e\n\u003cp\u003eMultivariable logistic regression analysis was performed with a forced entry procedure to identify factors independently associated with in-hospital mortality. The explanatory variables were selected based on previous studies and according to whether they were considered clinically relevant to diaphragmatic injury. The variables selected were age, type of trauma (blunt, penetrating), ISS, RTS, hypotension on hospital arrival, severe concomitant head injury, severe concomitant abdominal injury, severe concomitant upper extremity injury, severe concomitant lower extremity injury including pelvis, flail chest, thoracic aortic injury, cardiac injury, CT of the chest/abdomen, thoracotomy/laparotomy as initial management, diaphragm repair, and blood transfusion within 24 h. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.\u003c/p\u003e\n\u003cp\u003eAll tests were two-tailed, and values of \u003cem\u003eP\u0026lt;\u003c/em\u003e0.05 were considered statistically significant. All statistical analyses were conducted using JMP Pro 17 software (SAS Institute Japan Co., Minato-ku, Tokyo).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows patient flow in this study. Of all patients registered in the JTDB during the study period, 11,426 (3.4%) were due to penetrating injury and 311,712 (92%) were due to blunt injury. Of all patients, 1,147 (0.3%) had TDI and 771 of these patients were enrolled in this study. Of the excluded patients, 308 were in cardiac arrest on arrival.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the baseline characteristics, clinical findings, management, and outcomes of all patients with TDI. Comparisons between PTDI and BTDI are also shown. Patients with PTDI were younger, and suicide was the most common cause of injury, followed by assault. Patients with prehospital hypotension and SI \u0026ge;1 were significantly more common in PTDI, while the frequency of patients with hypotension and SI \u0026ge;1 on hospital arrival did not differ significantly between PTDI and BTDI. The abdomen was the most common region of severe concomitant injury in PTDI, while the lower extremity including the pelvis was the most common region of severe concomitant injury in BTDI. Any concomitant abdominal injury was significantly more common in PTDI. In PTDI, liver injury was the most common associated injury, followed by hemothorax/pneumothorax. In BTDI, the most common associated injuries were rib fracture, followed by hemothorax/pneumothorax, lung injury, and spleen injury. CT of the chest and/or abdomen was performed in more than 80% of both PTDI and BTDI. Thoracotomy/laparotomy as initial therapeutic management was significantly more common in PTDI, while NOM was significantly more common in BTDI. Diaphragm repair was significantly more common following PTDI. The mortality rate was significantly lower for PTDI than for BTDI.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients with traumatic diaphragm injury eligible for analysis and their comparisons based on penetrating and blunt injury mechanisms\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eoverall\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;771\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePenetrating\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;230 (30%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBlunt\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;541 (70%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 [39\u0026ndash;70]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 [36\u0026ndash;64]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 [41\u0026ndash;72]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e515 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e158 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e357 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause of trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e482 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e463 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-injury, suicide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssault\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork-related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTDI classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContusion (OIS I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (5.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaceration (OIS II-IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e370 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e177 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRupture with herniation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e348 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e324 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn-scene cardiac arrest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn-scene hypotension*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn-scene Shock Index\u0026thinsp;\u0026ge;\u0026thinsp;1**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypotension on hospital arrival*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock Index\u0026thinsp;\u0026ge;\u0026thinsp;1 on hospital arrival**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e292 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e209 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 [18\u0026ndash;38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 [13\u0026ndash;25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 [22\u0026ndash;42]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6 [6.0-7.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6 [6.6\u0026ndash;7.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.1 [5.7\u0026ndash;7.