Chapter 27 The Thorax and Abdomen 2014 The

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Figure 27 -4 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

Figure 27 -5 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

Figure 27 -6 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

Figure 27 -8 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

Figure 27 -9 & 10 © 2014 The Mc. Graw-Hill Companies, Inc. All rights

Figure 27 -11 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

Figure 27 -12 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

Preventing Injuries to the Thorax & Abdomen • Thorax injuries can be prevented through the use of by appropriate • protective equipment • The muscles of the abdomen should be strengthened to provide protection to the underlying viscera – A consistent regimen of core stabilization exercises done in various positions can markedly increase the strength and size of the abdominal musculature © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -11

• Making sure that the hollow organs are emptied prior to activity can reduce the chance of injury to those structures – Meals should be eaten at least 3 to 4 hours before activity to allow foods to clear the stomach – Urination immediately before stepping onto the field or court will protect the bladder from injury. © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -12

Assessment of the Thorax Abdomen • Injuries to this region can produce lifethreatening situations • Athletic trainer’s 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -13

• 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? © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -14

– 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? © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -15

• Observations – Is the patient breathing? Are they having difficulty breathing? Does breathing cause pain? – Is the patient holding their chest wall? – Is there symmetry of the chest during breathing? – If the patient’s 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 chest – Male external genitalia injury - lying on side holding scrotum © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -16

– 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? – Blood • Bright red = lung injury • Vomiting bright red and frothy = injury to esophagus and stomach although blood may be swallowed from mouth and nose © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -17

– 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 loss) • 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 junction • Semi-reclining position is useful if athlete is having difficulty breathing © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -18

Figures 27 -15, 16 & 17 © 2014 The Mc. Graw-Hill Companies, Inc. All

– 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 • Should be done prior to obtaining a history • Auscultation assessment sequence is a matter of personal preference • Patient is experiencing respiratory difficulties and or for whatever reason is not capable of providing a history, then logic dictates that auscultation should be done immediately © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -20

• Heart Sounds – “Lubbdupp” (may hear 3 rd sound in children) – Listen for murmur (abnormal period due to valve insufficiency) – Listening at a variety of points Figures 27 -19 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -21

– Breath sounds • Should be consistent • Abnormal patterns – Cheyne-Stokes breathing (rate changes over 1 -3 minutes) – Biot’s breathing - normal rate followed by cessation – Apneustic breathing - pauses in respiratory cycle at full inspiration – Wheeze, crackles, stridor, stertor, rales, & ronchi • Perform over apex, centrally and at base of each lung, both anteriorly and posteriorly – Bowel sounds • Liquid-like gurgling due to peristalsis • Diminished = paralytic ilieus or peritonitis • High pitched sounds = intestinal obstruction © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -22

• Percussion – Place fingers on abdomen and strike with other hand – Solid organ = dull sound – Hollow organ = tympanic or resonant sound © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -23

Figure 27 -18 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27

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 involved) • Point tenderness; pain with rib compression – Management • RICE and NSAID’s • Rest and decrease in activity © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -25

• Rib Fractures – Etiology • Caused by a direct blow or the result of a violent muscular contraction • Can be caused by violent coughing and sneezing • A flail chest is one where 3+ consecutive ribs are fractured – Signs and Symptoms • History is critically important • Pain with inspiration, point tenderness and possible deformity with palpation – Management Figure 27 -20 • Refer for X-rays • Support and rest; brace © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -26

• 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 junctions • Pain with movement; difficulty with breathing • Point tenderness and possible deformity – Management • Rest and immobilization • Healing may take 1 -2 months © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -27

Figures 27 -21 and 27 -22 © 2014 The Mc. Graw-Hill Companies, Inc. All

• Rib Tip Syndrome – Etiology • Involves ribs 8 -10 • Fibrous tissue connecting ribs damaged resulting in impingement of ribs on intercostal nerve – Signs and Symptoms • • Localize pain in upper abdomen Pain with lateral flexion and extension away from injury May present with popping or clicking Pain reproduced by pulling inferior rib anteriorly; positive sign = clicking – Management • Bracing & compression wrap • Manipulation/mobilization • Inject with corticosteroids or local anesthetic © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -29

