Chapter 26: The Thorax and Abdomen

1. Chapter 26: The Thorax and Abdomen

11. Assessment of the Thorax Abdomen • Injuries to this region can produce life-threatening 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

12. History • 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?

13. 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?

14. 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

15. 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

16. 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

17. 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

20. The Auscultation Assistant.mht

21. 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

22. Percussion • Place fingers on abdomen and strike with other hand • Solid organ = dull sound • Hollow organ = tympanic or resonant sound

25. 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

26. 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

27. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. Management/Prevention • Counseling and screening are critical in early identification and prevention of sudden death • Screening questions should address the following • 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

39. 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 if an • Surgery may be required if hemorrhaging continues • 2 weeks of rest and close surveillance following initial return to activity is necessary

40. 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)

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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 to palpation • Chronic cases may result in jaundice, diarrhea and mild to moderate pain that radiates into the back

48. 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

49. 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

50. 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)