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTRISS Ps, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 [55\u0026ndash;96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 [89\u0026ndash;97]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80 [42\u0026ndash;93]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsolated TDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody region of severe\u0026dagger; concomitant injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e156 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e324 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e208 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebra\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper extremity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower extremity including pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e185 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e184 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny concomitant abdominal injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e525 (68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e179 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e346 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemothorax or pneumothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e321 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e243 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTension pneumothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive hemothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlail chest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic aorta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e284 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e220 (41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrachea/main stem bronchus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e358 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e327 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSternum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsophagus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e155 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMesentery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpleen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuodenum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (1.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT of chest/abdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e656 (85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e469 (87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial therapeutic management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracotomy/laparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e549 (71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e362 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracotomy alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomy alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e314 (41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e228 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopic surgery alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-operative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e192 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e158 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiaphragm repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133 (58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e259 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion within 24 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e535 (71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e379 (71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e143 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eData are presented as number (percentage) or median [IQR]\u003c/p\u003e \u003cp\u003eTDI, traumatic diaphragmatic injury; OIS, organ injury scale; ISS, injury severity score; RTS, revised trauma score; TRISS, trauma-injury severity score; Ps, probability of survival.\u003c/p\u003e \u003cp\u003e*Systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg, excluding cardiac arrest\u003c/p\u003e \u003cp\u003e**Excluding cardiac arrest\u003c/p\u003e \u003cp\u003e\u0026dagger;maximum Abbreviated Injury Scale\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the ORs of each variable for in-hospital mortality following TDI. Univariable analysis for in-hospital mortality was conducted. Twenty-one percent of patients died in the hospital. Age, hypotension on hospital arrival, SI \u0026ge;1 on hospital arrival, ISS, severe concomitant head injury, severe concomitant abdominal injury, severe concomitant upper extremity injury, severe concomitant lower extremity injury including pelvis, flail chest, thoracic aortic injury, cardiac injury, rib injury, NOM, and blood transfusion within 24 h were all significantly associated with higher mortality. Penetrating injury, RTS, CT of the chest and/or abdomen, thoracotomy and/or laparotomy as initial management, and diaphragm repair were significantly associated with lower mortality. TDI classification, presence of any concomitant abdominal injury, and associated injury to each abdominal organ were not significantly associated with in-hospital mortality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOdds ratios of in-hospital mortality following TDI according to patient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;162 (21%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvived\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;609 (79%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 [44\u0026ndash;75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 [38\u0026ndash;68]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02 (1.01\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e411 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86 (0.60\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e198 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenetrating injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e211 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25 (0.15\u0026ndash;0.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlunt injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e398 (65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTDI classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContusion (OIS I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaceration (OIS II-IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e295 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86 (0.43\u0026ndash;1.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRupture with herniation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e273 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.93 (0.46\u0026ndash;1.