Download Thorax and Abdomen

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:
1. Primary Survey
2. 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:
1. History – The part of the evaluation in which
the examiner questions the athlete to
determine:
Secondary Survey - History
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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:
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Respiratory Rate
Moistness
Color
Temperature of Skin
Pulse Rate
Secondary Survey – Vital Signs
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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
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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
Bat
Flail Chest
Tracheal Deviation
Jugular Vein Distension (JVD)
Pupil equality and responsiveness
Evidence of penetrating trauma
Vomiting
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:
1. Anterior/Posterior chest compression test
– Test Lateral Ribs
2. Lateral chest compression test
– Test posterior anterior chest
• These test will help determine the extent of the
injury.
– Contusion vs. Fracture
Thorax & Abdomen Anatomy
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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;
aids the back muscles
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
Abdominal Quadrants
Right Lower (Inferior) Quadrant
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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
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
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
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.
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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
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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
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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:
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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
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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
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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
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Abdominal Crunches
Abdominal Lift
Abdominal Sit – ups
Arm Extensions
Arm Flexion
Bench Press
Incline Press
Pelvic Tilts
Prone Extensions
Prone Push -up