Thorax and Abdomen Evaluation

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Thorax and Abdomen Evaluation
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Evaluation format

• Fortunately, thoracic and abdominal injuries are
  less common than extremity injuries. However,
  these injuries can be life-threatening.
• These injuries demand immediate evaluation

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• When thoracic injury is suspected, begin your
  evaluation with the
• Primary Survey
• What is the primary survey?

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• Airway
• Breathing
• Circulation
• Once primary survey is completed and you
  determine the athletes condition is NOT
  life-threatening, perform a secondary survey

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Secondary SurveyHistory

• Mechanism of injury
• Onset of symptoms
• Location of injury
• Quantity and quality of pain
• Type and location of any abnormal sensations
• Progression of sign and symptoms
• Activities that make the symptom better or worse
• Nausea

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• Weakness
• Dyspnea ( shortness of breath)

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Physical Exam

• Some sign and symptoms that may vary are
• Respiratory rate
• Moistness, color and temperature of skin
• Pulse

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Vital Signs

• Abnormal nerve response
• Blood pressure
• Movement
• Pulse
• Pupils
• Respiration
• Skin color
• State of consciousness
• Temperature

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After vitals

• The physical exam progresses to
• Inspection
• Auscultation (listening for sounds)
• Percussion (tapping)
• Palpation and special test

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During the inspection observe the following

• LOC
• Skin color
• The athletes positions, movements and signs of
  guarding or apprehension
• Respiratory rate and rhythm for dyspnea
  (shortness of breath)
• Symmetry of chest appearance and chest movements

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• Signs of trauma such as..
• Hemoptysis (coughing up blood)
• Hematemesis (vomiting up blood)
• Ecchymosis (escaping of blood into tissue)
• Signs of respiratory distress such as cyanosis
  (pale or bluish skin color of the lips,
  fingertips, or fingernails from poor oxygenation
  of the blood)

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• Pupil equality and responsiveness
• Evidence of penetrating trauma
• Vomiting
• Next, Auscultation is the process of listening
  for sounds produced in the thoracic and abdominal
  cavities.

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Auscultation

• A stethoscope is usually used and auscultation is
  normally conducted by medical professionals with
  extensive training and experience in this complex
  skill.
• Normal vs abnormal chest sounds
• Breathing equality
• Depth of breaths

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• After completing auscultation, trained medical
  professionals usually perform percussion.
• Involves tapping on various part of the body and
  noting the sound produced.

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Palpation and special test

• Palpation determines
• General and specific areas of tenderness
• Location of deformities
• Location and extent of swelling
• Air crepitus
• Bony crepitus
• Asymmetry
• Muscle rigidity
• Abnormal tenderness

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Special test help

• Evaluate active ROM
• Provide resistance to movement in the different
  plane to elicit painful ranges, limitations and
  musculoskeletal weakness
• Evaluate pain and dysfunction associated with
  inspiration and expiration

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• Apply passive stress on the rib cage and sternum
  to check for fractures/separation

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• When evaluating ROM, your assessment is divided
  into active, passive, and resistive motions and
  may be approached from three cardinal planes of
  motion, the Sagittal Plane, the Transverse Plane,
  and the Frontal Plane.

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• Visually note any apprehension, limited range of
  motion, and painful arcs within the plane.

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Sagittal Plane range of motion

• Assesses ROM limitations and associated findings
  in the sagittal plane.
• Patient stands and slowly flexes the trunk to the
  point where the hands touch the toes or the
  floor. Ask the patient to slowly return from full
  trunk flexion to trunk extension

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Transverse Plane range of motion

• Assesses rom limitations associated findings in
  the transverse plane.
• To evaluate transverse plane, the athlete stands
  and slowly rotates the trunk to the right as far
  as possible

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Frontal Plane range of motion

• Assesses rom limitations and associted findings
  in the frontal plane.
• The athlete should stand and slowly, laterally
  flex the trunk to the right as far as possible.

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Inspiration and expiration tests

• Assess inspiratory and expiratory function and
  elicit signs and symptoms of thoracic injury.

