KIN 191B – Advanced Assessment of Upper Extremity Injuries

Abdomen and Thorax Anatomy and Evaluation

Review Bony Anatomy

• Thorax– Anterior: sternum– Posterior: vertebrae– Connecting: ribs

• True vs. false• Costal cartilages

• Abdomen– Posterior: vertebrae– Lateral: floating ribs– Inferior: sacrum and ilia (pelvis)

Muscular Anatomy

• Focus on function relative to internal organs vs. movement/strength

• Muscles of inspiration– Diaphragm– Intercostal muscles– Scalene muscles

• Muscles of expiration– “Traditional” abdominal muscles (IO, EO, RA, TA)

Muscles of Inspiration

Muscles of Expiration

Respiratory Tract Anatomy• Lungs

– Left, 2 lobes: upper and lower– Right, 3 lobes: upper, middle and lower

• Trachea– Divides into bronchi (2), segmental bronchi (2 left and 3 right),

bronchioles and alveoli (exchange of gases)

• Pleural linings– Parietal pleura: lines thoracic cavity walls– Visceral pleura: surrounds lungs– Creates potential space (pleural cavity) – important for injury

classification/evaluation

Respiratory Tract

Cardiovascular Anatomy

• Heart– Four chambers

• Right atrium – receives deoxygenated blood from body via superior/inferior vena cava, delivers deoxygenated blood to right ventricle

• Right ventricle – receives deoxygenated blood from right atrium, delivers deoxygenated blood to lungs via pulmonary arteries

• Left atrium – receives oxygenated blood from lungs via pulmonary veins, delivers oxygenated blood to left ventricle

• Left ventricle – receives oxygenated blood from left atrium, delivers oxygenated blood to body via aorta and its branches

Heart Chambers

Cardiovascular Anatomy

• Arterial structures– Aortic arch forms soon after aorta leaves heart– On R, brachiocephalic trunk arises and branches into R

subclavian and R common carotid arteries– On L, left subclavian and L common carotid arteries arise

individually from aortic arch– Destinations?– Aorta travels inferiorly from arch as thoracic and

abdominal aortas before branching into LE

Venous Structures

• Superior vena cava– Delivers deoxygenated blood to right atrium from

head, neck and upper extremities

• Inferior vena cava– Delivers deoxygenated blood to right atrium from

trunk and lower extremities

Great Vessels off Heart

Digestive Tract Anatomy• Esophagus

• Stomach

• Small intestine– Duodenum, jejunum and ileum

• Large intestine (colon)– Cecum (appendix), ascending-transverse-descending colon, sigmoid colon,

rectum, anus

• Liver (R and L lobes, ligamentum teres), gall bladder, common bile duct

Digestive Tract and Small Intestine

Large Intestine and Liver

Lymphatic Anatomy

• Spleen

Urinary Tract Anatomy

• Kidneys

• Ureters

• Bladder

• Urethra

Reproductive Tract Anatomy

• Male– Testes– Epididymis– Penis

• Female– Ovaries– Fallopian tubes– Uterus– Vagina

Male Reproductive Anatomy

Female Reproductive Anatomy

Abdomen and Thorax Evaluation

History

History• Location of pain

• Onset of symptoms

• Mechanism of injury

• Symptoms/chief complaint/s

• Medical history

• General health

Location of Pain

• Musculoskeletal injuries typically present with pain at site of injury

• Internal organ injuries often more difficult to localize

• Must appreciate anatomical locations

• Must be mindful of referred pain from organ injury

Onset of Symptoms

• Musculoskeletal injuries– Pain exacerbated by sneezing, breathing or coughing– Symptoms usually present immediately, but often

overlooked

• Internal injuries– Symptoms may present gradually, especially with internal

bleeding – depends on damaged organ and extent of damage

Mechanism of Injury

• Almost all etiology associated with direct trauma to abdomen/thorax– Another competitor– Equipment– Ground– Increased incidence with trauma to unprotected

areas

Symptoms/Chief Complaint/s

• Dyspnea, pain with inspiration/expiration

• Generalized abdominal pain

• Nausea

• Vomiting (if blood – coffee grounds)

• Dizziness

• Hematuria

• Blood in stool

Medical History

• Most abdominal and thoracic injuries acute in nature and typically have no associated prior history of similar problems

