1 Throat, Thorax, and Visceral ConditionsChapter 12 1

2 Throat Anatomy 2

3 Throat Anatomy (cont.) Pharynx, larynx, esophagus Trachea“Adam’s” apple Epiglottis Vocal cords Hyoid bone Esophageal sphincters Trachea Divides into right and left bronchial tubes Pharynx -- aka throat -- connects the nasal cavity and mouth to the larynx and esophagus -- lies between the base of the skull and the sixth cervical vertebra Larynx -- prominence on the thyroid cartilage that shields the front: “Adam’s apple” -- epiglottis -- specialized spoon-shaped cartilage -- covers the superior opening of the larynx during swallowing to prevent food and liquids from entering; if a foreign body does get past, cough reflex is initiated -- vocal cords -- two bands of elastic connective tissue surrounded by mucosal folds -- expired air from the lungs passes over the vocal cords, producing sound Hyoid bone -- only bone of the body that does not articulate directly with any other bone -- lies just inferior to the mandible in the anterior neck -- serves as an attachment point for neck muscles that raise and lower the larynx during swallowing and speech Esophagus -- carries food and liquids from the throat to the stomach -- muscle-walled tube that originates from the pharynx in the midneck and follows the anterior side of the spine -- body of the esophagus is divided into cervical, thoracic, and abdominal regions with upper and lower esophageal sphincters at each end -- action of esophagus walls propels food into the stomach Esophageal sphincters -- maintain a barrier against reverse movement of the esophageal contents into the pharynx and gastric fluids into the esophagus Trachea -- extends inferiorly from the larynx through the neck down into the midthorax -- divides into the two right and left bronchial tubes 3

4 Throat Anatomy (cont.) Blood vessels Common carotid arteriesBlood vessels of the throat Common carotid arteries -- divide into external and internal carotid arteries -- provide the major blood supply to the brain, head, and face Branches include: -- superior thyroid arteries, which supply the thyroid and larynx -- facial artery to the face and sinuses -- lingual artery to the mouth and tongue Several arteries branch from subclavian arteries and course upward through the posterior side of the neck, including the costocervical trunk, thyrocervical trunk, and vertebral artery. 4

5 Thoracic Cage Thoracic cavity -- aka chest cavity-- lies anterior to the spinal column -- extends from the level of the clavicle down to the diaphragm 5

6 Thorax Anatomy Thoracic cage and pleura Bronchial tree and lungsSternum, ribs, costal cartilage, thoracic vertebrae Cage around heart and lungs Pleura and pleural cavity Bronchial tree and lungs Bronchial tubes → terminal bronchioles Alveoli Sternum -- manubrium: articulates with the first and second ribs -- body: articulates with the second through seventh ribs -- xiphoid process: projection composed of hyaline cartilage that ossifies around age 40 Costal cartilages -- first 7 pairs of ribs attach directly to the sternum -- ribs 8 to 10 attach to the costal cartilages of the immediately superior ribs -- last two rib pairs: floating ribs; do not attach anteriorly to any other structure Pleura -- thin, double-layered membrane that lines the thoracic cavity Pleural cavity -- a narrow space between the pleural membranes filled with pleural fluid secreted by the membranes; enables lungs to move against thoracic wall with minimal friction during breathing Primary bronchial tubes - branch obliquely downward from the trachea, then branch into approximately 23 levels until the terminal bronchioles are reached; these tiny air sacs, called alveoli, serve as diffusion chambers where oxygen from the lungs enters adjacent capillaries, and carbon dioxide from the blood is returned to the lungs Lungs -- consist of an elastic network of air passageways and spaces bound together by connective tissue -- occupy the majority of the thoracic cavity -- each lung weighs only about 0.6 kg (1.25 lb) -- left lung is smaller than right lung; contains a concavity known as the cardiac notch in which the heart is nestled -- extend distally down to the level of, or slightly below, the twelfth rib in 80% of people, and extend down to about the L1 spinal level in about 18% 6

7 Anterior Muscles of Trunk7

8 Posterior Muscles of Trunk8

10 Injury Prevention Protective equipment Physical conditioningVariety of equipment available Concern: adolescent rib cage – less rigid Physical conditioning Flexibility Strength Protective equipment adolescent rib cages are less rigid, placing the heart at a greater risk from direct impact; in this age group, more baseball and softball deaths occur from impacts to the chest than to the head For specific equipment, refer to Chapter 3 Flexibility and strengthening of the torso muscles should not be an isolated program, but should include a well-rounded conditioning program for the back, shoulder, abdomen, and hip regions. 10

