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Thorax and Abdomen Evaluation

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Title: Thorax and Abdomen Evaluation


1
Thorax and Abdomen Evaluation
2
Evaluation format
  • Fortunately, thoracic and abdominal injuries are
    less common than extremity injuries. However,
    these injuries can be life-threatening.
  • These injuries demand immediate evaluation

3
  • When thoracic injury is suspected, begin your
    evaluation with the
  • Primary Survey
  • What is the primary survey?

4
  • Airway
  • Breathing
  • Circulation
  • Once primary survey is completed and you
    determine the athletes condition is NOT
    life-threatening, perform a secondary survey

5
Secondary SurveyHistory
  • Mechanism of injury
  • Onset of symptoms
  • Location of injury
  • Quantity and quality of pain
  • Type and location of any abnormal sensations
  • Progression of sign and symptoms
  • Activities that make the symptom better or worse
  • Nausea

6
  • Weakness
  • Dyspnea ( shortness of breath)

7
Physical Exam
  • Some sign and symptoms that may vary are
  • Respiratory rate
  • Moistness, color and temperature of skin
  • Pulse

8
Vital Signs
  • Abnormal nerve response
  • Blood pressure
  • Movement
  • Pulse
  • Pupils
  • Respiration
  • Skin color
  • State of consciousness
  • Temperature

9
After vitals
  • The physical exam progresses to
  • Inspection
  • Auscultation (listening for sounds)
  • Percussion (tapping)
  • Palpation and special test

10
During the inspection observe the following
  • LOC
  • Skin color
  • The athletes positions, movements and signs of
    guarding or apprehension
  • Respiratory rate and rhythm for dyspnea
    (shortness of breath)
  • Symmetry of chest appearance and chest movements

11
  • Signs of trauma such as..
  • Hemoptysis (coughing up blood)
  • Hematemesis (vomiting up blood)
  • Ecchymosis (escaping of blood into tissue)
  • Signs of respiratory distress such as cyanosis
    (pale or bluish skin color of the lips,
    fingertips, or fingernails from poor oxygenation
    of the blood)

12
  • Pupil equality and responsiveness
  • Evidence of penetrating trauma
  • Vomiting
  • Next, Auscultation is the process of listening
    for sounds produced in the thoracic and abdominal
    cavities.

13
Auscultation
  • A stethoscope is usually used and auscultation is
    normally conducted by medical professionals with
    extensive training and experience in this complex
    skill.
  • Normal vs abnormal chest sounds
  • Breathing equality
  • Depth of breaths

14
  • After completing auscultation, trained medical
    professionals usually perform percussion.
  • Involves tapping on various part of the body and
    noting the sound produced.

15
Palpation and special test
  • Palpation determines
  • General and specific areas of tenderness
  • Location of deformities
  • Location and extent of swelling
  • Air crepitus
  • Bony crepitus
  • Asymmetry
  • Muscle rigidity
  • Abnormal tenderness

16
Special test help
  • Evaluate active ROM
  • Provide resistance to movement in the different
    plane to elicit painful ranges, limitations and
    musculoskeletal weakness
  • Evaluate pain and dysfunction associated with
    inspiration and expiration

17
  • Apply passive stress on the rib cage and sternum
    to check for fractures/separation

18
  • When evaluating ROM, your assessment is divided
    into active, passive, and resistive motions and
    may be approached from three cardinal planes of
    motion, the Sagittal Plane, the Transverse Plane,
    and the Frontal Plane.

19
  • Visually note any apprehension, limited range of
    motion, and painful arcs within the plane.

20
Sagittal Plane range of motion
  • Assesses ROM limitations and associated findings
    in the sagittal plane.
  • Patient stands and slowly flexes the trunk to the
    point where the hands touch the toes or the
    floor. Ask the patient to slowly return from full
    trunk flexion to trunk extension

21
Transverse Plane range of motion
  • Assesses rom limitations associated findings in
    the transverse plane.
  • To evaluate transverse plane, the athlete stands
    and slowly rotates the trunk to the right as far
    as possible

22
Frontal Plane range of motion
  • Assesses rom limitations and associted findings
    in the frontal plane.
  • The athlete should stand and slowly, laterally
    flex the trunk to the right as far as possible.

