Chapter 9 Thorax and Abdomen

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

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

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

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.

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:

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

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

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

Secondary Survey Following 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

Secondary Survey Inspection 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

Secondary Survey Signs of Trauma Hemoptysis – coughing up blood Hematemesis – vomiting up blood Ecchymosis – escaping of blood into tissue

Secondary Survey Signs 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

Secondary Survey Signs of Trauma – Abdominal Cavity When examining the abdomen, each quadrant should be auscultated, percussed, and palpated

Secondary Survey Signs 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

Secondary Survey Signs 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

Secondary Survey Signs 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

Secondary Survey Signs 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

Secondary Survey Signs of Trauma – Abdominal Cavity Anatomical Plane Motions Visually Note: Apprehension Limited Range of Motion Painful Arcs

Secondary Survey Signs 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

Secondary Survey Signs 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

Secondary Survey Signs 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

Secondary Survey Signs of Trauma – Thoracic Cavity Inspiration and expiration test inspiratory and expiratory function and elicit signs and symptoms of thoracic injury.

Secondary Survey Signs 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

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

Secondary Survey Signs 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

Secondary Survey Signs 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

Thorax & Abdomen Anatomy Sternum Ribs 12 Lumbar Vertabrae Sacral Vertabrae Coccyx

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

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

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

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

Muscles & Functions Transverse Abdominis – Compresses abdominal contents

Internal Organs

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

Right Lower (Inferior) Quadrant 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

Hollow Organs Stomach Urinary Bladder Large an small Intestines Vessels

Solid Organs Kidneys Pancreas Liver

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

Compression Test: Thorax/Ribs Anterior/Posterior and Lateral: 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

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

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

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

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

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.

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

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

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

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

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

Common Injuries and Problems: Thorax Cardiac Contusion – results from a direct blow to the anterior chest wall in the heart region May cause Pericardial Tamponade

Common Injuries and Problems: Thorax Lungs Located in the thorasic cavity Protected by the rib cage Pneumothorax – characterized by air accumulation in the pleural space Occurs either spontaneously or traumatically from a blunt or sharp trauma to the chest wall Air escapes from the lung upon each inspiration, collects in the pleural space and leads to collapse of lung

Common Injuries and Problems: Thorax Thoracic related boney and joint injuries can occur to the rib cage structure. The rib cage outlines the thoracic borders and provides protection to the heart, lungs, great vessels (aorta and vena cava), liver, and spleen The ability to expand and relax is essential in assisting the lungs’ reparatory function

Common Injuries and Problems: Thorax Rib Fractures Nondisplaced fractures are usually benign Most common rib fracture Displaced fractures may result in lacerations to the lung and associated intercostal vessels. Usually involve the 5th to 9th ribs 1st and 2nd are not common because the tremendous force required Fractures in ribs 7 – 12 may be associated with liver, spleen, or kidney injuries

Common Injuries and Problems: Thorax Signs and Symptoms of Rib Fractures Pain at fracture site aggravated by coughing, breathing, movement, and compression test Dyspnea (shortness of breath) Localized tenderness Bony or air crepitation Contusion Ecchymosis (escaping of blood into tissue)

Respiratory Conditions: Thoracic Cavity Asthma – an inflammatory condition characterized by bronchospasm, resulting in wheezing, and shortness of breath (dyspnea) Asthma can be exercise induced Bronchitis – Inflammation of the bronchial tubes Usually characterized by a progressive cough. Hemoptysis – expectoration of blood arising from lungs Patient coughs up blood

Respiratory Conditions: Thoracic Cavity Hyperventilation – increase in respiratory rate usually associated with anxiety, which causes a change in the acid-base balance of the blood. Symptoms include: Dyspnea Numbness Tingling in the hands, fingers, and around the mouth

Respiratory Conditions: Thoracic Cavity Influenza – a viral illness characterized as an acute, rapid onset of fever, muscle ache, headache, and fatigue; usually one to two weeks Pleuritis Chest Wall Pain – Inflammation of serous membrane lining, which lies between the lung and the chest wall Causes pain with inspiration and expiration or cough

Respiratory Conditions: Thoracic Cavity Pneumonia – inflammation of the lungs caused primarily by bacteria, viruses, chemical irritants, vegetable dust, and allergy Symptoms: Fever Cough Chest pain

Common Injuries & Problems: Abdomen When examining the abdomen, each quadrant should be auscultated, percussed, and palpated. The most important function of palpation is to determine signs and symptoms of acute abdomen, which are rebound: Tenderness Rigidity Guarding