11 Throat Conditions Neck laceration Contusions and fracturesUncommon; severe bleeding Management: control hemorrhage; EMS Contusions and fractures Trachea, larynx, and hyoid bone S&S Hoarseness Dyspnea Difficulty swallowing Coughing Significant – severe pain, laryngospasm, acute respiratory distress Management: calm; assume cervical injury; potentially EMS Neck lacerations -- bleeding is profuse and, if sufficiently deep, can damage the jugular vein or carotid -- immediate control of hemorrhage is imperative -- in addition to blood loss, air may be sucked into the vein and carried to the heart as an air embolism, which may be fatal - management: provide firm, direct pressure over the wound; airway assessment Contusions and fractures to the trachea, larynx, and hyoid bone -- occur during hyperextension of the neck when the thyroid cartilage (Adam’s apple) becomes prominent and vulnerable to direct impact forces -- in rare instances, these injuries can be fatal as a result of the extravasation of blood into the laryngeal tissues leading to airway edema and asphyxia due to obstruction -- laryngospasm: adductor muscles of the vocal cords pull together in a shutter-like fashion, and the upper surface of the vocal cords closes over the top, causing complete obstruction - concern: individual may recover on-site and leave the area to return home, only to have increasing respiratory problems en route; ↑ internal hemorrhage and ↑ swelling, occlusion becomes more complete, and breathing becomes more difficult; swelling usually maximal within 6 hours, but may occur as late as hours after injury -- management: reassure the individual in an effort to diminish panic and anxiety; maintain open airway; focus on the breathing rate -- if individual recovers on-site, observation should continue throughout the day to note the presence of any delayed respiratory problems 11

12 Thoracic Conditions (cont.)Stitch in the side Sharp pain or spasm in chest wall (lower) during exertion Etiology: varies Management “Stitch in the side” -- potential causes include trapped colonic gas bubbles, localized diaphragmatic hypoxia with spasm, liver congestion with stretching of the liver capsule, and poor conditioning. Most individuals can run through the sharp pain by: -- forcibly exhaling through pursed lips -- breathing deeply and regularly -- leaning away from the affected side -- stretching the arm on the affected side over the head as high as possible 12

13 Thoracic Conditions (cont.)Breast conditions Contusions Can produce fat necrosis or hematoma formation → ↑ pain Management: standard acute Nipple irritation Runner’s nipples Friction → abrasions, blisters, or bleeding Prevention: petroleum-based product Cyclist’s nipples Perspiration + wind chill → ↑ pain Prevention: wind-proof jacket Breast contusions -- appearance of lesions on a mammogram may be indistinguishable from a malignant tumor; direct trauma should always be recorded on a female’s permanent medical record to avoid any erroneous conclusions when reading a future mammogram Nipple irritation -- commonly seen in distance runners when the shirt rubs over the nipples -- can be prevented by applying petroleum-based products and band-aids over the nipples to reduce irritation -- treatment involves cleansing the wound, applying an antibiotic ointment, and covering the wound with a nonadhering sterile gauze pad 13

14 Thoracic Conditions (cont.)Gynecomastia Excessive development of mammary glands Nipple soreness and tenderness Often physiologic; resolve spontaneously in 6– 12 months Associated with steroid use Gynecomastia -- seen particularly in the adolescent male -- usually bilateral -- seen in weight lifters and football players known to be taking anabolic steroids -- other causes include testicular, pituitary, and adrenal pathology 14

15 Thoracic Conditions (cont.)Strain of pectoralis major Mechanism: active contraction; overburdened by excessive load or extrinsic force S&S Sound: pop or tearing Immediate pain and weakness; aching or fatigue-like rather than sharp pain Deformity – muscle retracts Swelling and ecchymosis Limited motion, especially horizontal adduction and internal rotation Management: standard acute Pectoralis major muscle strain -- occurs in power lifting, particularly while bench pressing, water skiing, football, boxing, wrestling, and basketball, or in sudden deceleration maneuvers, such as when punching in boxing or blocking with an extended arm in football -- higher incidence of this injury is seen with anabolic steroid abuse -- rupture of proximal attachment: muscle retracts toward axillary fold, causing it to appear enlarged -- rupture of distal attachment: muscle will bulge medially into the chest region, causing the axillary fold to appear thin 15