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypotension on hospital arrival* (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (52%)\u003c/p\u003e \u003cp\u003e77 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121 (20%)\u003c/p\u003e \u003cp\u003e488 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.45 (3.08\u0026ndash;6.42)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock Index\u0026thinsp;\u0026ge;\u0026thinsp;1 on hospital arrival** (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (57%)\u003c/p\u003e \u003cp\u003e70 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200 (33%)\u003c/p\u003e \u003cp\u003e409 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.68 (1.88\u0026ndash;3.82)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 [28\u0026ndash;50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 [18\u0026ndash;34]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07 (1.06\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1 [2.8\u0026ndash;6.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6 [6.6\u0026ndash;7.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48 (0.42\u0026ndash;0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody region of severe concomitant injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (35%)\u003c/p\u003e \u003cp\u003e106 (65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 (17%)\u003c/p\u003e \u003cp\u003e506 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.59 (1.76\u0026ndash;3.82)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdomen (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (54%)\u003c/p\u003e \u003cp\u003e75 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e237 (39%)\u003c/p\u003e \u003cp\u003e372 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.82 (1.28\u0026ndash;2.58)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebra (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.9%)\u003c/p\u003e \u003cp\u003e154 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (4.6%)\u003c/p\u003e \u003cp\u003e581 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07 (0.48\u0026ndash;2.41)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper extremity (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (11%)\u003c/p\u003e \u003cp\u003e144 (89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (3.8%)\u003c/p\u003e \u003cp\u003e586 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.18 (1.67\u0026ndash;6.05)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower extremity including pelvis (+)\u003c/p\u003e \u003cp\u003e (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (45%)\u003c/p\u003e \u003cp\u003e89 (55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (18%)\u003c/p\u003e \u003cp\u003e497 (82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.63 (2.51\u0026ndash;5.27)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemothorax or pneumothorax (+)\u003c/p\u003e \u003cp\u003e (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (42%)\u003c/p\u003e \u003cp\u003e94 (58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e253 (42%)\u003c/p\u003e \u003cp\u003e356 (58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01 (0.71\u0026ndash;1.44)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTension pneumothorax (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.5%)\u003c/p\u003e \u003cp\u003e158 (98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (2.0%)\u003c/p\u003e \u003cp\u003e597 (98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25 (0.40\u0026ndash;3.95)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive hemothorax (+)\u003c/p\u003e \u003cp\u003e (-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.7%)\u003c/p\u003e \u003cp\u003e156 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (2.5%)\u003c/p\u003e \u003cp\u003e594 (98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.52 (0.58\u0026ndash;3.98)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlail chest (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8.6%)\u003c/p\u003e \u003cp\u003e148 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (3.6%)\u003c/p\u003e \u003cp\u003e587 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.52 (1.26\u0026ndash;5.05)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic aorta (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8.6%)\u003c/p\u003e \u003cp\u003e148 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (4.3%)\u003c/p\u003e \u003cp\u003e583 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.12 (1.08\u0026ndash;4.16)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (7.4%)\u003c/p\u003e \u003cp\u003e150 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (2.6%)\u003c/p\u003e \u003cp\u003e593 (97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.96 (1.37\u0026ndash;6.40)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (37%)\u003c/p\u003e \u003cp\u003e102 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e224 (37%)\u003c/p\u003e \u003cp\u003e385 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.01 (0.70\u0026ndash;1.44)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRib (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (56%)\u003c/p\u003e \u003cp\u003e72 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e268 (44%)\u003c/p\u003e \u003cp\u003e341 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.59 (1.12\u0026ndash;2.25)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSternum (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.7%)\u003c/p\u003e \u003cp\u003e156 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (2.0%)\u003c/p\u003e \u003cp\u003e597 (98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.91 (0.70\u0026ndash;5.17)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColon (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (7.4%)\u003c/p\u003e \u003cp\u003e150 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (7.1%)\u003c/p\u003e \u003cp\u003e566 (93%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.05 (0.54\u0026ndash;2.04)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestine (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.2%)\u003c/p\u003e \u003cp\u003e152 (94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (8.1%)\u003c/p\u003e \u003cp\u003e560 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.75 (0.37\u0026ndash;1.51)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (12%)\u003c/p\u003e \u003cp\u003e143 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (9.0%)\u003c/p\u003e \u003cp\u003e554 (91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.33 (0.76\u0026ndash;2.32)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (38%)\u003c/p\u003e \u003cp\u003e101 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187 (31%)\u003c/p\u003e \u003cp\u003e422 (69%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.36 (0.94\u0026ndash;1.95)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMesentery (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (14%)\u003c/p\u003e \u003cp\u003e140 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (10%)\u003c/p\u003e \u003cp\u003e547 (90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.38 (0.82\u0026ndash;2.33)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreas (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4.3%)\u003c/p\u003e \u003cp\u003e155 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (3.8%)\u003c/p\u003e \u003cp\u003e586 (96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.15 (0.48\u0026ndash;2.73)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpleen (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (22%)\u003c/p\u003e \u003cp\u003e127 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (20%)\u003c/p\u003e \u003cp\u003e489 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.12 (0.73\u0026ndash;1.71)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStomach (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.9%)\u003c/p\u003e \u003cp\u003e154 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (9.5%)\u003c/p\u003e \u003cp\u003e551 (90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.49 (0.23\u0026ndash;1.05)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT of chest/abdomen (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112 (69%)\u003c/p\u003e \u003cp\u003e50 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e544 (89%)\u003c/p\u003e \u003cp\u003e65 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.26 (0.17\u0026ndash;0.40)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial therapeutic management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracotomy/laparotomy (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (59%)\u003c/p\u003e \u003cp\u003e66 (41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e453 (74%)\u003c/p\u003e \u003cp\u003e156 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50 (0.34\u0026ndash;0.71)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopic surgery alone (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.6%)\u003c/p\u003e \u003cp\u003e161 (99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (4.8%)\u003c/p\u003e \u003cp\u003e580 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.12 (0.01\u0026ndash;0.91)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-operative management (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (40%)\u003c/p\u003e \u003cp\u003e97 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (21%)\u003c/p\u003e \u003cp\u003e482 (79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.54 (1.75\u0026ndash;3.68)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiaphragm repair (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (23%)\u003c/p\u003e \u003cp\u003e125 (77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e355 (58%)\u003c/p\u003e \u003cp\u003e254 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21 (0.14\u0026ndash;0.31)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion within 24 h (+)\u003c/p\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (85%)\u003c/p\u003e \u003cp\u003e24 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e401 (67%)\u003c/p\u003e \u003cp\u003e197 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.74 (1.72\u0026ndash;4.37)\u003c/p\u003e \u003cp\u003e1 (reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eCrude odds ratios were calculated for 771 patients. Data are presented as number (percentage) or median [IQR].\u003c/p\u003e \u003cp\u003eTDI, traumatic diaphragmatic injury; OIS, organ injury scale; ISS, injury severity score; RTS, revised trauma score; IQR, interquartile range; OR, odds ratio; CI, confidence interval.\u003c/p\u003e \u003cp\u003e*Systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg, excluding cardiac arrest\u003c/p\u003e \u003cp\u003e**Excluding cardiac arrest\u003c/p\u003e \u003cp\u003e\u0026dagger;maximum Abbreviated Injury Scale\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the multivariate logistic regression analysis for predictors of mortality following TDI. In the multivariable logistic regression analysis, 16 independent variables were used. Age, ISS, RTS, severe concomitant abdominal injury, and severe concomitant upper extremity injury were independent predictors for mortality, whereas CT of the chest and/or abdomen and diaphragm repair were independent predictors for survival. Hypotension on hospital arrival was not an independent predictor of mortality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis for predictors of mortality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01\u0026ndash;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of trauma (penetrating vs. blunt)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u0026ndash;1.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.006\u0026ndash;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRTS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u0026ndash;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypotension on hospital arrival*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.57\u0026ndash;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody region of severe\u0026dagger; concomitant injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.29\u0026ndash;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.32\u0026ndash;4.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper extremity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.24\u0026ndash;9.