Transcript Chapter 26: The Thorax and Abdomen

Chapter 27: The Thorax and
Abdomen
Assessment of the Thorax
Abdomen
• Injuries to this region can produce lifethreatening situations
• ATC’s evaluation should focus on signs
and symptoms that indicate potentially
life-threatening conditions
• Continually monitor breathing,
circulation and any indication of internal
bleeding or shock
• History
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What happened to cause this injury?
Was there direct contact or a direct blow?
What position were you in?
What type of pain, was it immediate or
gradual, location(s)?
Difficulty breathing?
What positions are most comfortable?
Do you feel faint, light-headed or
nauseous?
Chest pain?
– Hear or feel snap, crack or pop in your
chest?
– Muscle spasms?
– Blood or pain during urination?
– Was the bladder full or empty?
– How long has it been since you last ate?
– Is there a personal or family history of any
heart, abdominal problems or other
diseases involving the abdomen and
thorax?
• Observations
– Is the athlete breathing? Are they having
difficulty breathing? Does breathing cause
pain?
– Is the athlete holding the chest wall?
– Is there symmetry of the chest during
breathing?
– If the athlete’s wind was knocked out, is
normal breathing returning? How rapidly?
– Body position
• Thorax injury - leaning towards side that is injured
and splinting area w/ hand
• Abdominal injury - lie on side w/ knees pulled to
chest
• Male external genitalia injury - lying on side
holding scrotum
– Check for areas of discoloration, swelling
or deformities
• Around umbilicus = intra-abdominal bleed
• Flanks = swelling outside the abdomen
– Protrusion or swelling in any portion of
abdomen (internal bleeding)
– Does the thorax appear to be symmetrical?
– Are the abdominal muscles tight and
guarding?
– Is the athlete holding or splinting a
particular part?
– Blood
• Bright red = lung injury
• Vomiting bright red and frothy = injury to
esophagus and stomach although blood may
be swallowed from mouth and nose
– Cyanosis - respiratory difficulty
– Pale, cool, clammy skin indicates low BP
– Monitor vital signs (pulse, respiration, BP)
• Rapid weak pulse or drop in BP is an indication
of a serious internal injury (involves blood loss)
• Palpation
– Thorax
• Check for symmetry of chest wall movement
and search for areas of tenderness
• Palpate along ribs and intercostal spaces as
well as costochondral junctions
• AP pressure to rib cage to assess for fracture
• Transverse pressure assesses costochondral
junction
• Semi-reclining position is useful if athlete is
having difficulty breathing
– Abdomen
• Patient should have arms at side, knees and
hips flexed to relax abdomen
• Four abdominopelvic quadrants (move
clockwise starting from upper right quadrant)
• Feel for guarding and tenderness, rigidity
(internal bleeding)
• Rebound tenderness
• Assess each organ (if possible)
• Auscultation
– Heart Sounds
• “Lubbdupp” (may hear 3rd sound in children)
• Listen for murmur (abnormal period due to
valve insufficiency)
– Functional murmur versus pathogenic condition
– Breath sounds
• Should be consistent
• Abnormal patterns
– Cheyne-Stokes breathing (rate changes over 1-3
minutes)
– Biot’s breathing - normal rate followed by cessation
– Apneustic breathing - pauses in respiratory cycle at
full inspiration
– Wheeze or rhonchi or rales
• Perform over apex, centrally and at base of
each lung, both anteriorly and posteriorly
– Bowel sounds
• Liquid-like gurgling due to peristalsis
• Diminished = paralytic ilieus or peritonitis
• High pitched sounds = intestinal obstruction
• Percussion
– Place fingers on abdomen and strike with
other hand
– Solid organ = dull sound
– Hollow organ = tympanic or resonant
sound
Recognition and Management
of Specific Injuries
• Rib Contusion
– Etiology
• Blow to the rib cage can bruise ribs,
musculature or result in fracture
– Signs and Symptoms
• Painful breathing (particularly if muscles are
involved)
• Point tenderness; pain with rib compression
– Management
• RICE and NSAID’s
• Rest and decrease in activity
• Rib Fractures
– Etiology
• Caused by a direct blow or the result of a
