Thorax and Abdomen Chapter 9. Evaluation of Thorax and Abdomen Injuries are less common than...

Thorax and Abdomen

Chapter 9

Evaluation of Thorax and Abdomen

• Injuries are less common than extremity Injuries

• Can be Life Threatening• These Injuries demand immediate

evaluation and subsequent activation of the emergency medical system

Evaluation of Thorax and Abdomen

• Evaluation of the thorax and abdomen must follow a precise assessment process:

1.Primary Survey2.Secondary Survey• This helps the examiner distinguish

between acute trauma and non-traumatic conditions

Primary Survey• First Survey the scene

– Looking for indication of injury– Approach in a calm reassuring manner

• If the athlete is conscious this enhances relaxation and maintenance of the respiratory and circulatory systems

• Be prepared to clear and maintain airway– Potential obstructions such as blood,

vomitus, and foreign matter

Primary Survey• Once Cervical Spine injury is not

suspected assist the patient in finding the most comfortable position for breathing.

• Be prepared to give Artificial Ventilation or Cardiopulmonary Resuscitation and activate EMS.

Secondary Survey

• Once the primary survey is completed – Injury not life threatening

• Consist of two elements:1.History – The part of the evaluation in

which the examiner questions the athlete to determine:

Secondary Survey - History• Mechanism of Injury• Onset of Symptoms• Location of Injury• Quantity and Quality of Pain• Type and location of any abnormal

sensations• Progression of signs and symptoms• Nausea - The Feeling of Sickness• Weakness• Dyspnea – Difficulty breathing

Secondary Survey• The physical examination is the next

step• Can vary from athlete to athlete

– But stay within normal limits– Physical activity can add to variance – Variances Include:

• Respiratory Rate• Moistness• Color• Temperature of Skin• Pulse Rate

Secondary Survey – Vital SignsThese are Essential to Monitor

During Evaluation• Abnormal Nerve Response• Blood Pressure• Movement• Pulse• Respiration• Skin Color• State of Consciousness• Temperature

Secondary SurveyFollowing Vital Signs

• Inspection• Auscultation – The process of listening to the sounds of the chest and abdomen

– Determines: Normal vs. Abnormal breathing Chest Sounds

Breathing Equality Depth of Breaths

• Percussion – Tapping (Listening for sounds such as tympany, dullness, or

hyperresonance)• Palpation – the use of the hands to examine a body

part• Special Test

Secondary SurveyInspection Stage

• Level of Consciousness• Skin Color• The Athlete’s positions, movements and

signs of guarding or apprehension• Respiratory rate and rhythm for dyspnea

(shortness of breath)• Symmetry of chest appearance and chest

movements

Secondary SurveySigns of Trauma

Hemoptysis – coughing up bloodHematemesis – vomiting up bloodEcchymosis – escaping of blood into

tissue

Secondary SurveySigns of Trauma

• Signs of Respiratory Distress– Cyanosis – pale bluish skin color of the lips,

finger tips, or fingernails, from poor

oxygenation of the blood

• Flail Chest• Tracheal Deviation• Jugular Vein Distension (JVD)• Pupil equality and responsiveness• Evidence of penetrating trauma• Vomiting

Bat

Secondary SurveySigns of Trauma – Abdominal Cavity

• When examining the abdomen, each quadrant should be auscultated, percussed, and palpated


• Abdominal palpation determines signs and symptoms of an acute abdomen– Symptoms Include:

• Leakage of blood• Puss• Bowl contents into abdominal cavity causing

peritoneal irritation

– Signs of an Acute Abdomen:• Rebound Tenderness• Rigidity• Guarding


Rebound Tenderness – is identified by the examiner

pressing deeply into the abdominal

cavity and then quick• If it is painful peritoneal irritation may be

present• Rigidity of the abdominal wall muscles occurs

when peritoneal irritation causes reflex spasm of the abdominal muscles– Producing a board like-harness– Prevents the examiner from palpating the abdomen


