Thorax and Abdomen

1. Thorax and Abdomen Chapter 9

2. Evaluation of Thorax and Abdomen • Injuries are less common than extremity Injuries • Can be Life Threatening • These Injuries demand immediate evaluation and subsequent activation of the emergency medical system

3. Evaluation of Thorax and Abdomen • Evaluation of the thorax and abdomen must follow a precise assessment process: • Primary Survey • Secondary Survey • This helps the examiner distinguish between acute trauma and non-traumatic conditions

4. Primary Survey • First Survey the scene • Looking for indication of injury • Approach in a calm reassuring manner • If the athlete is conscious this enhances relaxation and maintenance of the respiratory and circulatory systems • Be prepared to clear and maintain airway • Potential obstructions such as blood, vomitus, and foreign matter

5. Primary Survey • Once Cervical Spine injury is not suspected assist the patient in finding the most comfortable position for breathing. • Be prepared to give Artificial Ventilation or Cardiopulmonary Resuscitation and activate EMS.

6. Secondary Survey • Once the primary survey is completed • Injury not life threatening • Consist of two elements: • History – The part of the evaluation in which the examiner questions the athlete to determine:

7. Secondary Survey - History • Mechanism of Injury • Onset of Symptoms • Location of Injury • Quantity and Quality of Pain • Type and location of any abnormal sensations • Progression of signs and symptoms • Nausea - The Feeling of Sickness • Weakness • Dyspnea – Difficulty breathing

8. Secondary Survey • The physical examination is the next step • Can vary from athlete to athlete • But stay within normal limits • Physical activity can add to variance • Variances Include: • Respiratory Rate • Moistness • Color • Temperature of Skin • Pulse Rate

9. Secondary Survey – Vital Signs These are Essential to Monitor During Evaluation • Abnormal Nerve Response • Blood Pressure • Movement • Pulse • Respiration • Skin Color • State of Consciousness • Temperature

10. Secondary SurveyFollowing Vital Signs • Inspection • Auscultation – The process of listening to the sounds of the chest and abdomen • Determines: Normal vs. Abnormal breathing Chest Sounds Breathing Equality Depth of Breaths • Percussion – Tapping (Listening for sounds such as tympany, dullness, or hyperresonance) • Palpation – the use of the hands to examine a body part • Special Test

11. Secondary SurveyInspection Stage • Level of Consciousness • Skin Color • The Athlete’s positions, movements and signs of guarding or apprehension • Respiratory rate and rhythm for dyspnea (shortness of breath) • Symmetry of chest appearance and chest movements

12. Secondary SurveySigns of Trauma Hemoptysis – coughing up blood Hematemesis – vomiting up blood Ecchymosis – escaping of blood into tissue

13. Secondary SurveySigns of Trauma • Signs of Respiratory Distress • Cyanosis – pale bluish skin color of the lips, finger tips, or fingernails, from poor oxygenation of the blood • Flail Chest • Tracheal Deviation • Jugular Vein Distension (JVD) • Pupil equality and responsiveness • Evidence of penetrating trauma • Vomiting Bat

14. Secondary SurveySigns of Trauma – Abdominal Cavity • When examining the abdomen, each quadrant should be auscultated, percussed, and palpated

15. Secondary SurveySigns of Trauma – Abdominal Cavity • Abdominal palpation determines signs and symptoms of an acute abdomen • Symptoms Include: • Leakage of blood • Puss • Bowl contents into abdominal cavity causing peritoneal irritation • Signs of an Acute Abdomen: • Rebound Tenderness • Rigidity • Guarding

16. Secondary SurveySigns of Trauma – Abdominal Cavity Rebound Tenderness – is identified by the examiner pressing deeply into the abdominal cavity and then quick • If it is painful peritoneal irritation may be present • Rigidity of the abdominal wall muscles occurs when peritoneal irritation causes reflex spasm of the abdominal muscles • Producing a board like-harness • Prevents the examiner from palpating the abdomen