violent muscular contraction
• Can be caused by violent coughing and
sneezing
– Signs and Symptoms
• History is critically important
• Pain with inspiration, point tenderness and
possible deformity with palpation
– Management
• Refer for X-rays
• Support and rest; brace
• Costochondral Separation
– Etiology
• Result of a direct blow to the anterolateral
aspect of the rib cage
– Signs and Symptoms
• Localized pain in region of costochondral
junctions
• Pain with movement; difficulty with breathing
• Point tenderness and possible deformity
– Management
• Rest and immobilization
• Healing may take 1-2 months
• Sternum Fractures
– Etiology
• Result of high impact blow to the chest
• May also cause contusion to underlying cardiac
muscle
– Signs and Symptoms
• Point tenderness over the sternum
• Pain with deep inspiration and forceful expiration
• Signs of shock, or weak rapid pulse may indicate
more severe injuries
– Management
• X-ray and monitor athlete for signs of trauma to
the heart
• Muscle Injuries
– Etiology
• Muscles are subject to contusions and strains
• Occur most often from direct blows or sudden
torsion of the trunk
– Signs and Symptoms
• Pain occurs on active motions; pain with
inspiration and expiration, coughing, sneezing
and laughing
– Management
• Immediate pressure and application of cold for
approximately one hour
• After hemorrhaging is controlled, immobilize the
injury to make the athlete comfortable
• Breast Injury
– Etiology
• Constant uncontrolled movement (particularly
in large breasted women)
• Stretching of Cooper’s ligament
• Runner’s and cyclist’s nipple
– Management
• Females should wear well-designed bra that
has minimum elasticity and allows for little
movement
• Special plastic cup-type brassieres may be
required in sports with high levels of physical
contact
• Use of an adhesive bandage can be used to
prevent runner’s nipple
• Wearing a windbreaker can prevent cyclist
nipple
• Breast Cancer
– Should be of great concern to all women
– Most common cause of cancer in females
– Females over 20 years old should perform
breast self-examinations every month and
receive a clinical evaluation every 3 years
– Not all lumps are cancer -- may be benign
fibrous cyst
– Mammograms are not recommended until
age 40
• Lung Injuries
– Etiology
• Pneumothorax
– pleural cavity becomes filled with air, negatively
pressurizing the cavity, causing a lung to collapse
– Will produce pain, difficulty with breathing and anoxia
• Tension Pneumothorax
– Pleural sac on one side fills with air displacing lung
and heart, compressing the opposite lung
– May cause shortness of breath, chest pain, absence
of breath sounds, cyanosis, distention of neck veins,
deviated trachea
• Hemothorax
– Blood in pleural cavity causes tearing or puncturing
of the lungs or pleural tissue
– Painful breathing, dypsnea, coughing up frothy blood
and signs of shock
• Traumatic Asphyxia
– Result of a violent blow or compression of rib cage
– Causes cessation of breathing
– Signs include purple discoloration of the trunk and
head, conjunctivas of the eye
– Condition requires immediate mouth to mouth
resuscitation
– Management
• Each of these conditions are medical
emergencies and require immediate attention
• Transport athlete to hospital immediately
• Hyperventilation
– Etiology
• Rapid rate of ventilation due to anxiety induced
stress or asthma
• Develop a decreased amount of carbon dioxide
relative to oxygen
– Signs and Symptoms
• Athlete has difficulty getting air in and seems to
struggle with breathing
• Panic state with gasping and wheezing
– Management
• Decrease rate of carbon dioxide loss
• Slow respiration rate and alter respiration
techniques
• Breath into a bag
• Normal respiration should return within
1-2 minutes, initial cause must be determined
• Heart Contusion
– Etiology
• Result of compression between sternum and
spine
• Most severe consequence would involve an
aortic rupture
– Signs and Symptoms
• Severe shock and heart pain
• Heart may exhibit arrhythmias causing a
decrease in cardiac output, followed by death if
medical attention is not administered
– Management
