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Chapter 26: The Thorax and Abdomen


Fluids to prevent dehydration (by mouth or intravenously depending on the situation) ... Nothing should be given by mouth if vomiting and nausea persist. Re ... – PowerPoint PPT presentation

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Title: Chapter 26: The Thorax and Abdomen

Chapter 26 The Thorax and Abdomen
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Assessment of the Thorax Abdomen
  • Injuries to this region can produce
    life-threatening situations
  • ATCs 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,
  • 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 athletes 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
  • Male external genitalia injury - lying on side
    holding scrotum

  • Check for areas of discoloration, swelling or
  • 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
  • Blood -
  • Bright red lung injury
  • Vomiting bright red and frothy injury to
    esophagus and stomach although blood may be
    swallowed from mouth and nose

  • 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
  • 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
  • Semi-reclining position is useful if athlete is
    having difficulty breathing

  • Abdomen
  • 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
  • Functional murmur versus pathogenic condition

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  • Breath sounds
  • Should be consistent
  • Abnormal patterns
  • Cheyne-Stokes breathing (rate changes over 1-3
  • Biots breathing - normal rate followed by
  • 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
  • Solid organ dull sound
  • Hollow organ tympanic or resonant sound

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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
  • Point tenderness pain with rib compression
  • Management
  • RICE and NSAIDs
  • Rest and decrease in activity

  • Rib Fractures
  • Etiology
  • 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
  • Pain with movement difficulty with breathing
  • Point tenderness and possible deformity
  • Management
  • Rest and immobilization
  • Healing may take 1-2 months

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  • Sternum Fractures
  • Etiology
  • Result of high impact blow to the chest
  • May also cause contusion to underlying cardiac
  • Signs and Symptoms
  • Point tenderness over the sternum
  • Pain with deep inspiration and forceful
  • 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
  • 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
  • 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
  • Use of an adhesive bandage can be used to prevent
    runners 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
  • Mammograms are not recommended until age 40

  • Lung Injuries
  • Etiology
  • Pneumothorax -
  • pleural cavity becomes filled with air,
    negatively pressurizing the cavity, causing a
    lung to collapse
  • Will produce pain, difficulty with breathing and
  • 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

  • Traumatic Asphyxia
  • Result of a violent blow or compression of rib
  • Causes cessation of breathing
  • Signs include purple discoloration of the trunk
    and head, conjunctivas of the eye
  • Condition requires immediate mouth to mouth
  • Management
  • Each of these conditions are medical emergencies
    and require immediate attention
  • Transport athlete to hospital immediately

  • Hyperventilation
  • Etiology
  • 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
  • Breath into a bag
  • Normal respiration should return within 1-2
    minutes, initial cause must be determined

  • Heart Contusion
  • Etiology
  • Result of compression between sternum and spine
  • Most severe consequence would involve an aortic
  • 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
  • Marfans syndrome- abnormality in connective
    tissue results in weakening of aorta and cardiac
  • Series of additional cardiac causes
  • Non-cardiac causes include drugs and alcohol,
    intracranial bleeding, obstructive respiratory
  • 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 Marfans
  • Cardiac screening - electrocardiograms and

  • Kidney Contusion
  • Etiology
  • Result of an external force (force and angle
  • Susceptible to injury due to normal distention of
  • Signs and Symptoms
  • May display signs of shock, nausea, vomiting,
    rigidity of back muscles and hematuria (blood in
  • Referred pain (costovertebral angle posteriorly
    radiating forward around the trunk)
  • Management
  • Monitor status of urine (hematuria) - refer if
  • 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
  • Unknown cause
  • Signs and Symptoms
  • 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 (runners 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

  • Cystitis
  • Inflammation of the bladder associated with a
    urinary tract infection
  • May involve kidney, prostate, and urethra
  • Causes frequent, painful urination, chills and
  • 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

  • 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 NSAIDs, 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
  • Blunt trauma - right side of rib cage
  • More susceptible if enlarged due to illness
  • 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

  • Pancreatitis
  • Etiology
  • 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
  • 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

  • Pancreatitis (continued)
  • Management
  • In acute cases, re-hydration is necessary along
    with pain reduction, treatment of shock,
    reduction of pancreatic activity through
  • 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
  • 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
  • Result of some irritation, most often in the
  • 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.
  • 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
  • Acids destroy mucous lining of stomach or small
  • Occurs in individuals with long periods of severe
  • 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
  • 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 athletes diet
  • Have athlete consume bland food that does not
    irritate system
  • Provide pectins 2-3 times daily to absorb excess

  • Constipation
  • Etiology
  • 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,
  • 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
  • Long term prognosis -- good

  • Appendicitis
  • Etiology
  • Inflammation of the vermiform appendix (chronic
    or acute)
  • Result of blockage, lymph swelling, or carcinoid
  • 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
    (McBurneys point)
  • Management
  • Surgical intervention is often necessary
    (particularly if it is resulting in an obstructed
    bowel life threatening)

  • Hemorrhoids (Piles)
  • Etiology
  • 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
  • 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
  • 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
  • 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

  • Injury of the Spleen
  • Etiology
  • 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
  • Kehrs 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
  • Management
  • Cold pack and compression
  • Be sure to check for signs of internal injuries

  • Hernia
  • Etiology
  • 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
  • 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
  • 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
  • Signs and Symptoms
  • Cramp-like pain that develops on either the right
    or left costal angle during hard physical
  • 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