Valsalva Maneuver • Used to provoke an increase in pain or mass

protrusion if significant intra-abdominal trauma has occurred

• To perform the Valsalva Maneuver:– the athlete takes a deep breath– hold their breath– strain as if a bowel movement

• Pain could indicate protrusion through the abdominal wall


Evaluating Range of Motion• The assessment is divided into active,

passive, and resistive motions• Motions are assessed in the three anatomical

planes:– Sagittal Plane– Frontal Plane– Transverse Plane


Anatomical Plane Motions• Visually Note:

– Apprehension – Limited Range of Motion– Painful Arcs


The Sagittal Plane• To evaluate:

– The athlete stands and slowly flexes the truck to the point where the hands touch the toes or the floor.

– Then the athlete is to return from flexion to standing upright and progress to trunk expression


The Frontal Plane• To evaluate:

– The athlete stands and slowly flexes the trunk laterally to the Right as far as possible

– Slowly returns to neutral – Repeat the motion to the left


The Transverse Plane• To evaluate:

– The athlete stands and slowly rotates the trunk to the Right as far as possible

– The Position is held– Repeat the motion to the left

Secondary SurveySecondary SurveySigns of Trauma – Thoracic CavitySigns of Trauma – Thoracic Cavity

• Inspiration and expiration test inspiratory and expiratory function and elicit signs and symptoms of thoracic injury.


• Evaluate inspiration and expiration by having athlete breathe in as much as possible and hold for a few seconds.

• Ask the athlete to breath out slowly and fully to expire all air from the lungs

• Instruct the athlete to breathe to hold that maximally expired position for a few seconds.

• During activity observe the athlete for apprehension or limitations in the inspiratory movement as well as pain


• Specific Signs and symptoms:– Inability to fully inspire– Pain during breathing– Guarding or apprehension with

respirations


Fractures and Separations• May occur in bones and costal cartilages

of the rib cage.• Complete separation or fracture,

crepitius, grating, and popping sensations may be present with active and passive chest movements

• In some cases passive stress can be applied to elicit further signs or symptoms

Secondary SurveySecondary SurveySigns of Trauma – Thoracic CavitySigns of Trauma – Thoracic CavityRib Cage Fracture/Separation Test

Two Test Should be Performed: 1.Anterior/Posterior chest compression

test– Test Lateral Ribs

2.Lateral chest compression test– Test posterior anterior chest

• These test will help determine the extent of the injury.– Contusion vs. Fracture

Thorax & Abdomen Anatomy• Sternum• Ribs 12• Lumbar Vertabrae• Sacral Vertabrae• Coccyx

Muscles & FunctionsPectoralis Major – Pulls rib cage up; adducts arms; rotates arms medially; prime mover for arm

flexionPectoralis Minor – Draws scapula forward and downward; draws rib cage superiorly

Muscles & Functions

Latissimus Dorsi – extends the upper arm, adducts

upper arm posteriorly.

Muscles & Functions

External Intercostals – Lifts the rib cageRectus Abdominis – Flexes and rotates

lumbar region

Muscles & Functions

Internal Abdominis Oblique – aids rectus abdominis; aids the back muscles in truck flexion and lateral flexion.External Abdominis Oblique - aids rectus abdominis; aids the back muscles in truck rotation and lateral flexion

Muscles & Functions

Transverse Abdominis – Compresses abdominal

contents

Internal Organs

Abdominal QuadrantsAbdominal Quadrants

Right Upper (Superior) Quadrant Right Upper (Superior) Quadrant • Liver and Adrenal Gland• Gallbladder Pylorus of the Stomach

Left Upper (Superior) QuadrantLeft Upper (Superior) Quadrant• Stomach• Spleen and Adrenal Gland• Portion of the Pancreas• Portions of the Colon and Small