• Immediate referral to an emergency room
• Prepare to administer CPR and treat for shock
• Sudden Death Syndrome in Athletes
– Etiology
• Hypertrophic cardiomyopathy- thickening of
cardiac muscle w/ no increase in chamber size
• Anomalous origin of coronary arteries
• Marfan’s syndrome- abnormality in connective
tissue results in weakening of aorta and cardiac
vessels
• Series of additional cardiac causes
• Non-cardiac causes include drugs and alcohol,
intracranial bleeding, obstructive respiratory
disease
– Signs and Symptoms
• Most do not exhibit any signs prior to death
• May exhibit chest pain, heart palpitations,
syncope, nausea, profuse sweating, shortness
of breath, malaise and/or fever
– Management/Prevention
• Counseling and screening are critical in early
identification and prevention of sudden death
• Screening questions should address the
following
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History of heart murmurs
Chest pain during activity
Periods of fainting during exercise
Family history
Thickening of heart or history of Marfan’s syndrome
• Cardiac screening - electrocardiograms and
echocardiograms
• Commotio Cordis
– Etiology
• Syndrome resulting in cardiac arrest due to
traumatic blunt impact to chest
– Unfortunate timing relative to re-polarization phase of
cardiac cycle
• Young athletes are at risk
– Signs and Symptoms
• Ventricular fibrillation
– Management
• Resuscitation of victim is seldom successful
• Early defibrillation with AED and resuscitation is
critical
Injuries and Conditions of the
Abdomen
• Kidney Contusion
– Etiology
• Result of an external force (force and angle
dependent)
• Susceptible to injury due to normal distention of
blood
– Signs and Symptoms
• May display signs of shock, nausea, vomiting,
rigidity of back muscles and hematuria (blood in
urine)
• Referred pain (costovertebral angle posteriorly
radiating forward around the trunk)
– Management
• Monitor status of urine (hematuria) - refer if
necessary
• 24 hour hospitalization and observation with a
gradual increase in fluid intake
• Surgery may be required if hemorrhaging
continues
• 2 weeks of rest and close surveillance following
initial return to activity is necessary
• Kidney Stones
– Etiology
• Unknown cause
– Signs and Symptoms
• Calculus - stone composed of crystalline
mineral salts that forms in urinary tract
• Painful condition
– Management
• Usually passes through the urethra and is
excreted (very painfully)
• Contusion of Ureters, Bladder and
Urethra
– Etiology
• Blunt force to the lower abdomen may avulse
ureter or contuse/rupture bladder
• Hematuria is often associated with contusion of
bladder during running (runner’s bladder)
• Injury to the urethra (more common in males)
may produce severe perineal pain and swelling
– Signs and Symptoms
• Pain, discomfort of lower abdominal region,
abdominal rigidity, nausea, vomiting, shock,
bleeding from the urethra, increased quantity of
bloody urine,
• Inability to urinate will present in case of
ruptured bladder
• Contusion of Ureters, Bladder and
Urethra
– Signs and Symptoms (continued)
• Referred pain to low back and trunk as well as
upper thigh region anteriorly and suprapubically
– Prevention
• Check periodically for blood in urine
• Empty bladder prior to practice or competition
• Wear protective equipment
• Cystitis
• Inflammation of the bladder associated with a
urinary tract infection
• May involve kidney, prostate, and urethra
• Causes frequent, painful urination, chills and
fever
• Antibiotics are required for treatment
• Urinary Tract Infections
• Caused by staphylococcus bacteria or
chlamydia
• Causes burning and painful urination and
requires antibiotics for treatment
• Can be prevented through increased fluid
intake, practicing sanitary bowel and bladder
habits, washing genitals before intercourse,
emptying the bladder after intercourse, removal
of contraceptive diaphragms and sponges
following intercourse
• Urethritis
• Inflammation of the urethra -- generally caused
by gonorrhea or by other nongonococcal
organisms
• Symptoms include pain on urination along with
urethral discharge
• Treated with antibiotic therapy
Conditions of the Digestive