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• Have the athlete breathe in as much as possible
  and hold for a few seconds. Then, ask the
  athlete to breathe out slowly and fully in an
  attempt to expire all air form the lungs.
• Instruct the patient to hold the maximally
  expired for a few seconds

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• During these breathing activities, observe any
  patient apprehension or limitations in the
  inspiratory movement as well as any display of
  associated pain.
• Question the patient regarding location and
  nature of any symptoms elicited by these
  procedures
• Some specific signs or sympptoms..

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• Inability to fully inspire
• Pain during breathing
• Guarding or apprehension with respirations
• Next, in assessing thoracic injuries, fractures
  and separation may occur in the bones and costal
  cartilage

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• If there is a complete separation or fracture,
  crepitus, grating, and popping sensations may be
  present with active and passive chest movement.
• Two test are performed to determine if rib cage
  and sternum fractures or separation exist

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2 test

• Anterior/posterior chest compression test and the
  lateral chest compression test.
• Anterior/posterior chest compressions assesses
  lateral rib cage bony integrity.
• Instruct the athlete to either sit or stand.

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• You should place the palmar surface of one hand
  anteriorly on the wall at the level of the
  affected area. Place your other hand at the
  corresponding level posteriorly. Compress the rib
  cage by pushing your hands toward each other.
  This inward pressure anteriorly and posteriorly
  will cause the rib cage to bow outward laterally
  which will elicit pain and bony crepitis if the
  injury to the lateral rib cage is a fracture.

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Lateral chest compression test

• Assesses anterior or posterior rib cage
  integrity.
• Place palmer surface of your hands laterally on
  the athletes chest wall sides at the affected
  area.
• Compress the rib cage by pushing your hands
  together.
• This inward pressure from both

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• Sides will cause the rib cage to bow outward
  anteriorly and posteriorly.

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Thorax Anatomy and Common Injuries

• Lets look at some anatomical components of the
  thorax.
• Acute traumatic injuries to the thorax may
  involve the heart, lungs, and rib cage.

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Heart

• Located in the center of the thoracic cavity and
  positioned slightly to the left. One of the most
  common conditions is a
• Myocardial infarction is ischemia (decrease in
  oxygenated blood flow) to cardiac tissue which
  may result in a disturbance of normal heart
  function characterized by arrhythmia.

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Signs and symptoms?

• As an allied health professional you should be
  aware of other conditions involving the heart
  including cardiac contusions and pericardial
  tamponade (compression of the heart)

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Cardiac contusions

• Result from a direct blow to the anterior chest
  wall.
• Blunt trauma to the anterior chest wall may cause
  Pericardial Tamponade, bleeding accumulates
  inside the pericardial sac and will gradually
  increase, causing external pressure on the heart.

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The Auscultation Assistant - Hear Heart Murmurs,
Heart Sounds, and Breath Sounds
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Lungs

• Pheumothorax occurs either spontaneously or
  traumatically from blunt or sharp trauma to the
  chest wall. It is characterized by air
  accumulation in the pleural space.

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• Traumatic/Tension
• Hemothorax

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Rib fractures

• Non-displaced
• Displaced
• Injuries usually involve the 5th to 9th ribs
• Tremendous forces are necessary to fracture the
  1st and 2nd rib.
• Fracture of 7th 12th ribs may be associated
  with liver, spleen, or kidney injuries

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Rib fractures and contusions
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Signs and symptoms

• Pain at fracture site
• Dyspnea (shortness of breath)
• Localized tenderness
• Bony or air crepitation
• Contusion
• eccymosis

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Sternum fracture

• Pain directly over sternum
• Pain aggravated by deep inspiration
• Possible associated myocardial contusion

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Flail chest

• A flail chest is often life-threatening injury
  which results when several ribs are fractured

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Signs and symptoms

• Point tenderness
• Possible ecchymosis
• Pain with excessive movement
• Pain with deep inspiration/expiration
• Lack of crepitus
• Negative compression test

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Muscular strains

• Point tenderness to direct palpation
• Pain with contractile movements of involved
  muscle
• Pain with passive stretching of involved muscle
• Pain with passive stretching of involved muscle
• Weakness in movements controlled by involved
  muscle

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• Deformity of muscle on the chest
• Ecchymosis
• Negative compression test