Intestine• Posterior - Left Kidney

Abdominal QuadrantsAbdominal Quadrants

Right Lower (Inferior) QuadrantRight Lower (Inferior) Quadrant• AppendixAppendix• Portions of the Large and Small IntestinesPortions of the Large and Small Intestines• Portion of the ColonPortion of the Colon• Structures of the Urinary and Reproductive Structures of the Urinary and Reproductive

systemssystems

Left Lower (Inferior) QuadrantLeft Lower (Inferior) Quadrant• Portions of the Large and Small IntestinesPortions of the Large and Small Intestines• Portion of the ColonPortion of the Colon• Structures of the Urinary and Reproductive Structures of the Urinary and Reproductive

systemssystems

Hollow OrgansHollow Organs

Vessels

Urinary Bladder

Large an small Intestines

Stomach

Solid OrgansSolid Organs

Pancreas

Kidneys

Liver

Assessment TestAssessment TestTest for Bony Integrity

Palpation: Physical InspectionCompression: Inward force applied to

thorax and ribs through inspiration

and manual pressureDistraction: Outward force applied to

thorax and ribs through expiration

Assessment TestAssessment Test

Compression Test: Thorax/Ribs• Anterior/Posterior and Lateral:

– compression force applied to thorax and ribs through manual pressure

Compression Test: Pelvis• Anterior/Posterior and Medial /

Lateral:– compression force applied to pelvis

through manual pressure

Assessment TestAssessment TestBreathing• Inspiration: Action of taking a breath

(inhalation)• Expiration: Action of releasing a breath

(exhaling)

Assessment TestAssessment TestSigns of Acute Abdomen• Rebound Tenderness – Pain in the abdomen upon the release of pressure from the

abdomen• Rigidity – Upon palpation, abdomen is rigid or

hard and not fully palpable• Guarding – Patient contract muscles while palpation so that the palpation does not hurt

Assessment TestAssessment TestTest to Detect Possible Peritoneal Irritation

(intra-abdominal Pressure)• Iliopsoas Test – Moving leg into hip flexion, which causes abdomen pain

Assessment Test - Assessment Test - Possible Peritoneal Irritation

• Obturator Test – With hip and knee in 90° flexion, internal and external rotation of hip will cause abdomen pain.

Assessment Test - Assessment Test - Possible Peritoneal Irritation

• Heel Pound Test – With hip and knee in full extension, tap heel to increase pain in the abdomen• Valsalva Maneuver – Athlete takes a deep breath, hold their breath, and strain as if having a bowel movement.

Immediate Referral• Difficulty Breathing

– Shortness of breath

• Severe increasing pain in chest

• Vomiting or coughing blood

• Diminished chest movement on the affected side

• Shifting or moving of trachea with each breath

• Suspected rib fracture

• Signs of acute abdominal pain

• Rebound tenderness• Rigidity• Guarding• Blood in urine or stool• Prolonged discomfort,

sensation of weakness, or pulling in groin

• Superficial protrusion or palpable mass

• Circulation or neurological impairment

Immediate Referral – cont.

• Increasing Nausea• Vomiting• Presence of Fever• Presence of radiating or referred pain• Signs of shock• Doubt regarding the nature and

severity of the thorax or abdomen injury

Common Injuries and Common Injuries and Problems: ThoraxProblems: Thorax

• Acute traumatic injuries occurring to the thorax may involve the heart, lungs, and rib cage.

Myocardial Infarction – is ischemia to cardiac tissue,

which may result in a disturbance of normal

heart function characterized by arrhythmia• Ischemia – decrease in oxygenated blood flow• Arrhythmia – irregular heart beat

Signs and Symptoms of Myocardial Signs and Symptoms of Myocardial InfarctionInfarction

• Persistent chest pain or pressure unrelieved by rest, position changes or medication

• Breathing difficulty: noisier, shorter, faster than normal

• Cyanosis• Moist face or profuse sweating• Radiation of pain to the left side (neck, shoulder,

arm)• Levine’s Sign (clenched fist over the chest)• Hypotension or shock

Common Injuries and Problems: Common Injuries and Problems: ThoraxThorax

Pericardial Tamponade – Compression of the heart

• Caused by blunt trauma to the anterior chest wall– Bleeding accumulates inside the pericardial sac and

will gradually increase– Causes external pressure on the heart– Preventing proper contraction