System
• Gastrointestinal Bleeding
– Etiology
• Distance running, gastritis, iron-deficiency
anemia, ingestion of aspirin or NSAID’s, stress,
bowel irritation, colitis
– Signs and symptoms
• Blood in stool
• Abdominal pain, watery stool (w/pus)
dehydration, intermittent fever (if colitis is
involved)
– Management
• Refer to physician is bleeding is occurring
• Liver Contusion
– Etiology
• Blunt trauma - right side of rib cage
• More susceptible if enlarged due to illness
(hepatitis)
– Signs and Symptoms
• Hemorrhaging and shock may present
• May require immediate surgery
• Presents with referred pain in right scapula,
shoulder and substernal area and occasionally in
left anterior side of chest
– Management
• Referral to a physician for diagnosis and
treatment
• Pancreatitis
– Etiology
• Inflammation of pancreas (acute or chronic) due
to obstruction of pancreatic duct
• Acute conditions may lead to necrosis,
suppuration, gangrene and hemorrhage
• Chronic cases may develop scar tissue, causing
malfunction -- may develop due to chronic
alcoholism
– Signs and Symptoms
• Acute epigastric pain causing vomiting, belching,
constipation and potentially shock
• Tenderness and rigidity during palpation
• Chronic cases may result in jaundice, diarrhea
and mild to moderate pain that radiates into the
back
• Pancreatitis (continued)
– Management
• In acute cases, re-hydration is necessary along
with pain reduction, treatment of shock,
reduction of pancreatic activity through
medication
• Surgery if the duct is blocked
• Chronic cases require large doses of
analgesics, pancreatic enzymes and modified
diet
• Indigestion (Dyspepsia)
– Etiology
• Some athletes develop food idiosyncrasies
which cause them distress after eating
• Reactions before competition
• Emotional stress, esophageal and stomach
spasms, or inflammation of mucous linings in
stomach and esophagus
– Signs and Symptoms
• Increased HCl secretion, nausea, and
flatulence
– Management
• Elimination of irritating foods, development of
regular eating habits, avoidance of anxieties
that cause gastric distress
• If problems persist or athlete appears high
strung and nervous -- follow-up with a physician
is needed
• Vomiting
– Etiology
• Result of some irritation, most often in the
stomach
• Stimulates vomiting center of the brain, causing
a series of forceful diaphragm and abdominal
contractions to compress stomach
– Management
• Antinausea medications should be
administered
• Fluids to prevent dehydration (by mouth or
intravenously depending on the situation)
• Food Poisoning (Gastroenteritis)
– Etiology
• Ranges from mild to severe
• Caused by infectious microorganisms that
contaminate food particularly during warm
weather and periods of improper refrigeration
– Signs and Symptoms
• Nausea, vomiting, cramps, diarrhea and
anorexia
• Usually subsides within 3-6 hours (staph.
infection)
• Salmonella infection may last 24-48 hours or
more
• Food Poisoning (Gastroenteritis)
– Management
• Rapid replacement of fluids lost
• Bed rest in all but mild cases
• Nothing should be given by mouth if vomiting
and nausea persist
• Re-introduce easy food first
• Peptic Ulcer
– Etiology
• Acids destroy mucous lining of stomach or
small intestine
• Occurs in individuals with long periods of
severe anxiety
– Signs and Symptoms
• Gnawing pain, localized to gastric region
• Appears 1-3 hours following a meal
• Dyspepsia, heartburn, nausea, vomiting, w/
pain lasting minutes rather than hours
– Management
• Antacids if pain persists
• If hemorrhaging or perforation occurs, surgery
may be required
• Gastroesophageal Reflux
– Etiology
• Reflux or backward flow of the acidic gastric
contents into the esophagus (malfunctioning
esophageal sphincter)
• Result of a hiatal hernia w/ incidence increased
with activity
• Repeated bouts can result in inflammation of
lower esophagus (esophagitis)
– Signs and Symptoms
• Heartburn-like retrosternal pain - similar to
angina pectoris sensation
• Burning feeling with sour liquid taste in throat
– Management
• Medication first, surgery if condition persists
• Diarrhea
– Etiology
• Abnormal, loose stool or passage of fluid,