16 Thoracic Conditions (cont.)Costochondral sprain Etiology: Collision force Severe twisting of thorax Result: separates cartilage at attachment to rib or sternum S&S Hear or feel a “pop” Localized sharp pain; changes to intermittent stabbing pain Visible deformity Severe: pain with deep inhalation Management: standard acute; physician referral Costochondral sprain -- separate the costal cartilage as it attaches to sternum or where anterior margin of rib attaches to anterior end of costal cartilage; puts pressure on intercostal nerve lying between it and rib above -- aka “slipping rib syndrome” -- more frequently involves 10th rib, followed by the 9th or 8th rib -- onset of symptoms may be insidious -- pain may slowly decrease in intensity, but sharp clicks may occur during bending maneuvers as the displaced cartilage overrides the bone -- pain can sometimes be reproduced by hooking the fingers under the anterior costal margin and pulling the rib cage anteriorly -- usually resolves itself with 3-4 weeks of rest and anti-inflammatory medication, but may persist for 9-12 weeks 16

17 17

18 Thoracic Conditions (cont.)Sternal fracture Rare; requires high impact S&S Immediate loss of breath Pain, especially with deep inspiration Suspected fracture – assess for underlying injury Management: activate EMS 18

19 Thoracic Conditions (cont.)Rib fracture Stress fracture – indirect force (muscle contraction) Acute Direct blow or compression Ribs 5-9 Most minor – undisplaced S&S Pain at site with deep inspiration or coughing Individual will take shallow breaths and lean toward fracture site Localized swelling, discoloration, crepitus Check for: Coughing up of blood Abnormal breath sounds Rate and depth of respiration Management: standard acute; immobilize chest; severe: immediate referral Stress fractures -- caused by an indirect force, such as a violent muscle contraction -- example: (1) opposing contractions of the scalene muscles and upper digitations of the serratus anterior may fracture the 1st rib at its thinnest segment, where the subclavian artery crosses; seen in weightlifting or baseball pitching; (2) anterolateral stress fractures of 4th and 5th ribs have been reported in golfers and rowers due to excessive action of the serratus anterior muscle -- if displaced, look for other injuries, such as a laceration of the intercostal artery -- fracture to lower 2 ribs may be associated with damage to the kidneys, liver, or spleen S&S -- stethoscope should be used to listen for abnormal or absent breath sounds in the lungs, and the rate and depth of respirations should be recorded -- manual compression of the rib cage in an anteroposterior direction and lateral compression will produce pain over the fracture site A 6-inch elastic bandage can be wrapped around the thorax with circular motions distal to the injury site, or if pain is intense or multiple fractures are suspected, a sling and swathe may be used to immobilize the chest. If 3 or more ribs are fractured, each in two locations (flail chest), or other serious signs such as those indicating a pneumothorax are present, activation of EMS is necessary. 19

20 Internal ComplicationsHyperventilation Etiology: pain, stress, trauma Rapid, deep inhalation – more O2 long exhalation – excessive CO2 loss S&S Inability to catch breath Numbness in lips and hands Spasm of hands Chest pain Dry mouth Dizziness Treatment: calm individual; slowly inhale through nose and exhale through mouth Hyperventilation -- rapid, deep inhalations draw more O2 into lungs; conversely, long exhalations result in too much CO2 being exhaled -- breathing into a paper bag has proven to be quite successful in restoring the oxygen-carbon dioxide balance, but many individuals find it embarrassing -- alternative treatment involves concentrating on slow inhalations through the nose and exhaling through the mouth until symptoms have stopped 20

21 Internal Complications (cont.)Pulmonary contusion Rare Force transmitted through thorax Bleeding in alveolar spaces S&S Hypoxia 2-4 hours after trauma Chest pain Shortness of breath Management: physician referral Pulmonary contusion -- usually results from nonpenetrating chest trauma -- force transmitted through the thorax (e.g., landing on a football or a body slam onto the hard ground) causes blood and protein to leak into the alveoli and interstitial spaces leading to pulmonary collapse -- mild contusions: heal within days; individual returns to full participation in as few as 10 days -- severe cases: individual is usually hospitalized and monitored with ventilatory support 21