Cardiac Contusion – results from a direct blow to the

anterior chest wall in the heart region• May cause Pericardial Tamponade

Common Injuries and Problems: Common Injuries and Problems: ThoraxThoraxLungs

• Located in the thorasic cavity• Protected by the rib cagePneumothorax – characterized by air

accumulation in the pleural space• Occurs either spontaneously or

traumatically from a blunt or sharp trauma to the chest wall

• Air escapes from the lung upon each inspiration, collects in the pleural space and leads to collapse of lung


• Thoracic related boney and joint injuries can occur to the rib cage structure.

• The rib cage outlines the thoracic borders and provides protection to the heart, lungs, great vessels (aorta and vena cava), liver, and spleenThe ability to

expand and relax is essential in assisting the lungs’ reparatory function


Rib Fractures• Nondisplaced fractures are usually benign

– Most common rib fracture

• Displaced fractures may result in lacerations to the lung and associated intercostal vessels.– Usually involve the 5th to 9th ribs– 1st and 2nd are not common because the

tremendous force required– Fractures in ribs 7 – 12 may be associated with

liver, spleen, or kidney injuries


Signs and Symptoms of Rib Fractures • Pain at fracture site aggravated by

coughing, breathing, movement, and compression test

• Dyspnea (shortness of breath)• Localized tenderness• Bony or air crepitation• Contusion• Ecchymosis (escaping of blood into

tissue)

Respiratory Conditions: Thoracic Cavity

Asthma – an inflammatory condition characterized by

bronchospasm, resulting in wheezing, and

shortness of breath (dyspnea) • Asthma can be exercise inducedBronchitis – Inflammation of the bronchial tubes• Usually characterized by a progressive cough.Hemoptysis – expectoration of blood arising

from lungs• Patient coughs up blood


Hyperventilation – increase in respiratory rate usually associated with

anxiety, which causes a change in the acid-base balance of the blood.• Symptoms include:

– Dyspnea– Numbness– Tingling in the hands, fingers, and around the mouth


Influenza – a viral illness characterized as an acute, rapid onset of fever, muscle ache, headache, and fatigue; usually one to two weeksPleuritis Chest Wall Pain – Inflammation of serous membrane lining, which lies between the lung and the chest wall• Causes pain with inspiration and expiration or cough


Pneumonia – inflammation of the lungs caused primarily by

bacteria, viruses, chemical irritants, vegetable

dust, and allergy• Symptoms:

– Fever– Cough– Chest pain

Common Injuries & Problems: Common Injuries & Problems: AbdomenAbdomen

• When examining the abdomen, each quadrant should be auscultated, percussed, and palpated.

• The most important function of palpation is to determine signs and symptoms of acute abdomen, which are rebound:– Tenderness– Rigidity– Guarding

Common Injuries & Problems: AbdomenCommon Injuries & Problems: Abdomen

• The spleen is the largest lymphatic organ and it is located in the upper left quadrant.– Directly below the diaphragm– Behind 9th, 10th, 11th ribs

• Reservoir of red blood cells• Regulates the number of red blood

cells in circulation• Destroys old or defective red blood

cells and produces white blood cells


Signs and Symptoms of Spleen Injury• Acute abdominal pain(rebound

tenderness, rigidity, guarding)• Abdominal pain in the upper left

quadrant• Pain radiating to the left shoulder and

one third of the way down the arm or neck pain (Kehr’s Sign)

• Shock• Possible left, lower rib fracture

Common Injuries & Problems: AbdomenCommon Injuries & Problems: AbdomenLiver

• Upper Right Quadrant– Small portion on the Left Upper

Quadrant• Solid organ• Functions:

– Manufacturing plasma proteins– Manufacturing and storage of blood cells– Removal of old or defective red blood cells– Breakdown of toxic substance– Glucose and fat metabolism– Mineral and vitamin storage– Bile production

Common Injuries & Problems: AbdomenCommon Injuries & Problems: AbdomenSigns & Symptoms of Acute Liver Injury

• Acute or gradual onset of abdominal pain– Palpable tenderness– Rebound tenderness– Rigidity– Guarding

• Abdominal pain in the right upper quadrant• Right shoulder or neck pain• Possible right, lower rib fracture

Common Injuries & Problems: AbdomenCommon Injuries & Problems: AbdomenKidneys

• Kidneys are paired solid, bean-shaped organs located in both the right and left upper quadrants near the spine.