unformed stool
• Acute or chronic
• Caused by a problem in diet, inflammation of
the intestinal lining, GI infection, ingestion of
certain drugs and psychogenic factors
– Signs and Symptoms
• Abdominal cramps, nausea, vomiting and
frequent elimination of stools
• Loss of appetite, and a light brown or gray, foulsmelling stool
• Extreme weakness caused by dehydration
• Diarrhea (continued)
– Management
• Determine cause (irritant, infection, or
emotional upset)
• ATC can treat less severe cases by omitting
certain foods from athlete’s diet
• Have athlete consume bland food that does not
irritate system
• Provide pectins 2-3 times daily to absorb
excess fluid
• Constipation
– Etiology
• Failure of the bowels to evacuate feces
• Causes include, lack of abdominal tone,
insufficient moisture in the feces, lack of
roughage and bulk in diet to stimulate
peristalsis, poor bowel habits, nervousness,
anxiety, and overuse of laxatives and enemas
– Signs and Symptoms
• Feeling of fullness, with occasional cramping
and pain in lower abdomen
• If straining occurs during defecation, blood
vessels may be ruptured
– Management
• Regulate eating patterns (cereal, fruits,
vegetables)
• Deal with psychological aspects
• Avoid medications unless prescribed by a
physician
• Irritable Bowel Syndrome
– Etiology
• Group of gastrointestinal tract disorders
– Signs and Symptoms
• Abdominal pain that is relieved with defecation,
irregular pattern of defecation (at least 25% of
the time), alterations in stool frequency, form,
and passage, abdominal bloating and
distension
– Management
• Refer to physician for long-term management
• Diet modification and antidiarrheal medications
may be helpful initially as well as psychological
counseling
• Long term prognosis -- good
• Appendicitis
– Etiology
• Inflammation of the vermiform appendix (chronic
or acute)
• Result of blockage, lymph swelling, or carcinoid
tumor
• Early stages it presents as a gastric complaint,
that gradually develops from red swollen vessel
to a gangrenous structure that can rupture into
bowels causing peritonitis
• Appendicitis
– Signs and Symptoms
• Mild to severe pain in lower abdomen,
associated with nausea, vomiting and low
grade fever
• Pain may localize in lower right abdomen
(McBurney’s point)
– Management
• Surgical intervention is often necessary
(particularly if it is resulting in an obstructed
bowel = life threatening)
• Hemorrhoids (Piles)
– Etiology
• Varicosities of the hemorrhoidal venous plexus
of the anus
• Constant straining or constipation may result in
stretching of anal vessels, protrusion and
bleeding, or a thrombus forming in the external
vessels
– Signs and Symptoms
• Painful nodular swellings near the anal
sphincter
• May cause slight bleeding and itching
• Hemorrhoids (Piles)
– Management
• Use of proper bowel habits, ingestion of mineral
oil daily to assist in lubricating a dry stool,
application of suppository and anesthetic (for
pain and itching)
• Surgery may be required if these measures fail
Injuries and Conditions
Related to Reproductive
Organs
• Scrotal Contusion
– Etiology
• Result of blunt trauma and contusion to the
vulnerable and sensitive scrotum
– Signs and Symptoms
• Hemorrhaging, fluid effusion, muscle spasm,
severe pain (disabling)
– Management
• Reduction of testicular spasm
– With athlete seated , lift and drop athlete a few
inches
– Have athlete bounce while in kneeling position
– Athlete brings knees to chest and performs Valsalva
maneuver
• Application of cold pack
• Unresolved pain after 15-20 minutes requires
referral to a physician
• Spermatic Cord Torsion
– Etiology
• Result of testicle revolving in the scrotum
following a direct blow or as the result of coughing
or vomiting
– Signs and Symptoms
• Acute testicular pain, nausea, vomiting and
inflammation in the area
– Management
• Immediate medical care is required to prevent
irreparable complications
• Traumatic Hydrocele of the Tunica
Vaginalis
– Etiology
• Fluid accumulation caused by a severe blow to
the testicular region (venous plexus on the
posterior aspect of the testicle becomes
engorged)
• Rupture of the plexus results in rapid
accumulation of blood in the scrotum