• Sternum Fractures – Etiology • Result of high impact blow to the chest • May also cause contusion to underlying cardiac muscle – Signs and Symptoms • Point tenderness over the sternum • Pain with deep inspiration and forceful expiration • Signs of shock, or weak rapid pulse may indicate more severe injuries – Management • X-ray and monitor patient for signs of trauma to the heart © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -30

• 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 patient comfortable © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -31

• Breast Injury – Etiology • Constant uncontrolled movement (particularly in large breasted women) • Stretching of Cooper’s ligament • Runner’s and cyclist’s 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 runner’s nipple • Wearing a windbreaker can prevent cyclist nipple © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -32

• Breast Cancer – Etiology • • Should be of great concern to all women Most common cause of cancer in females Risk factor – age, gender, family history Hormonal influences can put individuals at higher risk – Began menstruation prior to age 11; reached menopause after age 55 • More commonly seen in women with high dietary fat intake – Sign & Symptoms • Early on – no symptoms and pain free • Lump identified on breast, in arm pit, or on mammogram • Breast discharge, nipple inversion, redness or puckering skin overlying breast © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -33

– Management • Females over 20 years old should perform breast self-examinations every month and receive a clinical evaluation every 3 years • Not all lumps are malignant, but should be examined by a physician • If malignancy is identified surgery is primary treatment • Additional treatments are based on stage and type of cancer © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -34

• 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 anoxia • 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, dyspnea, coughing up frothy blood and signs of shock © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -35

• Traumatic Asphyxia – Result of a violent blow or compression of rib cage – Causes cessation of breathing – Signs include purple discoloration of the trunk and head, conjunctivas of the eye – Condition requires immediate mouth to mouth resuscitation – Management • Each of these conditions are medical emergencies and require immediate attention • Transport patient to hospital immediately © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -36

• 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 • Patient 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 techniques • Breath into a bag • Normal respiration should return within 1 -2 minutes, initial cause must be determined © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -37

• Sudden Cardiac Death Syndrome in Athletes – Etiology • Hypertrophic cardiomyopathy- thickening of cardiac muscle w/ no increase in chamber size • Anomalous origin of coronary arteries • Marfan’s syndrome- abnormality in connective tissue results in weakening of aorta and cardiac vessels • Series of additional cardiac causes • Coronary artery & peripheral artery disease • Right ventricular dysplasia; cardiac conduction abnormalities; aortic stenosis • Wolf-Parkinson-White syndrome • Non-cardiac causes include drugs and alcohol, intracranial bleeding, obstructive respiratory disease © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -38

– 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 Marfan’s syndrome • Cardiac screening - electrocardiograms and echocardiograms © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -39

• Heart Murmur – Etiology • Abnormal periodic sounds heard during auscultation • Functional murmur = no organic heart dysfunction – Forceful blood flow (high cardiac output) through healthy valves • Abnormal murmur = blood flow through damaged valve – Mitral valve prolapse – can lead to infective endocarditis or aortic regurgitation – Mitral valve or aortic stenosis – narrowing due to scarring from infections (rheumatic fever); if untreated could result in heart failure – Aortic sclerosis – scarring and thickening of aortic valve due to arthrosclerosis; tends not to be dangerous © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -40

• Heart Murmur – Signs and Symptoms • Abnormal or unusual sounds (clicking, whooshing, swishing) • Abnormal murmurs could result in symptoms of other heart problems – Management • Different types require different management • Mitral valve prolapse and innocent murmurs don’t require additional management • Others will require medication to reduce chance of infection, prevent clots, control irregular beats, control heart beat/fluttering, relax dilated vessels • Surgery may be required to fix valve issues or repair congenital defects © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -41