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others

• Muscle tears
• Respiratory conditions
• Asthma-an inflammatory respiratory condition
  characterized by bronchospams (wheezing) and
  shortness of breath (dyspnea) may be excersied
  induced

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• Bronchitis-inflammation of the bronchial tubes.
• Hemoptysis-expectoration of blood arising from
  the lungs
• Hyperventilation-increase in respiratory rate
  usually associated with anxiety which causes a
  change in acid/base balance of blood

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• Influenza-a viral illness characterized as an
  acute onset of fatigue, muscle ache, headache,
  and fever.
• Pleuritic chest wall pain- inflammation of the
  serous membrane lining, which lies between the
  lungs and chest wall, causing pain with
  inspiration and expiration or cough

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• Pneumonia-inflammation of the lungs caused by
  bacteria, viruses, chemical irritants, vegetable
  dusts, and allergy

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Circulatory

• Tachycardia-abnormal rapidity of heart action and
  usually defined in adults as a heart rate over
  100 bpm
• Bradycardia-abnormal slowness of heart action and
  usually defined in adults as a heart rate under
  60 bpm
• Arrhythmia- abnormal heart rhythm characterized
  by skipping of bear or an irregular pulse

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Immediate referral

• Difficulty in breathing
• Shortness of breath-inability to catch breath
• Severe pain increasing in chest
• Vomiting or coughing up blood
• Diminished chest movement on the affected side
• Shifting or moving of trachea with each breath

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• Suspected rib fracture of costochondral
  separation
• Signs of shock
• Doubt regarding the nature and severity of the
  chest injury

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Abdomen anatomy and common injuries

• 4 quadrants right upper, left upper, right lower
  and left lower.
• RUQ/LUQ
• RLQ/LLQ

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Right upper quadrant

• Liver, gallbladder, right kidney and adrenal
  gland, pylorus of the stomach, head of the
  pancreas, portion of the colon and small intestine

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Left upper quadrant

• Stomach, spleen, left kidney and adrenal gland,
  portion of the pancreas, portion of the colon,
  and small intestine

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Right lower quadrant

• Appendix, portion of the small and large
  intestine, portion of the colon, and structures
  of the urinary and reproductive systems.
• Mcburneys point
• Rovsing sign

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Left lower quadrant

• A portion of the small and large intestine,
  portion of the urinary and reproductive system.

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Hollow organs

• Stomach
• Gall bladder
• Urinary bladder
• Intestine
• vessels

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Solid organs

• Spleen
• Liver
• Kidneys
• Abdominal muscles

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Stomach

• J-shaped and found directly underneath the
  diaphragm in the LUQ
• Small intestines is principally located in the
  left and right lower quadrant.
• Large intestine is an inverted U

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Signs and symptoms of hollow organs injuries

• Decreased bowel sounds
• Tender abdomen
• Hard or rigid abdomen
• Guarding
• Distended abdomen
• Signs and symptoms of shock

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Spleen

• Largest lymphatic organ in the LUQ, directly
  below the diaphragm and behind the 9th, 10th and
  11th ribs.
• Regulates RBC and destroys old and defective
  blood cells and produces white blood cells

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Signs and symptoms

• Rebound tenderness
• Rigidity
• Guarding
• Abdominal pain in left upper quad
• Left shoulder or neck pain (Kehrs Sign)
• Shock
• Possible rib fracture

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Liver

• RUQ- manufactured of plasma proteins, storage of
  blood cells, breakdown of toxic substance,
  glucose and fat metabolism, mineral and vitamin
  storage, and bile production

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Signs and symptoms

• Rebound tenderness
• Rigidity
• Guarding
• Abdominal pain in RUQ
• Right shoulder or neck pain

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Kidneys

• RUQ, LUQ bean shaped organs
• Help control blood volume, also removes waste
  from the blood in the form of urine

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Signs and symptoms

• Rebound tenderness
• Rigidity
• Guarding
• Hematuria (blood in urine)
• Bloody discharge or inability to void
• Flank or back pain
• Positive Grey-Turner sign-ecchymosis in flank
• No acute abdominal signs

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Hernia

• Protrusion of abdominal viscera through portion
  of the abdominal wall
• Inguinal
• Umbilical
• Hiatal

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Hiatus Hernia
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Inguinal Hernia
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Umbilical Hernia
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• 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?

