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. Palpation 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. Auscultation Abdomen Heart Sounds
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 Bowel 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 Signs and Symptoms Management
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 Signs and Symptoms Management
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 Signs and Symptoms Management
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 Management
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 - Tension Pneumothorax Hemothorax
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. Management 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 Signs and Symptoms Management
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 Signs and Symptoms Management
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 Signs and Symptoms Management
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 Signs and Symptoms Management Unknown cause
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. Urinary Tract Infections
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 Signs and Symptoms Management
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 Signs and Symptoms
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 Management
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)

51. Food Poisoning (Gastroenteritis)
Etiology
Ranges from mild to severe
Caused by infectious microorganisms that contaminate food particularly during warm weather and periods of improper refrigeration
Signs and Symptoms
Nausea, vomiting, cramps, diarrhea and anorexia
Usually subsides within 3-6 hours (staph. infection)
Salmonella infection may last hours or more
Management
Rapid replacement of fluids lost
Bed rest in all but mild cases
Nothing should be given by mouth if vomiting and nausea persist
Re-introduce easy food first

52. Peptic Ulcer Etiology Signs and Symptoms Management
Acids destroy mucous lining of stomach or small intestine
Occurs in individuals with long periods of severe anxiety
Signs and Symptoms
Gnawing pain, localized to gastric region
Appears 1-3 hours following a meal
Dyspepsia, heartburn, nausea, vomiting, w/ pain lasting minutes rather than hours
Management
Antacids if pain persists
If hemorrhaging or perforation occurs, surgery may be required

53. Gastroesophageal Reflux
Etiology
Reflux or backward flow of the acidic gastric contents into the esophagus (malfunctioning esophageal sphincter)
Result of a hiatal hernia w/ incidence increased with activity
Repeated bouts can result in inflammation of lower esophagus
Signs and Symptoms
Heartburn-like retrosternal pain - similar to angina pectoris sensation
Burning feeling with sour liquid taste in throat
Management
Medication first, surgery if condition persists

54. Diarrhea Etiology Signs and Symptoms
Abnormal, loose stool or passage of fluid, unformed stool
Acute or chronic
Caused by a problem in diet, inflammation of the intestinal lining, GI infection, ingestion of certain drugs and psychogenic factors
Signs and Symptoms
Abdominal cramps, nausea, vomiting and frequent elimination of stools
Loss of appetite, and a light brown or gray, foul-smelling stool
Extreme weakness caused by dehydration

55. Diarrhea (continued) Management
Determine cause (irritant, infection, or emotional upset)
ATC can treat less severe cases by omitting certain foods from athlete’s diet
Have athlete consume bland food that does not irritate system
Provide pectins 2-3 times daily to absorb excess fluid

56. Constipation Etiology Signs and Symptoms Management
Failure of the bowels to evacuate feces
Causes include, lack of abdominal tone, insufficient moisture in the feces, lack of roughage and bulk in diet to stimulate peristalsis, poor bowel habits, nervousness, anxiety, and overuse of laxatives and enemas
Signs and Symptoms
Feeling of fullness, with occasional cramping and pain in lower abdomen
If straining occurs during defecation, blood vessels may be ruptured
Management
Regulate eating patterns (cereal, fruits, vegetables)
Deal with psychological aspects
Avoid medications unless prescribed by a physician

57. Irritable Bowel Syndrome
Etiology
Group of gastrointestinal tract disorders
Signs and Symptoms
Abdominal pain that is relieved with defecation, irregular pattern of defecation (at least 25% of the time), alterations in stool frequency, form, and passage, abdominal bloating and distension
Management
Refer to physician for long-term management
Diet modification and antidiarrheal medications may be helpful initially as well as psychological counseling
Long term prognosis -- good

58. Appendicitis Etiology Signs and Symptoms Management
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 and Symptoms
Mild to severe pain in lower abdomen, associated with nausea, vomiting and low grade fever
Pain may localize in lower right abdomen (McBurney’s point)
Management
Surgical intervention is often necessary (particularly if it is resulting in an obstructed bowel = life threatening)