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower extremity including pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.64\u0026ndash;2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlail chest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.27\u0026ndash;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic aorta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.34\u0026ndash;2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47-11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT of chest/abdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u0026ndash;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracotomy/laparotomy as initial management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.30\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiaphragm repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25\u0026ndash;0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion within 24 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77\u0026ndash;4.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eOR, odds ratio; CI, confidence interval; ISS, injury severity score; RTS, revised trauma score.\u003c/p\u003e \u003cp\u003e*Systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90 mmHg, excluding cardiac arrest\u003c/p\u003e \u003cp\u003e\u0026dagger;maximum Abbreviated Injury Scale\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aims of the present study were to describe the clinical characteristics of PTDI and BTDI in Japan, to compare PTDI with BTDI, and to identify risk factors for mortality. We found three important clinical issues for TDI in Japan. First, PTDI differed significantly from BTDI in many respects: cause of trauma, type of injury, on-scene hemodynamics, severity, body region of severe concomitant injury, associated injuries, initial treatment management, and mortality. Second, TDI was rare but frequently fatal even in Japan, mainly due to blunt injury mechanisms, often with severe concomitant injuries to the abdomen, lower extremities including the pelvis, and head. Third, younger age, CT of the chest/abdomen, and diaphragm repair were associated with favorable outcomes following TDI, while higher ISS, lower RTS, concomitant severe abdominal injury, and concomitant severe upper extremity injury were independent predictors of death.\u003c/p\u003e \u003cp\u003eFirst, PTDI differed significantly from BTDI in many ways. Sadly, the most common cause of PTDI in Japan was self-injury or suicide attempt (accounting for half), not assault as in other countries [20,21]. In Japan, where gunshot wounds are extremely rare, penetrating trauma is almost always from a stab wound, and over 70% of abdominal stab wounds are reportedly self-inflicted, with TDI present in just under 4% of these [22]. Further, while the proportion of male patients with PTDI has been reported as around 90% in other countries [1,2,23], no sex difference was evident in Japan. A strong correlation has been reported between assault as a cause of penetrating injury and male patients [24]. As with other organ injuries, a clear difference was noted between most PTDIs resulting from self-injury, suicide, or assault and most BTDI resulting from accidents. These findings have not been well described in previous studies of TDI.\u003c/p\u003e \u003cp\u003eThe mortality rate of PTDI was significantly lower than that of BTDI in Japan, similar to countries like the United States [1,2,4]. In the present study, despite worse prehospital hemodynamics than BTDI, PTDI showed a higher RTS (better physiological severity) on hospital arrival and consequently a lower mortality rate. This would indicate that PTDI is evaluated as more severe than BTDI in the prehospital setting, but actually has a good prognosis. More thoracotomy and/or laparotomy and less NOM as initial therapeutic management and more diaphragm repair may be associated with lower mortality in PTDI than in BTDI. In principle, all diaphragmatic injuries require surgical repair, but NOM is only acceptable under certain conditions for PTDI [5,6]. Thoracoabdominal stab wounds are suspected to result in PTDI and NOM may be recommended as initial management of the injury in the United States and elsewhere. In Japan, however, poor experience with penetrating trauma may make the decision for NOM difficult, and laparotomy or thoracotomy may be performed more often. PTDI was associated with a significantly higher prevalence of concomitant severe abdominal injury than BTDI. Associated injuries to abdominal organs were most common in the order of liver, stomach and spleen, similar to the study using the National Trauma Data Bank (NTDB) by Fair et al.[1].\u003c/p\u003e \u003cp\u003eSecond, TDI was rare but fatal even in Japan, mainly due to blunt trauma mechanisms and often accompanied by severe injuries to the abdomen, lower extremities including the pelvis, and head. Previous reports have shown that the incidence of TDI is less than 0.5% of all trauma [1,25], with a mortality rate of 7\u0026ndash;21% [1,2,4,25,26], and the results of the present study were almost the same. In this study, the in-hospital mortality rate was 21%, but 27% (308/1,147) of patients with cardiac arrest on hospital arrival were excluded from the study. The \"true mortality\" of all cases of TDI, including cardiac arrest on hospital arrival, would therefore certainly be higher. The fact that more than a quarter of the patients with TDI in this study were in cardiac arrest on hospital arrival may mean that TDI itself is extremely lethal, as suggested by several case reports [27\u0026ndash;29]. However, no previous investigations have reported that such a high proportion of TDI cases were in cardiac arrest on hospital arrival. Excluding those in cardiac arrest on hospital arrival, just under 30% of TDI patients showed hypotension and just under 40% had an SI\u0026thinsp;\u0026ge;\u0026thinsp;1 in this study. This also suggests that TDI is likely to be severe. In two cohort studies limited to BTDI using the JTDB [14,15], the proportion of shock was calculated without excluding cardiac arrest on arrival, so the proportion of shock included cardiac arrest. Such a methodology does not accurately represent the rate of shock.\u003c/p\u003e \u003cp\u003eThe present study revealed that in Japan, patients with PTDI accounted for only 30% of TDI, relatively similar to the situations in Australia (37.5%) [16] and Germany (8.6%) [30], but the exact opposite of the United States (67\u0026ndash;75%) [1,2,4] and South Africa (94%) [26], where penetrating trauma is more common [9\u0026ndash;13]. The PTDI proportion may offer a direct reflection of the incidence of penetrating trauma in a country or region.