• Kidney’s function to help control blood volume

• Remove waste from the blood


Kidneys• Acute or gradual onset of abdominal

pain, palpable tenderness, rebound tenderness, rigidity, guarding.

• Hematuria (passing of blood in urine)• Bloody discharge or inability to void• Flank or low back pain• Positive Grey-Turner sign – ecchymosis

in flank• Possible bony crepitus due to rib

fracture

Non-Traumatic Injuries/Conditions: Non-Traumatic Injuries/Conditions: AbdomenAbdomen

Appendicitis – Inflammation of the appendix.• Generally affect the young and more

common in males• Characterized by low grade fever, signs of

acute abdominal pain (lower right quadrant)

• Nausea / Vomiting

Non-Traumatic Injuries/Conditions: Non-Traumatic Injuries/Conditions: AbdomenAbdomen

Indigestion (heartburn) – Incomplete or imperfect digestion, usually accompanied by one or more of the following symptoms: pain, nausea, vomitingStitch in the Side – Sharp pain in the side usually associated with strenuous physical activity, caused by muscle spasms and/or trapped gas

Musculoskeletal Conditions/DisordersMusculoskeletal Conditions/Disorders

Arrhythmia - is a problem with the rate or rhythm of the heartbeat.

• The heart can beat too fast, too slow, or with an irregular rhythm.

Bradycardia – Arrhythmia with a slow heart beat

Flail Chest - occurs when a segment of the thoracic wall becomes

unattached from the rest of the chest

wall.


Hemopneumothorax - The presence of air or gas and blood in the thoracic cavity.Hemothorax - a collection of blood in the space between the chest wall and the lung (the pleural cavity).Spontaneous Pneumothorax• collapsed lung, or pneumothorax, the

collection of air in the space around the lungs. This buildup of air puts pressure on the lung, so it cannot expand as much as it normally does when you take a breath


Tachycardia - A heart rate of more than 100 beats per minute (BPM) in adultsDysmenorrhea - defined as difficult menstrual flow or painful menstruation.Ectopic Pregnancy - an abnormal pregnancy that occurs outside the womb (uterus). The baby (fetus) cannot survive, and often

does not develop at all in this type of pregnancy


Gastroenteritis - a condition that causes irritation and inflammation of the stomach and

intestinesHernia - a sac formed by the lining of the abdominal

cavity (peritoneum). • The sac comes through a hole or weak area in the

fascia, the strong layer of the abdominal wall that surrounds the muscle.

Musculoskeletal Conditions/DisordersMusculoskeletal Conditions/DisordersMuscular Strains - when the muscle is stretched

too far.

RehabilitationRehabilitation• Before sending an athlete back to

competition, the following rehabilitation guidelines must met:– Full Range of Motion– Strength, power, and endurance are

proportional to the athletes size and sport– No pain during running, jumping, or cutting

Rehabilitation ProgramRange of Motion Exercises

TorsoFlexionExtensionLateral FlexionRotation Anatomical Plane MovementSagittalFrontalTransverse

Rehabilitation ProgramRange of Motion Exercises

Thorax and Abdomen Exercise Abdominal Crunches Abdominal Lift Abdominal Sit – ups Arm Extensions Arm Flexion Bench Press Incline Press Pelvic Tilts Prone Extensions Prone Push -up

Thorax and Abdomen Chapter 9. Evaluation of Thorax and Abdomen Injuries are less common than...

Documents

Transcript of Thorax and Abdomen Chapter 9. Evaluation of Thorax and Abdomen Injuries are less common than...