23
Inspiration and expiration tests
  • Assess inspiratory and expiratory function and
    elicit signs and symptoms of thoracic injury.

24
  • Have the athlete breathe in as much as possible
    and hold for a few seconds. Then, ask the
    athlete to breathe out slowly and fully in an
    attempt to expire all air form the lungs.
  • Instruct the patient to hold the maximally
    expired for a few seconds

25
  • During these breathing activities, observe any
    patient apprehension or limitations in the
    inspiratory movement as well as any display of
    associated pain.
  • Question the patient regarding location and
    nature of any symptoms elicited by these
    procedures
  • Some specific signs or sympptoms..

26
  • Inability to fully inspire
  • Pain during breathing
  • Guarding or apprehension with respirations
  • Next, in assessing thoracic injuries, fractures
    and separation may occur in the bones and costal
    cartilage

27
  • If there is a complete separation or fracture,
    crepitus, grating, and popping sensations may be
    present with active and passive chest movement.
  • Two test are performed to determine if rib cage
    and sternum fractures or separation exist

28
2 test
  • Anterior/posterior chest compression test and the
    lateral chest compression test.
  • Anterior/posterior chest compressions assesses
    lateral rib cage bony integrity.
  • Instruct the athlete to either sit or stand.

29
  • You should place the palmar surface of one hand
    anteriorly on the wall at the level of the
    affected area. Place your other hand at the
    corresponding level posteriorly. Compress the rib
    cage by pushing your hands toward each other.
    This inward pressure anteriorly and posteriorly
    will cause the rib cage to bow outward laterally
    which will elicit pain and bony crepitis if the
    injury to the lateral rib cage is a fracture.

30
Lateral chest compression test
  • Assesses anterior or posterior rib cage
    integrity.
  • Place palmer surface of your hands laterally on
    the athletes chest wall sides at the affected
    area.
  • Compress the rib cage by pushing your hands
    together.
  • This inward pressure from both

31
  • Sides will cause the rib cage to bow outward
    anteriorly and posteriorly.

32
Thorax Anatomy and Common Injuries
  • Lets look at some anatomical components of the
    thorax.
  • Acute traumatic injuries to the thorax may
    involve the heart, lungs, and rib cage.

33
Heart
  • Located in the center of the thoracic cavity and
    positioned slightly to the left. One of the most
    common conditions is a
  • Myocardial infarction is ischemia (decrease in
    oxygenated blood flow) to cardiac tissue which
    may result in a disturbance of normal heart
    function characterized by arrhythmia.

34
Signs and symptoms?
  • As an allied health professional you should be
    aware of other conditions involving the heart
    including cardiac contusions and pericardial
    tamponade (compression of the heart)

35
Cardiac contusions
  • Result from a direct blow to the anterior chest
    wall.
  • Blunt trauma to the anterior chest wall may cause
    Pericardial Tamponade, bleeding accumulates
    inside the pericardial sac and will gradually
    increase, causing external pressure on the heart.

36
The Auscultation Assistant - Hear Heart Murmurs,
Heart Sounds, and Breath Sounds
37
Lungs
  • Pheumothorax occurs either spontaneously or
    traumatically from blunt or sharp trauma to the
    chest wall. It is characterized by air
    accumulation in the pleural space.

38
  • Traumatic/Tension
  • Hemothorax

39
Rib fractures
  • Non-displaced
  • Displaced
  • Injuries usually involve the 5th to 9th ribs
  • Tremendous forces are necessary to fracture the
    1st and 2nd rib.
  • Fracture of 7th 12th ribs may be associated
    with liver, spleen, or kidney injuries

40
Rib fractures and contusions
41
Signs and symptoms
  • Pain at fracture site
  • Dyspnea (shortness of breath)
  • Localized tenderness
  • Bony or air crepitation
  • Contusion
  • eccymosis

42
Sternum fracture
  • Pain directly over sternum
  • Pain aggravated by deep inspiration
  • Possible associated myocardial contusion