\u003c/p\u003e \u003cp\u003eRegarding concomitant injuries, very few cases showed isolated TDI, and the most common regions of severe concomitant injury were the abdomen, lower extremities including the pelvis, and head, in that order, and most TDIs involved some concomitant injury to the abdomen. The results were similar to findings from previous studies [2,25,31,32].\u003c/p\u003e \u003cp\u003eThird, in our multivariate logistic analysis, independent predictors of TDI survival were younger age, CT of the chest/abdomen, and diaphragm repair, while independent predictors of death were higher ISS, lower RTS, concomitant severe abdominal injury, and concomitant severe upper extremity injury. Previous studies have also reported similar independent predictors to this study [2,16,23,25,33]. Penetrating injury was not a significant independent predictor of TDI survival. The unique independent predictors in the present study were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. Severe upper extremity injuries suggest that a strong external force may also have been applied to the trunk. As long as permitted by the general condition of the patient, CT is recommended to carefully explore for diaphragmatic injuries and any diaphragmatic injuries identified should be surgically repaired.\u003c/p\u003e \u003cp\u003eThe significance of the present study lies in its position as the only nationwide study of PTDI and BTDI from a country with a relatively low incidence of penetrating trauma, and this study was second in size only to the nationwide cohort study by Fair et al. [1] using the NTDB. We expect that the present results will contribute to trauma care worldwide, particularly in countries with low rates of penetrating trauma.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e[Limitations]\u003c/h2\u003e \u003cp\u003eWe acknowledge that there are several limitations in this study. First, the present study was limited by the inherent constraints of the JTDB. Because the JTDB is a hospital-based registry, not a population-based registry, selection bias is present in that only patients who visited and were admitted to JTDB-registered facilities are registered in the JTDB. The use of registries such as the JTDB also allows only retrospective analysis. Second, the JTDB data did not allow us to determine how or when the TDI was diagnosed. We could not evaluate whether surgery was performed after obtaining a radiographic or CT imaging diagnosis, or whether the diagnosis was made intraoperatively rather than preoperatively. One issue for future investigation may be to consider the factors that led to a higher-than-expected rate of NOM for TDI, since surgical repair is supposed to be the principle of treatment. Third, during the observation period of this study, the JTDB did not register whether the diaphragmatic injury was on the left or right side as a variable, and no data were available on any organs that prolapsed in diaphragmatic hernia. The characteristics of TDI reportedly differ significantly between the left and right sides, and differences also exist in the recommendations for therapeutic management [2,6,7]. With data on whether TDI is left, right, or bilateral available in the revised JTDB from 2019, future studies will now be able to compare left- and right-sided TDI in Japan. In addition, in the case of diaphragmatic hernia, the prolapsed organs are also now being registered in the revised JTDB. We would like to conduct further research on TDI using the revised JTDB in the future.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study revealed the clinical characteristics and prognosis of PTDI and BTDI in Japan. PTDI in Japan showed no difference in the ratio of male and female patients, displayed a population characteristic of self-injury as the most common cause of trauma, and had worse prehospital hemodynamics but lower physiological severity on hospital arrival and better prognosis compared with BTDI. TDI in Japan was also very rare but frequently fatal, mostly caused by blunt trauma mechanisms and often accompanied by severe injuries to the abdomen, lower extremities including the pelvis, and head. For penetrating and blunt TDI, factors associated with favorable outcomes were younger age, CT of the chest/abdomen, and diaphragm repair, while independent predictors of death were higher ISS, lower RTS, concomitant severe abdominal injury, and concomitant severe upper extremity injury. These findings may be helpful in the diagnosis and management of TDI not only in Japan, but also in other countries with less penetrating trauma.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTDI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;traumatic diaphragmatic injury\u003c/p\u003e\n\u003cp\u003ePTDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;penetrating traumatic diaphragmatic injury\u003c/p\u003e\n\u003cp\u003eBTDI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;blunt traumatic diaphragmatic injury\u003c/p\u003e\n\u003cp\u003eJTDB\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Japan Trauma Data Bank\u003c/p\u003e\n\u003cp\u003eSTROBE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Strengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n\u003cp\u003eJTCR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Japan Trauma Care and Research\u003c/p\u003e\n\u003cp\u003eAIS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Abbreviated Injury Scale\u003c/p\u003e\n\u003cp\u003eISS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Injury Severity Score\u003c/p\u003e\n\u003cp\u003eRTS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Revised Trauma Score\u003c/p\u003e\n\u003cp\u003eTRISS\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Trauma-Injury Severity Score\u003c/p\u003e\n\u003cp\u003ePs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;probability of survival\u003c/p\u003e\n\u003cp\u003eOIS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Organ Injury Scale\u003c/p\u003e\n\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;computed tomography\u003c/p\u003e\n\u003cp\u003eSI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Shock Index\u003c/p\u003e\n\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;interquartile range\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;odds ratio\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;confidence interval\u003c/p\u003e\n\u003cp\u003eNOM\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;non-operative management\u003c/p\u003e\n\u003cp\u003eNTDB \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; National Trauma Data Bank\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e[Ethics approval and consent to participate]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board of Jichi Medical University. The need to obtain informed consent was waived because all analyses used anonymized data (approval no. RINDAI 21-079).