Chapter 26: The Thorax and Abdomen

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

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?

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?

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

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

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

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

The Auscultation Assistant.mht

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

Percussion Place fingers on abdomen and strike with other hand Solid organ = dull sound Hollow organ = tympanic or resonant sound

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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)

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 24-48 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

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

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

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

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

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

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

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)

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

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 15-20 minutes requires referral to a physician

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

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

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

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

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

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

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

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

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

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