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• 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?

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• 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 athletes wind was knocked out, is normal
  breathing returning? How rapidly?
• Body position

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• 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?
• Monitor vital signs (pulse, respiration, BP)
• Rapid weak pulse or drop in BP is an indication
  of a serious internal injury (involves blood
  loss)

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• Sudden Death Syndrome in Athletes
• Cause of Condition
• Hypertrophic cardiomyopathy- thickening of
  cardiac muscle w/ no increase in chamber size
• Anomalous origin of coronary arteries
• Marfans 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 of Condition
• 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

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• Care
• Immediate medical attention is necessary life
  threatening condition
• 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 Marfans
  syndrome
• Cardiac screening - electrocardiograms and
  echocardiograms may be needed to determine
  existing pathology

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• Blow to Solar Plexus
• Cause of Injury
• Transitory paralysis of the diaphragm due to blow
  to the middle portion of the abdomen
• Signs of Injury
• Stops respiration and leads to anoxia
• Generally transitory
• Care
• Must help athlete overcome apprehension
• Use short inspirations and long expirations
• Calm athlete, prevent hyperventilation, blow into
  a paper bag
• ATC should question possibility of internal injury

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• Stitch in the Side
• Cause of Injury
• Idiopathic condition with obscure cause and
  several hypotheses
• 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 of Injury
• 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

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• Injury of the Spleen
• Cause of Injury
• Result of a direct blow
• Infectious mononucleosis (causing an enlarged
  spleen)
• Signs of Injury
• Indications of a ruptured spleen involve history
  of a direct blow, signs of shock, abdominal
  rigidity, nausea, vomiting
• Kehrs sign
• Ability to splint self may produce delayed
  hemorrhaging - easily disrupted resulting in
  internal bleeding

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• Care
• 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
• In cases of mononucleosis athlete may resume
  training in 3 weeks if spleen not enlarged and if
  there is no fever

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• Kidney Contusion
• Cause of Injury
• Result of an external force (force and angle
  dependent)
• Susceptible to injury due to normal distention of
  blood
• Signs of Injury
• 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)
• Care
• 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

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• Liver Contusion
• Cause of Injury
• Blunt trauma - right side of rib cage
• More susceptible if enlarged due to illness
  (hepatitis)
• Signs of Injury
• 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
• Care
• Referral to a physician for diagnosis and
  treatment

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• Appendicitis
• Cause of Injury
• 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
• Signs of Injury
• Mild to severe pain in lower abdomen, associated
  with nausea, vomiting and low grade fever
• Pain may localize in lower right abdomen
  (McBurneys point)
• Care
• Surgical intervention is often necessary
  (particularly if it is resulting in an obstructed
  bowel life threatening)

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• Injuries to the Bladder
• Cause of Injury
• Blunt force to the lower abdomen may cause injury
  to urinary bladder if distended with urine
• Hematuria is often associated with contusion of
  bladder during running (runners bladder)
• Signs of Injury
• Pain, discomfort of lower abdominal region,
  abdominal rigidity, nausea, vomiting, shock,
  bleeding from the urethra, increased quantity of
  bloody urine
• Athlete should be instructed to monitor urine
• Inability to urinate will present in case of
  ruptured bladder

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• Scrotal/Testicular Contusion
• Cause of Injury
• Result of blunt trauma and contusion to the
  vulnerable and sensitive scrotum
• Signs and Symptoms
• Hemorrhaging, fluid effusion, muscle spasm,
  severe pain (disabling)
• May cause nauseating, disabling and painful
  condition
• Care
• Place athlete on side with knees to chest
• Apply cold pack as pain subsides
• If pain persist after 15-20 minutes referral will
  be necessary

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• Breast Injuries
• Cause of Injury
• Constant uncontrolled movement (particularly in
  large breasted women)
• Stretching of Coopers ligament
• Runners and cyclists 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
  runners nipple
• Wearing a windbreaker can prevent cyclist nipple