22 Internal Complications (cont.)Pneumothorax Hemothorax Tension Pneumothorax 22

23 Internal Complications (cont.)Pneumothorax Air trapped in pleural space, causing portion of lung to collapse; lung can’t fully expand Etiology Traumatic – penetrating wound Spontaneous – unexpectedly without underlying disease S&S Shortness of breath, Severe chest pain on the affected side, Deviation of the trachea, Decreased ipsilateral breath sounds, Hyperresonance to percussion, Confusion, fatigue, anxiety restlessness, ↓ BP, Pain referred to shoulder tip, across chest, or over abdomen Management: calm, focus on controlled breathing; EMS Traumatic injury -- examples: stab wound, fractured rib, or severe chest trauma Spontaneous pneumothorax -- strongly associated with smoking -- individuals are commonly tall, lean males, predominantly in their late teens and early 20s, who have a long and narrow chest, with condition usually occurring after heavy exertion or running -- if not recognized and treated promptly, the condition can develop into tension pneumothorax -- if pneumothorax recurs, the individual should be advised to discontinue collision and contact sports 23

24 Internal Complications (cont.)Hemothorax Loss of blood into pleural cavity Etiology: fracture of rib could tear lung tissue or blood vessels in chest S&S Percussion of the thoracic area – dull Severe pain Difficulty breathing Cyanosis Decreased breath sounds Coughing up blood Potential for shock Management: treat for shock; EMS 24

25 Internal Complications (cont.)Tension pneumothorax Air accumulates in pleural space during inspiration and cannot escape on exhalation; expansion compresses heart and lung S&S Chest pain Tracheal deviation away from tension pneumothorax Respiratory distress Unilateral absence of breath sounds on affected side Distention of neck veins Hypotension Circulatory compromise Management: activate EMS Tension pneumothorax -- air progressively accumulates in the pleural space during inspiration and cannot escape on expiration; pleural space expands with each breath, resulting in the mediastinum being displaced to the opposite side; displacement compresses the heart, uninjured lung, thoracic aorta, and vena cava, causing a decrease in blood return to the right side of the heart; decreases cardiac output 25

26 Internal Complications (cont.)Traumatic asphyxia Direct , massive trauma to thorax S&S Bluish tinge on neck and facial region Subconjunctival hemorrhage Minute hemorrhagic spots on face Possible loss of vision Management: activate EMS Loss of vision has also been reported as a result of retinal edema, but vision may improve within hours or days. 26

27 Abdominal Wall ConditionsLacerations If penetrating, concern: possible contamination of abdominal organs Management: activate EMS Muscle strains Due to: direct trauma, sudden twisting, or sudden hyperextension of spine Most common – rectus abdominis Lacerations -- because further examination is necessary to rule out intra-abdominal injuries, ointments or creams should not be placed on the wound; instead, the wound is irrigated with sterile water, and the area covered with an absorbent pad to control hemorrhage Cullen’s sign -- bluish discoloration around the periumbilical region 72 hours after injury 27

28 Abdominal Wall Conditions (cont.)Solar plexus contusion Dyspnea Complicated by fear and anxiety Management: Flex the knees toward the chest Have athlete take a deep breath and hold it; repeat several times Have the athlete whistle Solar plexus contusion -- dyspnea thought to be caused by diaphragmatic spasm and transient contusion to the sympathetic celiac plexus 28