43
Flail chest
  • A flail chest is often life-threatening injury
    which results when several ribs are fractured

44
Signs and symptoms
  • Point tenderness
  • Possible ecchymosis
  • Pain with excessive movement
  • Pain with deep inspiration/expiration
  • Lack of crepitus
  • Negative compression test

45
Muscular strains
  • Point tenderness to direct palpation
  • Pain with contractile movements of involved
    muscle
  • Pain with passive stretching of involved muscle
  • Pain with passive stretching of involved muscle
  • Weakness in movements controlled by involved
    muscle

46
  • Deformity of muscle on the chest
  • Ecchymosis
  • Negative compression test

47
others
  • Muscle tears
  • Respiratory conditions
  • Asthma-an inflammatory respiratory condition
    characterized by bronchospams (wheezing) and
    shortness of breath (dyspnea) may be excersied
    induced

48
  • Bronchitis-inflammation of the bronchial tubes.
  • Hemoptysis-expectoration of blood arising from
    the lungs
  • Hyperventilation-increase in respiratory rate
    usually associated with anxiety which causes a
    change in acid/base balance of blood

49
  • Influenza-a viral illness characterized as an
    acute onset of fatigue, muscle ache, headache,
    and fever.
  • Pleuritic chest wall pain- inflammation of the
    serous membrane lining, which lies between the
    lungs and chest wall, causing pain with
    inspiration and expiration or cough

50
  • Pneumonia-inflammation of the lungs caused by
    bacteria, viruses, chemical irritants, vegetable
    dusts, and allergy

51
Circulatory
  • Tachycardia-abnormal rapidity of heart action and
    usually defined in adults as a heart rate over
    100 bpm
  • Bradycardia-abnormal slowness of heart action and
    usually defined in adults as a heart rate under
    60 bpm
  • Arrhythmia- abnormal heart rhythm characterized
    by skipping of bear or an irregular pulse

52
Immediate referral
  • Difficulty in breathing
  • Shortness of breath-inability to catch breath
  • Severe pain increasing in chest
  • Vomiting or coughing up blood
  • Diminished chest movement on the affected side
  • Shifting or moving of trachea with each breath

53
  • Suspected rib fracture of costochondral
    separation
  • Signs of shock
  • Doubt regarding the nature and severity of the
    chest injury

54
Abdomen anatomy and common injuries
  • 4 quadrants right upper, left upper, right lower
    and left lower.
  • RUQ/LUQ
  • RLQ/LLQ

55
Right upper quadrant
  • Liver, gallbladder, right kidney and adrenal
    gland, pylorus of the stomach, head of the
    pancreas, portion of the colon and small intestine

56
Left upper quadrant
  • Stomach, spleen, left kidney and adrenal gland,
    portion of the pancreas, portion of the colon,
    and small intestine

57
Right lower quadrant
  • Appendix, portion of the small and large
    intestine, portion of the colon, and structures
    of the urinary and reproductive systems.
  • Mcburneys point
  • Rovsing sign

58
Left lower quadrant
  • A portion of the small and large intestine,
    portion of the urinary and reproductive system.

59
Hollow organs
  • Stomach
  • Gall bladder
  • Urinary bladder
  • Intestine
  • vessels

60
Solid organs
  • Spleen
  • Liver
  • Kidneys
  • Abdominal muscles

61
Stomach
  • J-shaped and found directly underneath the
    diaphragm in the LUQ
  • Small intestines is principally located in the
    left and right lower quadrant.
  • Large intestine is an inverted U

62
Signs and symptoms of hollow organs injuries
  • Decreased bowel sounds
  • Tender abdomen
  • Hard or rigid abdomen
  • Guarding
  • Distended abdomen
  • Signs and symptoms of shock

63
Spleen
  • Largest lymphatic organ in the LUQ, directly
    below the diaphragm and behind the 9th, 10th and
    11th ribs.
  • Regulates RBC and destroys old and defective
    blood cells and produces white blood cells