• Other health concerns may increase risk of abdominal or thoracic injury– Mononucleosis/spleen

Inspection

Inspection

• Posture/guarding

• Breathing pattern

• Capillary refill

• Muscle tone

• Discoloration, ecchymosis

• Vomiting

• Hematuria

Posture/Guarding

• Be aware of trunk positioning – is posture abnormal in effort to minimize pain– Often lean toward pain as opposed to away from

it

• Anatomical alignment– Trachea positioned in midline?– If not, may be indicative of tracheal injury or

tension pneumothorax

Breathing Pattern

• Observe rate, depth and quality of breaths

• Observe chest wall movements for abnormalities (flail segment, rib fracture/s)

• Subcutaneous emphysema = “rice crispies” under skin – indicative of lung injury

• Dyspnea – identify source

Capillary Refill

• Quick evaluation of nail beds can be assistive in r/o cardiac and/or lung injuries

• Fingers often best site due to relative proximity to torso

Muscle Tone

• Tension or distension in abdominal muscles may be indicative of internal bleeding

• Typically requires some time for this to occur

Discoloration/Ecchymosis

• Contusions generally not acutely visible

• Presence of wounds and abrasions indicative of trauma and increases suspicion of injury to underlying structures

Vomiting

• Presence of vomiting is indication of likely internal injury, with or without associated bleeding

• Blood in vomit often indicative of GI and/or respiratory injury– If partially digested, appears as coffee grounds

Hematuria

• At minimum, question individual about appearance of urine

• If blood present, indicative of kidney and/or genitourinary injury in need of immediate attention

• If able, perform dipstick urinalysis to evaluate for presence of blood otherwise not seen

Palpation

Abdominal Quadrants

Quadrants• Upper left

– Stomach, spleen, L kidney, gut, ½ pancreas

• Lower left– Gut, ureter, ½ bladder, L ovary (female)

• Upper right– Liver, gall bladder, R kidney, gut, ½ pancreas

• Lower right– Gut, ureter, ½ bladder, appendix, R ovary (female)

Palpation• Positioning

• Quadrant analysis

• Rigidity

• Rebound tenderness

• Tissue density

• Auscultation

Positioning

• “Hook-laying” position allows for relaxation of abdominal musculature and promotes ease of palpation of abdominal structures

Quadrant Analysis

• Tenderness associated with palpation of quadrant generally indicative of injury to contents of that quadrant

• Must have perspective on underlying tissue – anatomy!!!

Rigidity

• Abdominal rigidity may occur due to– Muscle guarding due to musculoskeletal and/or

internal injury– Internal bleeding – actual accumulation of blood

in abdominal cavity

Rebound Tenderness

• Peritoneum is lining of abdominal cavity – extremely well innervated and sensitive to tension, especially when inflamed secondary to internal injury

• When pressure applied to injured site, stretch is typically gradual and non-irritating

• When pressure released, stretch is typically quick and pain results

Tissue Density

• Percussion– Hollow (stomach, gut) vs. solid (liver, spleen)

organs– Analogize to finding stud in wall behind drywall– Typically percussion done by placing fingers of one

hand over area and tapping with other hand

Percussion

Special Tests

Auscultation• Utilizes stethoscope to assess for internal injury

• For thorax, listen for normal heart “lub-dub”– r/o presence of murmurs

• For thorax, listen for breath sounds in all lobes of lungs– If absent, may indicate lung injury– Rales – fluid in lung (pneumonia, etc.)

• For abdomen, listen for “gurgling” indicative of peristalsis– If absent, may indicate intra-abdominal injury

Vital Signs

• Used to assess function of thoracic and abdominal structures

• Heart rate – assesses cardiovascular function– Rate and quality

• Respiratory rate – assesses respiratory function– Rate, depth and quality

Vital Signs

• Blood pressure– Pressure exerted on arterial walls of circulatory

system– Decreased blood pressure may be indicative of

shock, decreased blood volume and/or decreased ability of heart to pump and deliver blood

Neurological Signs• Referred pain is most common neurological sign of abdominal and

thoracic injury

• L shoulder – spleen (Kehr’s sign)

• R shoulder – liver

• Flanks – kidney

• Groin – gonads

• Medial thigh - bladder