29 Abdominal Wall Conditions (cont.)Hernia Protrusion of abdominal viscera through weakened portion of abdominal wall Congenital or acquired Common – indirect; direct; femoral S&S: visible, tender swelling and an aching feeling in the groin Management: surgical repair Congenital hernias -- present at birth and may be related to family history Acquired hernias -- occur after birth and may be aggravated by a direct blow, strain, or abnormal intra-abdominal pressure Indirect hernias -- most common type of hernia in young athletes -- weakness in the peritoneum around the deep inguinal ring allows the abdominal viscera to protrude through the ring into the inguinal canal and occasionally extend into the scrotum -- weakness in the peritoneum is not typically present in women -- large indirect hernias may reduce spontaneously because they cannot extend easily into the inguinal canal Direct hernias -- common in men over 40 -- result from a weakness in an area of fascia bounded by the rectus abdominis muscle, the inguinal ligament, and the epigastric vessels Femoral hernias -- more commonly seen in women -- allow the abdominal viscera to protrude through the femoral ring into the femoral canal, compressing the lymph vessels, connective tissue, and the femoral artery and vein -- presents as a mass inferolateral to the pubic tubercle and medial to the femoral artery and vein Many hernias are asymptomatic until the preparticipation exam, when the physician palpates the protrusion by invaginating the scrotum with a finger. Protrusion of the hernia increases with coughing. Danger -- continued trauma to the weakened area during falls, blows, or increased intra-abdominal pressure exerted during activity -- hernia can twist on itself and produce a strangulated hernia, which can become gangrenous Most hernias are surgically repaired. Indirect hernia repair -- can begin walking, mild upper extremity exercises, and bicycling within 6 weeks of surgery -- return to noncontact sport participation in 7 weeks and contact sports within 8-10 weeks Repair of direct inguinal and femoral hernias -- all strenuous activities are prohibited for 3 weeks postsurgery -- return to noncontact sports can occur after 8 weeks and contact sports in 12 weeks 29

30 Intra-Abdominal ConditionsTrauma to abdomen: potential for severe internal hemorrhage “Red flags” Abdominal pain Nausea Thirst Localized tenderness and rigidity Cramps or muscle guarding Rebound pain Referred pain Solid organs are more commonly injured in sport participation. 30

31 Intra-Abdominal Conditions (cont.)Trauma to abdomen: potential for severe internal hemorrhage “Red flags” (cont.) Shallow breathing; rapid, weak pulse; decreased BP Coughing up blood Management: activate EMS; treat for shock; monitor vitals 31

32 Intra-Abdominal Conditions (cont.)Splenic rupture Enlarged spleen: increases susceptibility Most frequent cause of death from abdominal blunt trauma in sport Ability to splint itself S&S Trauma to left upper quadrant Kehr’s sign Signs of shock at time of injury Spleen -- rarely injured in sport participation, but certain systemic disorders (e.g., infectious mononucleosis) can enlarge the spleen, making it vulnerable to injury -- most commonly injured abdominal organ -- most frequent cause of death from abdominal blunt trauma in sport -- reason: spleen can splint itself and stop hemorrhaging, only to produce delayed hemorrhage days, weeks, or months later, after a seemingly minor jarring motion, such as a cough -- athletes with infectious mononucleosis should be disqualified from contact and strenuous noncontact sports for at least 3 weeks; after 3 weeks, return to strenuous noncontact sports is acceptable if individual feels up to activity, the spleen is nonpalpable, and liver function tests are normal -- Kehr’s sign: persistent dull pain in the upper left quadrant, left lower chest, and left shoulder -- treatment usually involves nonoperative intravenous therapy, strict bed rest, and intensive monitoring of vital signs 32

33 Intra-Abdominal Conditions (cont.)Liver contusion and rupture Direct blow to upper right quadrant S&S Palpable pain Hypotension Referred pain to inferior angle of right scapula Enlarged liver: avoid contact sports Liver contusion and rupture -- if lacerated, the liver is capable of massive bleeding, but it often is stopped by the time the wound is exposed in surgery; for this reason, there has been an increasing trend toward nonoperative management 33

34 Intra-Abdominal Conditions (cont.)Appendicitis If appendix becomes obstructed – leads to circulation problems – leads to bacterial growth and formation of pus Rupture!!!!! S&S Acute pain in lower right quadrant, loss of appetite, nausea and vomiting, low-grade fever Rebound pain – McBurney’s point Vermiform appendix is a pouch extending from the cecum; if it becomes obstructed (e.g., with hardened fecal material), venous circulation may be impaired, leading to an increase in bacterial growth and the formation of pus; appendicitis can lead to ischemia and gangrene; if the appendix ruptures, feces and bacteria are sprayed over the abdominal contents, causing peritonitis McBurney’s point: one-third the distance between the ASIS and the umbilicus 34