64
Signs and symptoms
  • Rebound tenderness
  • Rigidity
  • Guarding
  • Abdominal pain in left upper quad
  • Left shoulder or neck pain (Kehrs Sign)
  • Shock
  • Possible rib fracture

65
Liver
  • RUQ- manufactured of plasma proteins, storage of
    blood cells, breakdown of toxic substance,
    glucose and fat metabolism, mineral and vitamin
    storage, and bile production

66
Signs and symptoms
  • Rebound tenderness
  • Rigidity
  • Guarding
  • Abdominal pain in RUQ
  • Right shoulder or neck pain

67
Kidneys
  • RUQ, LUQ bean shaped organs
  • Help control blood volume, also removes waste
    from the blood in the form of urine

68
Signs and symptoms
  • Rebound tenderness
  • Rigidity
  • Guarding
  • Hematuria (blood in urine)
  • Bloody discharge or inability to void
  • Flank or back pain
  • Positive Grey-Turner sign-ecchymosis in flank
  • No acute abdominal signs

69
Hernia
  • Protrusion of abdominal viscera through portion
    of the abdominal wall
  • Inguinal
  • Umbilical
  • Hiatal

70
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71
Hiatus Hernia
72
Inguinal Hernia
73
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74
Umbilical Hernia
75
  • 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?

76
  • 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?

77
  • 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

78
  • Check for areas of discoloration, swelling or
    deformities
  • Around umbilicus intra-abdominal bleed
  • Flanks swelling outside the abdomen
  • Protrusion or swelling in any portion of abdomen
    (internal bleeding)
  • Does the thorax appear to be symmetrical?
  • Are the abdominal muscles tight and guarding?
  • Is the athlete holding or splinting a particular
    part?
  • Monitor vital signs (pulse, respiration, BP)
  • Rapid weak pulse or drop in BP is an indication
    of a serious internal injury (involves blood
    loss)

79
  • Sudden Death Syndrome in Athletes
  • Cause of Condition
  • Hypertrophic cardiomyopathy- thickening of
    cardiac muscle w/ no increase in chamber size
  • Anomalous origin of coronary arteries
  • Marfans syndrome- abnormality in connective
    tissue results in weakening of aorta and cardiac
    vessels
  • Series of additional cardiac causes
  • Non-cardiac causes include drugs and alcohol,
    intracranial bleeding, obstructive respiratory
    disease
  • Signs of Condition
  • Most do not exhibit any signs prior to death
  • May exhibit chest pain, heart palpitations,
    syncope, nausea, profuse sweating, shortness of
    breath, malaise and/or fever

80
  • Care
  • Immediate medical attention is necessary life
    threatening condition
  • Prevention
  • Counseling and screening are critical in early
    identification and prevention of sudden death
  • Screening questions should address the following
  • History of heart murmurs
  • Chest pain during activity
  • Periods of fainting during exercise
  • Family history
  • Thickening of heart or history of Marfans
    syndrome
  • Cardiac screening - electrocardiograms and
    echocardiograms may be needed to determine
    existing pathology

81
  • Blow to Solar Plexus
  • Cause of Injury
  • Transitory paralysis of the diaphragm due to blow
    to the middle portion of the abdomen
  • Signs of Injury
  • Stops respiration and leads to anoxia
  • Generally transitory
  • Care
  • Must help athlete overcome apprehension
  • Use short inspirations and long expirations
  • Calm athlete, prevent hyperventilation, blow into
    a paper bag
  • ATC should question possibility of internal injury

82
  • Stitch in the Side
  • Cause of Injury
  • Idiopathic condition with obscure cause and
    several hypotheses
  • Constipation, intestinal gas, overeating,
    diaphragmatic spasm, poor conditioning, lack of
    visceral support and weak abdominals, distended
    spleen, breathing techniques resulting in lack of
    oxygen, ischemia of diaphragm or intercostal
    muscles
  • Signs of Injury
  • Cramp-like pain that develops on either the right
    or left costal angle during hard physical
    activity
  • Management
  • Relaxation of the spasm
  • Stretch arm on affected side as high as possible
  • Flex trunk forward on the thighs
  • Additional problems may warrant further study