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Consent for publication]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Availability of data and materials]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the Japan Trauma Care and Research (JTCR) but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Competing interests]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Funding]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Authors’ contributions]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. TS drafted and wrote the manuscript. YI substantively revised the manuscript. TS, YI, CY, and Tomohiro, M interpreted the data. Takashi, M supervised the study.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Acknowledgements]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Shizukiyo Ishikawa, Professor at the Center for Information of Jichi Medical University, for advice on study design and handling of real-world data. We also thank FORTE Science Communications (https://www.forte-science.co.jp/) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFair KA, Gordon NT, Barbosa RR, Rowell SE, Watters JM, Schreiber MA. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015;209: 864\u0026ndash;8; discussion 868-9.\u003c/li\u003e\n\u003cli\u003eZarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC. Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg. 2013;74: 1392\u0026ndash;8; quiz 1611.\u003c/li\u003e\n\u003cli\u003eDavid V. Feliciano, Kenneth L. Mattox, Ernest E. Moore. Trauma, Ninth Edition. McGraw Hill; 2021.\u003c/li\u003e\n\u003cli\u003eTies JS, Peschman JR, Moreno A, Mathiason MA, Kallies KJ, Martin RF, et al. Evolution in the management of traumatic diaphragmatic injuries: a multicenter review. J Trauma Acute Care Surg. 2014;76: 1024\u0026ndash;1028.\u003c/li\u003e\n\u003cli\u003eMcDonald AA, Robinson BRH, Alarcon L, Bosarge PL, Dorion H, Haut ER, et al. Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018;85: 198\u0026ndash;207.\u003c/li\u003e\n\u003cli\u003eKarmy-Jones R, Namias N, Coimbra R, Moore EE, Schreiber M, McIntyre R Jr, et al. Western Trauma Association critical decisions in trauma: penetrating chest trauma. J Trauma Acute Care Surg. 2014;77: 994\u0026ndash;1002.\u003c/li\u003e\n\u003cli\u003eMartin MJ, Brown CVR, Shatz DV, Alam HB, Brasel KJ, Hauser CJ, et al. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018;85: 1007\u0026ndash;1015.\u003c/li\u003e\n\u003cli\u003eJapan Trauma Care and Research. Japan Trauma Data Bank Report 2019. In: Japan Trauma Data Bank [Internet]. Nov20.2019 [cited Sep2.2023]. Available: https://www.jtcr-jatec.org/traumabank/dataroom/data/JTDB2019e.pdf\u003c/li\u003e\n\u003cli\u003eMoran CG, Lecky F, Bouamra O, Lawrence T, Edwards A, Woodford M, et al. Changing the system - major trauma patients and their outcomes in the NHS (England) 2008-17. EClinicalMedicine. 2018;2\u0026ndash;3: 13\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eKaim A, Bodas M, Bieler D, Radomislensky I, Matthes G, Givon A, et al. Severe trauma in Germany and Israel: are we speaking the same language? A trauma registry comparison. Front Public Health. 2023;11: 1136159.\u003c/li\u003e\n\u003cli\u003eHeathcote K, Devlin A, McKie E, Cameron P, Earnest A, Morgan G, et al. Rural and urban patterns of severe injuries and hospital mortality in Australia: An analysis of the Australia New Zealand Trauma Registry: 2015-2019. Injury. 2022;53: 1893\u0026ndash;1903.\u003c/li\u003e\n\u003cli\u003eNational Trauma Data Bank Report 2013 Annual Report. In: National Trauma Data Bank 2013 Annual Report (facs.org) [Internet]. Available: https://www.facs.org/media/mhkgvvy5/ntdb-annual-report-2013.pdf\u003c/li\u003e\n\u003cli\u003eLaing GL, Skinner DL, Bruce JL, Aldous C, Oosthuizen GV, Clarke DL. Understanding the burden and outcome of trauma care drives a new trauma systems model. World J Surg. 2014;38: 1699\u0026ndash;1706.\u003c/li\u003e\n\u003cli\u003eShibahashi K, Kato T, Hikone M, Sugiyama K. The edemiological state of blunt diaphragmatic injury: An analysis of a nationwide trauma registry in Japan. Injury. 2023;54: 110790.\u003c/li\u003e\n\u003cli\u003eKatayama Y, Tanaka K, Ishida K, Hirose T, Tachino J, Nakao S, et al. Factors associated with traumatic diaphragmatic rupture among patients with chest or abdominal injury: A nationwide study from Japan. J Clin Med Res. 2022;11: 4462.\u003c/li\u003e\n\u003cli\u003eHogarty J, Jassal K, Ravintharan N, Adhami M, Yeung M, Clements W, et al. Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes. Emerg Med Australas. 2023;35: 842\u0026ndash;848.\u003c/li\u003e\n\u003cli\u003eMahamid A, Peleg K, Givon A, Alfici R, Olsha O, Israeli Trauma Group, et al. Blunt traumatic diaphragmatic injury: A diagnostic enigma with potential surgical pitfalls. Am J Emerg Med. 2017;35: 214\u0026ndash;217.\u003c/li\u003e\n\u003cli\u003eLim KH, Park J. Blunt traumatic diaphragmatic rupture: Single-center experience with 38 patients. Medicine . 2018;97: e12849.\u003c/li\u003e\n\u003cli\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370: 1453\u0026ndash;1457.\u003c/li\u003e\n\u003cli\u003eAhn S, Kim DJ, Paik KY, Chung JH, Park W-C, Kim W, et al. A comparison of self-inflicted stab wounds versus assault-induced stab wounds. Trauma Mon. 2016;21: e25304.\u003c/li\u003e\n\u003cli\u003eBarbois S, Abba J, Guigard S, Quesada JL, Pirvu A, Waroquet PA, et al. Management of penetrating abdominal and thoraco-abdominal wounds: A retrospective study of 186 patients. J Visc Surg. 2016;153: 69\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003eMatsumoto S, Hayashida K, Furugori S, Shimizu M, Sekine K, Kitano M. Impact of self-inflicted injury on nontherapeutic laparotomy in patients with abdominal stab wounds. Injury. 