59. Hemorrhoids (Piles) Etiology Signs and Symptoms Management
Varicosities of the hemorrhoidal venous plexus of the anus
Constant straining or constipation may result in stretching of anal vessels, protrusion and bleeding, or a thrombus forming in the external vessels
Signs and Symptoms
Painful nodular swellings near the anal sphincter
May cause slight bleeding and itching
Management
Use of proper bowel habits, ingestion of mineral oil daily to assist in lubricating a dry stool, application of suppository and anesthetic (for pain and itching)
Surgery may be required if these measures fail

60. Scrotal Contusion Etiology Signs and Symptoms --Management
Result of blunt trauma and contusion to the vulnerable and sensitive scrotum
Signs and Symptoms
Hemorrhaging, fluid effusion, muscle spasm, severe pain (disabling)
--Management
Reduction of testicular spasm
Application of cold pack
Unresolved pain after minutes requires referral to a physician

61. Spermatic Cord Torsion
Etiology
Result of testicle revolving in the scrotum following a direct blow or as the result of coughing or vomiting
Signs and Symptoms
Acute testicular pain, nausea, vomiting and inflammation in the area
Management
Immediate medical care is required to prevent irreparable complications

62. Traumatic Hydrocele of the Tunica Vaginalis
Etiology
Fluid accumulation caused by a severe blow to the testicular region (venous plexus on the posterior aspect of the testicle becomes engorged)
Rupture of the plexus results in rapid accumulation of blood in the scrotum (hematocele)
Signs and Symptoms
Pain and significant swelling in the scrotum
Management
Cold pack application and referral to a physician

63. Vaginitis Etiology Signs and Symptoms Management
Inflammation of the vagina can be caused by a variety of microorganisms, bacterial infections, chemicals from douching, irritation from a tampon or poor hygiene habits
Signs and Symptoms
Purulent and bloody vaginal discharge; strong odor with vaginal itching
Frequent and painful urination
Vagina is red and painful to the touch
Management
Vaginitis caused by an STD will require appropriate antibiotic or antifungal medication
Instruction on proper bladder and bowel hygiene as well as sexual behavior may also be necessary

64. Contusion of the Female Genitalia
Etiology
Low incidence of injury in sports
Most common occurrence involve contusion of external genitalia (vulva - including the labia, clitoris and the vaginal vestibule)
Signs and Symptoms
Hematoma results from contusion - may also involve pubic symphysis resulting in osteitis pubis

65. Injury of the Spleen Etiology Signs and Symptoms Management
Result of a direct blow, infectious mononucleosis (causing an enlarged spleen)
Signs and Symptoms
Indications of a ruptured spleen involve history of a direct blow, signs of shock, abdominal rigidity, nausea, vomiting
Kehr’s sign
Management
Ability to splint self may produce delayed hemorrhaging - easily disrupted resulting in internal bleeding
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

66. Abdominal Muscle Strain
Etiology
Result of sudden twisting or reaching of trunk, tearing abdominal musculature
Signs and Symptoms
Severe pain and hematoma formation
Generally involves rectus abdominus
Management
Ice and compression with conservative treatment
Exercise within pain free limits

67. Contusions of Abdominal Wall
Etiology
Caused by a compressive force - generally occurring in collision sports
Extent of injury depends on whether force is blunt or penetrating
Signs and Symptoms
May cause a hematoma to develop under fascia of surrounding muscle tissue
Swelling may cause pain and tightness w/in the region
Management
Cold pack and compression
Be sure to check for signs of internal injuries

68. Hernia Etiology Signs and Symptoms Management
Protrusion of abdominal viscera through portion of abdominal wall (congenital or acquired)
Inguinal vs. femoral hernias
Complications and strangulated hernias
Signs and Symptoms
Acquired hernia occur when natural weakness is further aggravated by a direct blow or strain
History of direct blow to groin area, pain and prolonged discomfort, superficial protrusion with pain increasing with coughing & reported pulling sensation in groin area
Management
Surgery is preferred by most physicians
Mechanical devices are not suitable for athletics due to friction and irritation they produce

69. Blow to Solar Plexus Etiology Signs and Symptoms Management
Transitory paralysis of the diaphragm
Signs and Symptoms
Stops respiration and leads to anoxia
Generally transitory
Management
Must help athlete overcome apprehension
Use short inspirations and long expirations
Calm athlete, prevent hyperventilation
ATC should question possibility of internal injury

70. Stitch in the Side Etiology Signs and Symptoms Management
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 and Symptoms
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