thorax and abdomen chapter 9. evaluation of thorax and abdomen injuries are less common than...
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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
Secondary SurveySigns of Trauma – Abdominal Cavity
• 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
Secondary SurveySigns of Trauma – Abdominal Cavity
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
Secondary SurveySigns of Trauma – Abdominal Cavity
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
Secondary SurveySigns of Trauma – Abdominal Cavity
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
Secondary SurveySigns of Trauma – Abdominal Cavity
Anatomical Plane Motions• Visually Note:
– Apprehension – Limited Range of Motion– Painful Arcs
Secondary SurveySigns of Trauma – Abdominal Cavity
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
Secondary SurveySigns of Trauma – Abdominal Cavity
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
Secondary SurveySigns of Trauma – Abdominal Cavity
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.
Secondary SurveySecondary SurveySigns of Trauma – Thoracic CavitySigns of Trauma – Thoracic Cavity
• 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
Secondary SurveySecondary SurveySigns of Trauma – Thoracic CavitySigns of Trauma – Thoracic Cavity
• Specific Signs and symptoms:– Inability to fully inspire– Pain during breathing– Guarding or apprehension with
respirations
Secondary SurveySecondary SurveySigns of Trauma – Thoracic CavitySigns of Trauma – Thoracic Cavity
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
Common Injuries and Problems: Common Injuries and Problems: ThoraxThorax
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
Common Injuries and Problems: Common Injuries and Problems: ThoraxThorax
• 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
Common Injuries and Problems: Common Injuries and Problems: ThoraxThorax
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
Common Injuries and Problems: Common Injuries and Problems: ThoraxThorax
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
Respiratory Conditions: Thoracic Cavity
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
Respiratory Conditions: Thoracic Cavity
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
Respiratory Conditions: Thoracic Cavity
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
Common Injuries & Problems: AbdomenCommon Injuries & Problems: Abdomen
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: Abdomen
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
Common Injuries & Problems: AbdomenCommon Injuries & Problems: Abdomen
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.
Musculoskeletal Conditions/DisordersMusculoskeletal Conditions/Disorders
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
Musculoskeletal Conditions/DisordersMusculoskeletal Conditions/Disorders
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
Musculoskeletal Conditions/DisordersMusculoskeletal Conditions/Disorders
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