2018;49: 1706\u0026ndash;1711.\u003c/li\u003e\n\u003cli\u003eLewis JD, Starnes SL, Pandalai PK, Huffman LC, Bulcao CF, Pritts TA, et al. Traumatic diaphragmatic injury: experience from a level I trauma center. Surgery. 2009;146: 578\u0026ndash;83; discussion 583-4.\u003c/li\u003e\n\u003cli\u003eWhittaker G, Norton J, Densley J, Bew D. Epidemiology of penetrating injuries in the United Kingdom: A systematic review. Int J Surg. 2017;41: 65\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eHanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85: 1044\u0026ndash;1048.\u003c/li\u003e\n\u003cli\u003eD\u0026rsquo;Souza N, Clarke D, Laing G. Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service. Ann R Coll Surg Engl. 2017;99: 394\u0026ndash;401.\u003c/li\u003e\n\u003cli\u003eShinjo T, Tanaka Y, Izawa Y, Yonekawa C, Matsumura T, Mato T. The need to suspect tension gastrothorax as a cause of obstructive shock in trauma care: A case report. Int J Surg Case Rep. 2024;118: 109612.\u003c/li\u003e\n\u003cli\u003eBunya N, Sawamoto K, Uemura S, Toyohara T, Mori Y, Kyan R, et al. How to manage tension gastrothorax: a case report of tension gastrothorax with multiple trauma due to traumatic diaphragmatic rupture. Int J Emerg Med. 2017;10: 4.\u003c/li\u003e\n\u003cli\u003eParamasivam SJ, Purushothaman S, Al Bshabshe A, Eltaher Osman MJ, Alwadai NM, Sulaiman N, et al. An unusual presentation of acute diaphragmatic hernia complicated by tension gastrothorax an under-recognized cause of cardiac arrest due to a fall from a height: A case report and literature review. SAGE Open Med Case Rep. 2022;10: 2050313X221140241.\u003c/li\u003e\n\u003cli\u003eSchurr LA, Thiedemann C, Alt V, Schlitt HJ, G\u0026ouml;tz M, Riedl M, et al. Diaphragmatic Injuries among Severely Injured Patients (ISS \u0026ge; 16)-An Indicator of Injury Pattern and Severity of Abdominal Trauma. Medicina . 2022;58. doi:10.3390/medicina58111596\u003c/li\u003e\n\u003cli\u003eDirican A, Yilmaz M, Unal B, Piskin T, Ersan V, Yilmaz S. Acute traumatic diaphragmatic ruptures: A retrospective study of 48 cases. Surg Today. 2011;41: 1352\u0026ndash;1356.\u003c/li\u003e\n\u003cli\u003eOkada M, Adachi H, Kamesaki M, Mikami M, Ookura Y, Yamakawa J, et al. Traumatic diaphragmatic injury: experience from a tertiary emergency medical center. Gen Thorac Cardiovasc Surg. 2012;60: 649\u0026ndash;654.\u003c/li\u003e\n\u003cli\u003eWilliams M, Carlin AM, Tyburski JG, Blocksom JM, Harvey EH, Steffes CP, et al. Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries. Am Surg. 2004;70: 157\u0026ndash;62; discussion 162-3.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"traumatic diaphragmatic injury (TDI), penetrating TDI (PTDI), blunt TDI (BTDI), Japan Trauma Data Bank (JTDB), associated injury, severe concomitant injury, independent predictor of mortality, epidemiology","lastPublishedDoi":"10.21203/rs.3.rs-5296552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5296552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTraumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. Our purposes were to describe the characteristics of TDI patients, to compare penetrating TDI with blunt TDI, and to identify risk factors for mortality in Japan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating TDI and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression analysis was performed to identify risk factors for mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1147 patients (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Blunt TDI represented 70% and penetrating TDI 30%. In penetrating TDI, the most common cause was self-inflicted (49%), and compared to blunt TDI, males were 69% of patients (vs. 66%; P\u0026thinsp;=\u0026thinsp;0.50) and the mortality rate was 8.3% (vs. 26%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01\u0026ndash;1.04), Injury Severity Score (OR 1.03, 95%CI 1.006\u0026ndash;1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45\u0026ndash;0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32\u0026ndash;4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24\u0026ndash;9.17), computed tomography (CT) (OR 0.32, 95%CI 0.15\u0026ndash;0.69), and diaphragm repair (OR 0.44, 95%CI 0.25\u0026ndash;0.78) were independent predictors of mortality.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma.\u003c/p\u003e","manuscriptTitle":"Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-11 07:09:36","doi":"10.21203/rs.3.rs-5296552/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-17T03:09:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-14T10:00:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94050101929877156920347739542075521712","date":"2024-11-14T09:19:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80887369786517339779524240109354048974","date":"2024-11-13T06:29:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-07T03:08:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179251835683317291249325707937751100876","date":"2024-11-03T19:33:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230820076481296260874487799810735062607","date":"2024-10-30T18:47:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262067643446310641331471167902251841829","date":"2024-10-29T16:29:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-29T13:23:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-25T11:55:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-25T11:53:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2024-10-20T03:02:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8128ab5-2e0f-4c13-a6e2-ca3e4b205dc0","owner":[],"postedDate":"November 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:10:15+00:00","versionOfRecord":{"articleIdentity":"rs-5296552","link":"https://doi.org/10.1186/s12245-025-00826-2","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2025-02-11 15:58:00","publishedOnDateReadable":"February 11th, 2025"},"versionCreatedAt":"2024-11-11 07:09:36","video":"","vorDoi":"10.1186/s12245-025-00826-2","vorDoiUrl":"https://doi.org/10.1186/s12245-025-00826-2","workflowStages":[]},"version":"v1","identity":"rs-5296552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5296552","identity":"rs-5296552","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}