(hematocele)
– Signs and Symptoms
• Pain and significant swelling in the scrotum
– Management
• Cold pack application and referral to a
physician
• Vaginitis
– Etiology
• Inflammation of the vagina can be caused by a
variety of microorganisms, bacterial infections,
chemicals from douching, irritation from a
tampon or poor hygiene habits
– Signs and Symptoms
• Purulent and bloody vaginal discharge; strong
odor with vaginal itching
• Frequent and painful urination
• Vagina is red and painful to the touch
– Management
• Vaginitis caused by an STD will require
appropriate antibiotic or antifungal medication
• Instruction on proper bladder and bowel
hygiene as well as sexual behavior may also be
necessary
• Contusion of the Female Genitalia
– Etiology
• Low incidence of injury in sports
• Most common occurrence involve contusion of
external genitalia (vulva - including the labia,
clitoris and the vaginal vestibule)
– Signs and Symptoms
• Hematoma results from contusion - may also
involve pubic symphysis resulting in osteitis
pubis
Injury to Lymphatic Organs
and Abdominal Wall
• Injury of the Spleen
– Etiology
• Result of a direct blow or infectious
mononucleosis (causing an enlarged spleen)
– Signs and Symptoms
• Indications of a ruptured spleen involve history
of a direct blow, signs of shock, abdominal
rigidity, nausea, vomiting
• Kehr’s sign
– Management
• Ability to splint self may produce delayed
hemorrhaging - easily disrupted resulting in
internal bleeding
• Conservative treatment involves 1 wk of
hospitalization and a gradual return to activity
• Surgery will result in three months of recovery
while removal of spleen will result in a 6 month
removal from activity
• Abdominal Muscle Strain
– Etiology
• Result of sudden twisting or reaching of trunk,
tearing abdominal musculature
– Signs and Symptoms
• Severe pain and hematoma formation
• Generally involves rectus abdominus
– Management
• Ice and compression with conservative
treatment
• Exercise within pain free limits
• Contusions of Abdominal Wall
– Etiology
• Caused by a compressive force - generally
occurring in collision sports
• Extent of injury depends on whether force is blunt
or penetrating
– Signs and Symptoms
• May cause a hematoma to develop under fascia
of surrounding muscle tissue
• Swelling may cause pain and tightness w/in the
region
– Management
• Cold pack and compression
• Be sure to check for signs of internal injuries
• Hernia
– Etiology
• Protrusion of abdominal viscera through portion
of abdominal wall (congenital or acquired)
• Inguinal vs. femoral hernias
• Complications and strangulated hernias
– Signs and Symptoms
• Acquired hernia occur when natural weakness
is further aggravated by a direct blow or strain
– History of direct blow to groin area, pain and
prolonged discomfort, superficial protrusion with pain
increasing with coughing & reported pulling
sensation in groin area
– Management
• Surgery is preferred by most physicians
• Mechanical devices are not suitable for
athletics due to friction and irritation they
produce
• Blow to Solar Plexus
– Etiology
• Transitory paralysis of the diaphragm due to
direct blow to stomach
– Signs and Symptoms
• Stops respiration and leads to anoxia
• Generally transitory
– Management
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Must help athlete overcome apprehension
Use short inspirations and long expirations
Calm athlete, prevent hyperventilation
ATC should question possibility of internal
injury
• Stitch in the Side
– Etiology
• Idiopathic condition with obscure cause and
several hypotheses
• Potential causes include constipation, intestinal
gas, overeating, diaphragmatic spasm, poor
conditioning, lack of visceral support and weak
abdominals, distended spleen, breathing
techniques resulting in lack of oxygen, ischemia
of diaphragm or intercostal muscles
– Signs and Symptoms
• Cramp-like pain that develops on either the
right or left costal angle during hard physical
activity
– Management
• Relaxation of the spasm
– Stretch arm on affected side as high as possible
– Flex trunk forward on the thighs
• Additional problems may warrant further study