83
  • Injury of the Spleen
  • Cause of Injury
  • Result of a direct blow
  • Infectious mononucleosis (causing an enlarged
    spleen)
  • Signs of Injury
  • Indications of a ruptured spleen involve history
    of a direct blow, signs of shock, abdominal
    rigidity, nausea, vomiting
  • Kehrs sign
  • Ability to splint self may produce delayed
    hemorrhaging - easily disrupted resulting in
    internal bleeding

84
  • Care
  • Conservative treatment involves 1 wk of
    hospitalization and a gradual return to activity
  • Surgery will result in three months of recovery
    while removal of spleen will result in a 6 month
    removal from activity
  • In cases of mononucleosis athlete may resume
    training in 3 weeks if spleen not enlarged and if
    there is no fever

85
  • Kidney Contusion
  • Cause of Injury
  • Result of an external force (force and angle
    dependent)
  • Susceptible to injury due to normal distention of
    blood
  • Signs of Injury
  • May display signs of shock, nausea, vomiting,
    rigidity of back muscles and hematuria (blood in
    urine)
  • Referred pain (costovertebral angle posteriorly
    radiating forward around the trunk)
  • Care
  • Monitor status of urine (hematuria) - refer if
    necessary
  • 24 hour hospitalization and observation with a
    gradual increase in fluid intake
  • Surgery may be required if hemorrhaging continues
  • 2 weeks of rest and close surveillance following
    initial return to activity is necessary

86
  • Liver Contusion
  • Cause of Injury
  • Blunt trauma - right side of rib cage
  • More susceptible if enlarged due to illness
    (hepatitis)
  • Signs of Injury
  • Hemorrhaging and shock may present
  • May require immediate surgery
  • Presents with referred pain in right scapula,
    shoulder and substernal area and occasionally in
    left anterior side of chest
  • Care
  • Referral to a physician for diagnosis and
    treatment

87
  • Appendicitis
  • Cause of Injury
  • Inflammation of the vermiform appendix (chronic
    or acute)
  • Result of blockage, lymph swelling, or carcinoid
    tumor
  • Early stages it presents as a gastric complaint,
    that gradually develops from red swollen vessel
    to a gangrenous structure that can rupture into
    bowels causing peritonitis
  • Signs of Injury
  • Mild to severe pain in lower abdomen, associated
    with nausea, vomiting and low grade fever
  • Pain may localize in lower right abdomen
    (McBurneys point)
  • Care
  • Surgical intervention is often necessary
    (particularly if it is resulting in an obstructed
    bowel life threatening)

88
  • Injuries to the Bladder
  • Cause of Injury
  • Blunt force to the lower abdomen may cause injury
    to urinary bladder if distended with urine
  • Hematuria is often associated with contusion of
    bladder during running (runners bladder)
  • Signs of Injury
  • Pain, discomfort of lower abdominal region,
    abdominal rigidity, nausea, vomiting, shock,
    bleeding from the urethra, increased quantity of
    bloody urine
  • Athlete should be instructed to monitor urine
  • Inability to urinate will present in case of
    ruptured bladder

89
  • Scrotal/Testicular Contusion
  • Cause of Injury
  • Result of blunt trauma and contusion to the
    vulnerable and sensitive scrotum
  • Signs and Symptoms
  • Hemorrhaging, fluid effusion, muscle spasm,
    severe pain (disabling)
  • May cause nauseating, disabling and painful
    condition
  • Care
  • Place athlete on side with knees to chest
  • Apply cold pack as pain subsides
  • If pain persist after 15-20 minutes referral will
    be necessary

90
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91
  • Breast Injuries
  • Cause of Injury
  • Constant uncontrolled movement (particularly in
    large breasted women)
  • Stretching of Coopers ligament
  • Runners and cyclists nipple
  • Management
  • Females should wear well-designed bra that has
    minimum elasticity and allows for little movement
  • Special plastic cup-type brassieres may be
    required in sports with high levels of physical
    contact
  • Use of an adhesive bandage can be used to prevent
    runners nipple
  • Wearing a windbreaker can prevent cyclist nipple
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