35 Intra-Abdominal Conditions (cont.)Kidney contusion Mechanism: direct blow or contrecoup injury from a high-speed collision S&S Pain, tenderness Hematuria Pain referred posteriorly to low back region, sides of the buttocks, and anteriorly to lower abdomen Management: ice for pain and inflammation; refer Kidneys -- located in the retroperitoneal upper lumbar area of abdomen -- upper third of the right kidney and the upper half of the left kidney are located under 12th rib -- posteriorly, protected by psoas, paravertebral, and latissimus dorsi muscles -- injured when the body is extended and the abdominal muscles are relaxed (e.g., when a receiver leaps to catch a pass) -- the kidney is normally distended by blood; the degree of renal injury depends on the extent of distension and the angle and magnitude of blow -- most injuries are managed conservatively with rest and fluid management -- spontaneous healing and return of good renal function can be expected 35

36 Intra-Abdominal Conditions (cont.)Kidney stones Risk factors / Causes S&S Asymptomatic until stone is large enough (≥7 mm) to cause blockage or infection Intense, colicky pain begins suddenly and intensifies over minutes Usually starts in the back or flank just below the edge of the ribs moving anteriorly toward the groin as the stone moves down the ureter toward the bladder Management: varies depending on type of stone and cause Kidney stones -- some substances filtered by the kidneys (i.e., calcium, oxalate, uric acid, and cystine) tend to form crystals; other substances (e.g., citrate and magnesium) help prevent crystal formation; if substances are not in balance, the urine becomes too concentrated or is too acidic or alkaline, and crystals can form -- risk factors include: family history of kidney stones; white males age years; certain diseases (e.g., gout, chronic UTIs, cystic kidney disease, hyperparathyroidism, renal tubular acidosis, cystinuria); certain medications (e.g., diuretics); having only one kidney; a diet high in protein and low in fiber; lack of adequate water intake; and living a sedentary life Four main types of kidney stones, each stemming from a different cause: -- calcium stones: most stones are calcium (85% in men, 65% in women); these stones may result from large amounts of vitamin D, drugs such as thyroid hormones and some diuretics, certain cancers, overactive parathyroid glands, and some kidney conditions -- uric acid stones: formed from uric acid, a byproduct of protein metabolism; diet high in meat may cause excess amounts of uric acid, as can chemotherapy treatment -- struvite stones: found mainly in women; struvite stones are almost always the result of chronic urinary tract infections (UTIs) -- cystine stones: only about 1% of kidney stones; form in people with a hereditary disorder that causes the kidneys to excrete excessive amounts of certain amino acids -- if the stone stops moving, the pain may also stop; other signs and symptoms may include a bloody, cloudy, or foul-smelling urine, nausea and vomiting, persistent urge to urinate, and fever and chills if an infection is present -- may be able to move the stone through the urinary tract by drinking water (as much as 2-3 qt a day) and by staying physically active -- if stones are too large to pass on their own or because they cause bleeding, kidney damage, or an ongoing UTI, surgical intervention with extracorporeal shock wave lithotripsy (ESWL) may be necessary; ESWL uses shock waves to break the stones into small crystals that are then passed in the urine; following treatment, it may take months for all the stone fragments to pass 36

37 Intra-Abdominal Conditions (cont.)Urinary tract infection (UTI) Any infection that begins in urinary system Cause: bacteria Most common Cystitis: inflammation of the bladder Urethritis: inflammation of the urethra S&S Pain during urination, urinary frequency and urgency, and pain superior to the pubic region; cloudy, bloody, or foul-smelling urine may also be noted Management: physician referral UTI -- many are simply painful and annoying -- can become a serious health problem if the infection spreads to the kidneys -- caused by the bacteria Escherichia coli, which ascend the urinary tract from the opening in the urethra, although the bacteria may also be introduced during urinary tract catheterization -- urethritis may also be caused by sexually transmitted diseases (e.g., chlamydia and gonorrhea) -- signs and symptoms may not be indicative of the severity of the condition; may present with very few symptoms, yet have significant bacteriuria (bacteria in the urine) A urine culture is necessary to identify the organism responsible for the infection. Medications most commonly recommended include antibiotics and sulfa drugs; usually, symptoms clear within a few days of treatment. 37

38 Assessment History Observation/inspection 38

39 Assessment (cont.) AuscultationBefore any physical contact to prevent alteration of peristalsis by physical stimulation Stethoscope Bell Used to detect low-pitched sound Apply with light pressure Diaphragm Better at detecting higher pitched sounds Apply with firm pressure Never acceptable to listen through clothing May take 2-3 minutes in each area to adequately evaluate nature and character of underlying conditions 39