• Athletic Heart Syndrome – Etiology • Structural and functional heart changes due to greater than one hour on most days • Results in increased left ventricle mass, diastolic capacity dimension, wall thickness • Maximum cardiac output increases = low resting heart rate & longer diastolic filling time • Systolic and diastolic function remain normal – Signs and Symptoms • Typically asymptomatic • May exhibit bradycardia, systolic murmur, extra heart sounds with ECG abnormalities being common – Management • If serious cardiac conditions are ruled out – no treatment necessary © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -42

• Commotio Cordis – Etiology • Syndrome resulting in cardiac arrest due to traumatic blunt impact to chest – Unfortunate timing relative to re-polarization phase of cardiac cycle • Young athletes are at risk – Signs and Symptoms • Ventricular fibrillation – Management • Resuscitation of victim is seldom successful • Early defibrillation with AED and resuscitation is critical © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -43

• Heart Contusion – Etiology • Result of compression between sternum and spine • Most severe consequence would involve an aortic rupture – 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -44

Injuries and Conditions of the Abdomen © 2014 The Mc. Graw-Hill Companies, Inc. All

• Kidney Contusion – Etiology • Result of an external force (force and angle dependent) • Susceptible to injury due to normal distention of blood – Signs and Symptoms • 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) – Management • 24 hour observation and gradual increase of fluid intake • Surgery required if hemorrhage fails to stop • Bed rest and close observation after activity resumes © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -46

– Management • 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -47

• Kidney Stones – Etiology • Unknown cause • May be small (grain of sand), large (marble-size), smooth, or jagged • May remain in kidney causing blockage and pressure in renal system • If breaks free and travels through urinary tract it is very painful – Signs and Symptoms • • • Sudden painful, severe and sharp pain initially Referred pain in low back, flank, and groin Nausea and vomiting Cool, clammy, pale and sweaty skin Burning with frequent urination (possible blood in urine © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -48

– Management • Fluids – especially water • OTC for pain • In 80 -85% of cases smaller stones move through ureter and drops into bladder, coming out in urine • Larger stones may require procedure to break up or be surgically removed © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -49

• 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 (runner’s 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -50

• 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -51

• Cystitis and Urinary Tract Infections – Etiology • Inflammation of the bladder associated with a urinary tract infection (bacteria-related) • Occurs due to incorrectly wiping following bowel movement, rough sexual intercourse or activities that push bacteria into bladder • Occurs most often in sexually active females ages 20 -50; rarely occurs in men with normal urinary tracts – Signs & Symptoms • Strong or persistent urge to urinate • Burning sensation with urination; passing small amounts of urine, blood in urine, passing cloudy or strong smelling urine • Pressure in lower abdomen or low grade fever © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -52

– Management • Oral antibiotics • Symptoms usually subside within a few days • Fluids are critical – Water – Cranberry juice due to potential infection fighting properties – Practicing sanitary bowel and bladder habits – Washing genitals before intercourse and emptying bladder after – Immediately removing contraceptive diaphragms after intercourse © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -53

• Urethritis – Etiology • Inflammation of the urethra caused by gonorrhea, chlamydia, herpes virus, or bacterial infection • Chemical irritation due to soap, lotions, spermicides – Signs & Symptoms • Pain on urination, urethral discharge, urge to urinate more often • Itching, tenderness or swelling in penis; pain with intercourse; ulcers on genitals; blood in urine or semen • If it spreads to other organs there may be back or abdominal pain, fever, nausea or swollen joints – Management • Treated with antibiotic therapy; fluids, NSAID’s for pain © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -54

Conditions of the Digestive System © 2014 The Mc. Graw-Hill Companies, Inc. All rights

• Gastrointestinal Bleeding – Etiology • Distance running, gastritis, iron-deficiency anemia, ingestion of aspirin or NSAID’s, 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 if bleeding is occurring © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -56

• Liver Contusion – Etiology • Blunt trauma - right side of rib cage • More susceptible if enlarged due to illness (hepatitis) – Signs and Symptoms • Hemorrhaging and shock may present • May require immediate surgery • Presents with referred pain in right scapula, shoulder and sub-sternal area and occasionally in left anterior side of chest – Management • Referral to a physician for diagnosis and treatment © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -57

