tachycardia, or dyspnea A CXR may show a pneumothorax, pneumomediastinum, subcutaneous emphysema in the neck, a left pleural effusion, or an air–fluid level in the mediastinum Perforation of the intraabdominal esophagus may cause retrosternal, epigastric, or shoulder pain Patients with suspected esophageal perforation should be adequately volume resuscitated and receive antibiotics covering gram-positive, gram-negative, and anaerobic organisms The diagnosis of an esophageal perforation can be made by either an esophagram, esophagoscopy, or both In one study, flexible esophagoscopy had a sensitivity of 100% and specificity of 96% Depending on the expertise at each institution and the stability of the patient, these studies may be paired to lessen the chance of a misdiagnosis Once the diagnosis is made, if the leak is large and not contained, prompt surgical correction is mandatory Smaller, contained leaks may be successfully managed nonoperatively If the diagnosis is made within 24 hours, mortality rate is approximately 5% Delayed diagnosis for more than 24 hours after injury is associated with a mortality rate of 70% DIAPHRAGMATIC INJURIES A crushing abdominal force will produce a sudden increase in intrathoracic and intra-abdominal pressure against the fixed diaphragm A diaphragmatic injury should also be suspected in any thoracic or upper abdominal penetrating injury The level of the diaphragm fluctuates greatly with respirations, and injuries of the diaphragm have been reported with penetrating wounds as high as the third rib and as low as the 12th rib Blunt traumatic diaphragmatic rupture is more commonly left sided (80%) because the left diaphragm is relatively unprotected compared to the right, though right and bilateral diaphragmatic injuries have been reported ( Fig 115.11 ) Right-sided diaphragmatic injuries are associated with increased mortality rate as these patients usually have a greater physiologic insult and associated injuries