17. Secondary SurveySigns of Trauma – Abdominal Cavity Valsalva Maneuver • Used to provoke an increase in pain or mass protrusion if significant intra-abdominal trauma has occurred • To perform the Valsalva Maneuver: • the athlete takes a deep breath • hold their breath • strain as if a bowel movement • Pain could indicate protrusion through the abdominal wall

18. Secondary SurveySigns of Trauma – Abdominal Cavity Evaluating Range of Motion • The assessment is divided into active, passive, and resistive motions • Motions are assessed in the three anatomical planes: • Sagittal Plane • Frontal Plane • Transverse Plane

19. Secondary SurveySigns of Trauma – Abdominal Cavity Anatomical Plane Motions • Visually Note: • Apprehension • Limited Range of Motion • Painful Arcs

20. Secondary SurveySigns of Trauma – Abdominal Cavity The Sagittal Plane • To evaluate: • The athlete stands and slowly flexes the truck to the point where the hands touch the toes or the floor. • Then the athlete is to return from flexion to standing upright and progress to trunk expression

21. Secondary SurveySigns of Trauma – Abdominal Cavity The Frontal Plane • To evaluate: • The athlete stands and slowly flexes the trunk laterally to the Right as far as possible • Slowly returns to neutral • Repeat the motion to the left

22. Secondary SurveySigns of Trauma – Abdominal Cavity The Transverse Plane • To evaluate: • The athlete stands and slowly rotates the trunk to the Right as far as possible • The Position is held • Repeat the motion to the left

23. Secondary SurveySigns of Trauma – Thoracic Cavity • Inspiration and expiration test inspiratory and expiratory function and elicit signs and symptoms of thoracic injury.

24. Secondary SurveySigns of Trauma – Thoracic Cavity • Evaluate inspiration and expiration by having athlete breathe in as much as possible and hold for a few seconds. • Ask the athlete to breath out slowly and fully to expire all air from the lungs • Instruct the athlete to breathe to hold that maximally expired position for a few seconds. • During activity observe the athlete for apprehension or limitations in the inspiratory movement as well as pain

25. Secondary SurveySigns of Trauma – Thoracic Cavity • Specific Signs and symptoms: • Inability to fully inspire • Pain during breathing • Guarding or apprehension with respirations

26. Secondary SurveySigns of Trauma – Thoracic Cavity Fractures and Separations • May occur in bones and costal cartilages of the rib cage. • Complete separation or fracture, crepitius, grating, and popping sensations may be present with active and passive chest movements • In some cases passive stress can be applied to elicit further signs or symptoms

27. Secondary SurveySigns of Trauma – Thoracic Cavity Rib Cage Fracture/Separation Test Two Test Should be Performed: • Anterior/Posterior chest compression test • Test Lateral Ribs • Lateral chest compression test • Test posterior anterior chest • These test will help determine the extent of the injury. • Contusion vs. Fracture

28. Thorax & Abdomen Anatomy • Sternum • Ribs 12 • Lumbar Vertabrae • Sacral Vertabrae • Coccyx

29. Muscles & Functions Pectoralis Major – Pulls rib cage up; adducts arms; rotates arms medially; prime mover for arm flexion Pectoralis Minor – Draws scapula forward and downward; draws rib cage superiorly

30. Muscles & Functions Latissimus Dorsi – extends the upper arm, adducts upper arm posteriorly.

31. Muscles & Functions External Intercostals – Lifts the rib cage Rectus Abdominis – Flexes and rotates lumbar region

32. Muscles & Functions Internal Abdominis Oblique – aids rectus abdominis; aids the back muscles in truck flexion and lateral flexion. External Abdominis Oblique - aids rectus abdominis; aids the back muscles in truck rotation and lateral flexion