40 Auscultation Sites Auscultation. Auscultation is performed with a stethoscope to listen at various sites for air exchange in the lobes of the lungs. A, Anterior view. B, Posterior view. C, Cardiac sounds can also be auscultated over four specific sites. 40

41 Assessment (cont.) Auscultation of lungsAssess various regions of each lung Most breath sounds are high pitched: use diaphragm Patient: breathe deeply though open mouth Examiner: listen for at least one full breath at each site, moving side to side, comparing symmetric areas of lungs Note intensity of breath sounds 41

42 Assessment (cont.) Auscultation of heartNormal cardiac cycle consists of two sounds, often called “lubb-dubb” Abnormal sound – murmur Described as “blowing,” “rumbling,” or “harsh” Abnormal sounds – click, snap, or a murmur Auscultation of the heart -- normal cardiac cycle consists of two sounds, which are caused by the blood flowing against the valves as they close -- abnormal sound is called a murmur -- produced when there is turbulent energy in the walls of the heart and blood vessels; obstruction to flow or flowing from a narrow to a larger diameter vessel produces the turbulence, which sets up eddies that strike the walls and produce vibrations that can be heard with a stethoscope -- also produced when there is a large volume of blood flowing through a normal opening 42

43 Assessment (cont.) Auscultation of abdomen Determine bowel motilityBowel sounds: frequency and character Normal: clicks and gurgles, estimated frequency of per minute Sounds widely transmitted throughout abdomen; only need to listen to one area Hypoperistalsis Auscultation of abdomen -- important to listen to the abdomen before performing percussion or palpation, since these maneuvers may alter the frequency of bowel sounds -- diaphragm of the stethoscope should be placed gently on the abdomen -- hyperperistalsis with rushes, cramps, and diarrhea suggests gastroenteritis -- hypoperistalsis, or a silent abdomen, could indicate a serious underlying problem (e.g., obstruction or internal hemorrhage); activate EMS 43

44 Assessment (cont.) Palpation Individual supine with knees flexedStructures Trachea Clavicle, sternum, costochondral cartilage, and ribs Rib cage (anterior and posterior) Abdomen Palpation Individual should be positioned supine with the knees flexed for more comfort. Trachea -- during breathing to ensure that it does not move -- movement may indicate tension pneumothorax Clavicle, sternum, costochondral cartilage, and ribs -- anterior-to-posterior direction -- note pain, deformity, or crepitus Left anterior rib cage -- enlarged spleen -- spleen may be more prominent if the patient raises their arms above their head Posterior rib cage -- locate the approximate position of the kidneys -- left kidney well protected by posterolateral rib cage; right kidney rests more inferior Abdomen -- begin by gently stroking the abdomen -- underlying peritoneal irritation: light touch perceived as dysesthesia, or a disagreeable sensation; suggests a serious underlying condition -- performed using flat part of several fingers with both hands moving in small circular motions; avoid poking or making sudden moves; may cause individual to jerk and tighten muscles -- begin away from the injured site and move across the abdomen in a straight line -- note muscle guarding or rigidity: muscle guarding that cannot be voluntarily relaxed may indicate internal peritoneal hemorrhage -- palpate for tenderness, muscle resistance, and superficial masses or deficits in the continuity of the abdominal wall -- deeper palpation can detect rigidity, swelling, or masses 44

45 Assessment (cont.) Physical examination tests ROM Vital signsUrinalysis Neurologic testing If the condition is not serious and a muscular strain is suspected, active, passive, and resisted muscle testing can be performed. Pulse rate and rhythm, blood pressure, temperature, respiratory rate, and characteristics of the breathing pattern should be noted. -- deep, quick breaths may indicate asthma or pulmonary obstruction -- noisy, raspy breaths may indicate a partial airway obstruction -- pink or bloody sputum indicates internal bleeding Urinalysis -- provides fast, general results for such information as specific gravity, pH, and levels of leukocytes, nitrate, protein, glucose, ketones, urobilinogen, bilirubin, and blood in the urine Neurologic tests in the thorax and abdomen are somewhat limited. -- dermatomes vary and often overlap Sites for referred pain can indicate the origin of injury. Myotome testing includes finger abduction and adduction (T1) and hip flexion (L1-L2); no other myotome testing exists for the axial region. 45