• 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 alcoholism – Signs and Symptoms • Acute epigastric pain causing vomiting, belching, constipation and potentially shock • Tenderness and rigidity during palpation • Chronic cases may result in jaundice, diarrhea and mild to moderate pain that radiates into the back © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -58

• Pancreatitis (continued) – Management • In acute cases, re-hydration is necessary along with pain reduction, treatment of shock, reduction of pancreatic activity through medication • Surgery if the duct is blocked • Chronic cases require large doses of analgesics, pancreatic enzymes and modified diet © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -59

• Indigestion (Dyspepsia) – Etiology • Some patients 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 esophagus – 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -60

• Vomiting – Etiology • Result of some irritation, most often in the stomach • 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) © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -61

• 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. infection) • Salmonella infection may last 24 -48 hours or more © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -62

• Food Poisoning (Gastroenteritis) – 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -63

• Peptic Ulcer – Etiology • Acids destroy mucous lining of stomach or small intestine • Occurs in individuals with long periods of severe anxiety – 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -64

• 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 (esophagitis) – 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -65

• 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 • "Travelers'" diarrhea affects travelers to highrisk international destinations – Occurs during the first week of travel, but may occur even after returning home – Affects young adults, immunosuppressed persons, individuals with inflammatory-bowel disease or diabetes, and people taking antacids © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -66

– Signs and Symptoms • Abdominal cramps, nausea, vomiting and frequent elimination of stools • Loss of appetite, and a light brown or gray, foulsmelling stool • Extreme weakness caused by dehydration – Management • Determine cause (irritant, infection, or emotional upset) • Athletic trainer can treat less severe cases by omitting certain foods from athlete’s diet • Have patient consume bland food that does not irritate system • Provide pectins 2 -3 times daily to absorb excess fluid © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -67

• 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, vegetables) • Deal with psychological aspects • Avoid medications unless prescribed by a physician © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -68

• 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 counseling • Long term prognosis -- good © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -69

• Appendicitis – Etiology • 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -70

• Appendicitis – 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 (Mc. Burney’s point) – Management • Surgical intervention is often necessary (particularly if it is resulting in an obstructed bowel = life threatening) © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -71

• 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 vessels – Signs and Symptoms • Painful nodular swellings near the anal sphincter • May cause slight bleeding and itching © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -72

• Hemorrhoids (Piles) – 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -73

Injuries and Conditions Related to Reproductive Organs © 2014 The Mc. Graw-Hill Companies, Inc.

• 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 – With patient seated , lift and drop patient a few inches – Have patient bounce while in kneeling position – Patient brings knees to chest and performs Valsalva maneuver • Application of cold pack • Unresolved pain after 15 -20 minutes requires referral to a physician © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -75

• 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 Figure 27 -24 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -76

• 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 Figure 27 -25 – Management • Cold pack application and referral to a physician © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -77

• 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -78

• 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 pubis © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -79

Injury to Lymphatic Organs and Abdominal Wall © 2014 The Mc. Graw-Hill Companies, Inc.

• Injury of the Spleen – Etiology • Result of a direct blow or 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 • Kehr’s 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -81

• 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -82

• 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 region – Management • Cold pack and compression • Be sure to check for signs of internal injuries © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -83

• 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -84

– Management • Surgery is preferred by most physicians • Mechanical devices are not suitable for athletics due to friction and irritation they produce © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -85

• Blow to Solar Plexus – Etiology • Transitory paralysis of the diaphragm due to direct blow to stomach – 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 Athletic trainer should question possibility of internal injury © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -86

• Stitch in the Side – Etiology • Idiopathic condition with obscure cause and several hypotheses • Potential causes include 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -87

– Signs and Symptoms • 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 © 2014 The Mc. Graw-Hill Companies, Inc. All rights reserved. 27 -88