Common Injuries & Problems: Abdomen The spleen is the largest lymphatic organ and it is located in the upper left quadrant. Directly below the diaphragm Behind 9th, 10th, 11th ribs Reservoir of red blood cells Regulates the number of red blood cells in circulation Destroys old or defective red blood cells and produces white blood cells

Common Injuries & Problems: Abdomen Signs and Symptoms of Spleen Injury Acute abdominal pain(rebound tenderness, rigidity, guarding) Abdominal pain in the upper left quadrant Pain radiating to the left shoulder and one third of the way down the arm or neck pain (Kehr’s Sign) Shock Possible left, lower rib fracture

Common Injuries & Problems: Abdomen

Common Injuries & Problems: Abdomen Liver Upper Right Quadrant Small portion on the Left Upper Quadrant Solid organ Functions: Manufacturing plasma proteins Manufacturing and storage of blood cells Removal of old or defective red blood cells Breakdown of toxic substance Glucose and fat metabolism Mineral and vitamin storage Bile production

Common Injuries & Problems: Abdomen Signs & Symptoms of Acute Liver Injury Acute or gradual onset of abdominal pain Palpable tenderness Rebound tenderness Rigidity Guarding Abdominal pain in the right upper quadrant Right shoulder or neck pain Possible right, lower rib fracture

Common Injuries & Problems: Abdomen Kidneys Kidneys are paired solid, bean-shaped organs located in both the right and left upper quadrants near the spine. Kidney’s function to help control blood volume Remove waste from the blood

Common Injuries & Problems: Abdomen Kidneys Acute or gradual onset of abdominal pain, palpable tenderness, rebound tenderness, rigidity, guarding. Hematuria (passing of blood in urine) Bloody discharge or inability to void Flank or low back pain Positive Grey-Turner sign – ecchymosis in flank Possible bony crepitus due to rib fracture

Non-Traumatic Injuries/Conditions: Abdomen Appendicitis – Inflammation of the appendix. Generally affect the young and more common in males Characterized by low grade fever, signs of acute abdominal pain (lower right quadrant) Nausea / Vomiting

Non-Traumatic Injuries/Conditions: Abdomen Indigestion (heartburn) – Incomplete or imperfect digestion, usually accompanied by one or more of the following symptoms: pain, nausea, vomiting Stitch in the Side – Sharp pain in the side usually associated with strenuous physical activity, caused by muscle spasms and/or trapped gas

Musculoskeletal Conditions/Disorders Arrhythmia -  is a problem with the rate or rhythm of the heartbeat. The heart can beat too fast, too slow, or with an irregular rhythm. Bradycardia – Arrhythmia with a slow heart beat Flail Chest -  occurs when a segment of the thoracic wall becomes unattached from the rest of the chest wall. 

Musculoskeletal Conditions/Disorders Hemopneumothorax - The presence of air or gas and blood in the thoracic cavity. Hemothorax -  a collection of blood in the space between the chest wall and the lung (the pleural cavity). Spontaneous Pneumothorax collapsed lung, or pneumothorax, the collection of air in the space around the lungs. This buildup of air puts pressure on the lung, so it cannot expand as much as it normally does when you take a breath

Musculoskeletal Conditions/Disorders Tachycardia - A heart rate of more than 100 beats per minute (BPM) in adults Dysmenorrhea - defined as difficult menstrual flow or painful menstruation. Ectopic Pregnancy - an abnormal pregnancy that occurs outside the womb (uterus). The baby (fetus) cannot survive, and often does not develop at all in this type of pregnancy

Musculoskeletal Conditions/Disorders Gastroenteritis - a condition that causes irritation and inflammation of the stomach and intestines Hernia - a sac formed by the lining of the abdominal cavity (peritoneum). The sac comes through a hole or weak area in the fascia, the strong layer of the abdominal wall that surrounds the muscle.

Musculoskeletal Conditions/Disorders Muscular Strains - when the muscle is stretched too far.

Rehabilitation Before sending an athlete back to competition, the following rehabilitation guidelines must met: Full Range of Motion Strength, power, and endurance are proportional to the athletes size and sport No pain during running, jumping, or cutting

Rehabilitation Program Range of Motion Exercises Torso Flexion Extension Lateral Flexion Rotation Anatomical Plane Movement Sagittal Frontal Transverse

Rehabilitation Program Range of Motion Exercises Thorax and Abdomen Exercise Abdominal Crunches Abdominal Lift Abdominal Sit – ups Arm Extensions Arm Flexion Bench Press Incline Press Pelvic Tilts Prone Extensions Prone Push -up