33. Muscles & Functions Transverse Abdominis – Compresses abdominal contents

34. Internal Organs

35. Abdominal Quadrants Right Upper (Superior) Quadrant • Liver and Adrenal Gland • Gallbladder Pylorus of the Stomach Left Upper (Superior) Quadrant • Stomach • Spleen and Adrenal Gland • Portion of the Pancreas • Portions of the Colon and Small Intestine • Posterior - Left Kidney

36. Abdominal Quadrants Right Lower (Inferior) Quadrant • Appendix • Portions of the Large and Small Intestines • Portion of the Colon • Structures of the Urinary and Reproductive systems Left Lower (Inferior) Quadrant • Portions of the Large and Small Intestines • Portion of the Colon • Structures of the Urinary and Reproductive systems

37. Hollow Organs Stomach Urinary Bladder Large an small Intestines Vessels

38. Solid Organs Kidneys Pancreas Liver

39. Assessment Test Test for Bony Integrity Palpation: Physical Inspection Compression: Inward force applied to thorax and ribs through inspiration and manual pressure Distraction: Outward force applied to thorax and ribs through expiration

40. Assessment Test Compression Test: Thorax/Ribs • Anterior/Posterior and Lateral: • compression force applied to thorax and ribs through manual pressure Compression Test: Pelvis • Anterior/Posterior and Medial / Lateral: • compression force applied to pelvis through manual pressure

41. Assessment Test Breathing • Inspiration: Action of taking a breath (inhalation) • Expiration: Action of releasing a breath (exhaling)

42. Assessment Test Signs of Acute Abdomen • Rebound Tenderness – Pain in the abdomen upon the release of pressure from the abdomen • Rigidity – Upon palpation, abdomen is rigid or hard and not fully palpable • Guarding – Patient contract muscles while palpation so that the palpation does not hurt

43. Assessment Test Test to Detect Possible Peritoneal Irritation (intra-abdominal Pressure) • Iliopsoas Test – Moving leg into hip flexion, which causes abdomen pain

44. Assessment Test - Possible Peritoneal Irritation • Obturator Test – With hip and knee in 90° flexion, internal and external rotation of hip will cause abdomen pain.

45. Assessment Test - Possible Peritoneal Irritation • Heel Pound Test – With hip and knee in full extension, tap heel to increase pain in the abdomen • Valsalva Maneuver – Athlete takes a deep breath, hold their breath, and strain as if having a bowel movement.

46. Immediate Referral • Difficulty Breathing • Shortness of breath • Severe increasing pain in chest • Vomiting or coughing blood • Diminished chest movement on the affected side • Shifting or moving of trachea with each breath • Suspected rib fracture • Signs of acute abdominal pain • Rebound tenderness • Rigidity • Guarding • Blood in urine or stool • Prolonged discomfort, sensation of weakness, or pulling in groin • Superficial protrusion or palpable mass • Circulation or neurological impairment

47. Immediate Referral – cont. • Increasing Nausea • Vomiting • Presence of Fever • Presence of radiating or referred pain • Signs of shock • Doubt regarding the nature and severity of the thorax or abdomen injury

48. Common Injuries and Problems: Thorax • Acute traumatic injuries occurring to the thorax may involve the heart, lungs, and rib cage. Myocardial Infarction – is ischemia to cardiac tissue, which may result in a disturbance of normal heart function characterized by arrhythmia • Ischemia – decrease in oxygenated blood flow • Arrhythmia – irregular heart beat

49. Signs and Symptoms of Myocardial Infarction • Persistent chest pain or pressure unrelieved by rest, position changes or medication • Breathing difficulty: noisier, shorter, faster than normal • Cyanosis • Moist face or profuse sweating • Radiation of pain to the left side (neck, shoulder, arm) • Levine’s Sign (clenched fist over the chest) • Hypotension or shock

50. Common Injuries and Problems: Thorax Pericardial Tamponade – Compression of the heart • Caused by blunt trauma to the anterior chest wall • Bleeding accumulates inside the pericardial sac and will gradually increase • Causes external pressure on the heart • Preventing proper contraction