AH 325

Pelvic Injuries Laboratories

1.  
2. Secondary Survey
3. 1. History
   2. 1. Calm & reassure
      2. Mechanism of injury
      3. Onset of symptoms
      4. Location of injury
      5. Quantity and quality of pain
      6. Type & location of any abnormal sensations
      7. Progression of signs & symptoms
      8. Activities that make the symptoms better or worse
      9. Nausea
      10. Weakness
      11. Bleeding (fecal discharge)
      12. Dyspnea or (shortness of breath)
      13. Black tarry stools
   3. Observation
   4. 1. Patient's positions, movements & signs of guarding or apprehension
      2. Respiratory rate & rhythm for dyspnea (shortness of breath)
      3. Temperature
      4. Skin
      5. 1. Moistness
         2. Color
      6. Level of consciousness
      7. Signs of trauma
      8. 1. Hemoptysis (coughing up blood)
         2. Hematemesis (vomiting up blood)
         3. Ecchymosis
         4. Evidence of mass
         5. Evidence of penetrating trauma
         6. Evidence of shock
         7. 1. pale skin
            2. cyanosis (pale or bluish skin color from poor oxygenation of the blood)
            3. 1. lips
               2. fingertips
               3. fingernails
      9. Vomiting
      10. Hematuria (may be microscopic)
   5. Auscultation
   6. 1. Assesses the presence or absence of bowel sounds
      2. Assesses abnormal bowel sounds
   7. Percussion
   8. 1. Listen for normal/abnormal sounds such as tympany, dullness, or hyperresonance
   9. Palpation
   10. 1. Pulse rate
       2. Skin Temperature
       3. General and specific areas of tenderness
       4. Location of deformities
       5. Location & extent of swelling
       6. Signs of acute abdomen
       7. 1. Rebound tenderness
          2. Rigidity
          3. Guarding
       8. Asymmetry
       9. Muscle rigidity
       10. Special tests
       11. 1. Evaluate active, resistive, & passive range of motion to elicit painful ranges, limitations & musculoskeletal weaknesses
           2. 1. Sagittal plane range of motion test (standing, sitting, supine, sidelying) with hips flexed, neutral & supine
              2. Transverse plane range of motion test (standing, sitting, sidelying)
              3. Frontal plane range of motion test (standing, sitting, sidelying)
           3. Valsalva Maneuver - provoke pain increase or mass protrusion
           4. Peritoneal irritation tests
           5. 1. Iliopsoas test
              2. Obturator test
              3. Heel Pound test
   11. Hollow Organ Injury (Signs & Symptoms)
   12. 1. Decreased bowel sounds
       2. Signs of acute abdomen
       3. 1. Rebound tenderness
          2. Rigidity
          3. Guarding
       4. Distended abdomen
       5. Signs and symptoms of shock--such as hypotension and tachycardia
   13. Kidney Injury (Signs & Symptoms)
   14. 1. Hematuria
       2. Bloody discharge or inability to void
       3. Flank pain
       4. Positive Grey-Turner sign - Ecchymosis in flank
       5. No acute abdominal signs
       6. Possible bony crepitus due to rib fracture
   15. Pelvic muscle strains and contusions (Signs & Symptoms)
   16. 1. Superficial, but not deep tenderness to palpation
       2. Point tenderness to direct palpation
       3. Pain with contractile movements of involved muscle
       4. Pain with passive stretching of involved muscle
       5. Weakness in movements controlled by involved muscle
       6. Deformity of muscle
       7. Ecchymosis
       8. Positive bowel sounds
       9. No distention
       10. No signs and symptoms of shock
       11. No signs of acute abdomen
   17. Abdominal Muscle Hematoma (Signs & Symptoms)
   18. 1. Muscle guarding and tenderness
       2. Palpable mass in abdominal wall
       3. Point tenderness to direct palpation
       4. Pain with contractile movements of involved muscle
       5. Pain with passive stretching of involved muscle
       6. Weakness in movements controlled by involved muscle
       7. No signs of acute abdomen
   19. Non-traumatic abdominal injuries/conditions
   20. 1. Appendicitis - Inflammation of the appendix, characterized by high fever, abdominal pain often localized in the right lower quadrant, nausea, vomiting, and anorexia. May be signs of acute abdomen.
       2. Ectopic pregnancy - Implantation of a fertilized ovum outside of the uterine cavity. May be signs of acute abdomen if it ruptures.
       3. Gastroenteritis - Inflammation of the stomach and intestinal tract which is characterized by one or more of the following symptoms: nausea, vomiting, diarrhea. Usually due to viral infection, but can be bacterially induced.
       4. Hernia - Protrusion of abdominal viscera through a portion of the abdominal wall. May be aggravated by athletic activity. Areas most susceptible are inguinal & femoral canals. In male, the inguinal canal is the point at which the spermatic cord containing blood vessels, nerves, and the vas deferens of the male reproductive system leaves the abdominal cavity & enters the scrotum. In the female, the round ligament of the uterus passes through the canal and terminates in the labia majora. The femoral canalis the point at which the femoral blood vessels & nerves pass from the abdominal cavity into the lower extremity. These 2 openings are protected by muscular control, like the shutter of a camera. The opening may be congenitally weak or weakened by continued intra-abdominal pressure, resulting in abdominal viscera being forced through these canals and out of the abdominal cavity. May be minor to severe abdominal wall defect. Symptoms are pain & prolonged discomfort & a feeling of weakness or pulling in the groin. Protrusion may also be felt in the groin, which will increase upon coughing. Danger is a strangulated hernia needing immediate medical attention whereby blood supply to the protruding viscera is occluded.
       5. Indigestion (heartburn) - Incomplete or imperfect digestion, usually accompanied by one or more of the following symptoms: pain, nausea, vomiting.
       6. Stitch in the side (sideache) - Sharp pain in the side usually associated with strenuous physical activity. May be caused by muscle spasm and/or trapped gas.
       7. Diarrhea - condition of abnormally frequent & liquid bowel movement which can be caused by anxiety, gastroenteritis, bacterial infections, parasitic infestations, inflammatory processes.
       8. Constipation - infrequent or difficult evacuation of the feces, caused by disease or condition of the G-I tract, lack of sufficient roughage & bulk in the diet, overuse of laxatives, nervousness & anxiety. If defecation urge is neglected or depressed, water is absorbed form fecal matter causing it to become hard & dry. Be aware of abnormal change in in defecation patterns & character of stools.
       9. Gastritis - inflammation of the stomach lining, possibly caused by the use of aspirin, alcohol, some medications, & stress. Results in gastric bleeding varying form slight to massive. Characterized by vague indefinite pain in upper left quadrant or epigastrium.
       10. Ulcer - the disintegration of the G-I tract & necrosis of the mucous membrane caused by the acid gastric juices. Stomach ulcers are peptic ulcers. Duodenal ulcers are in nearby duodenum. When any portion of the gastric or duodenum becomes necrotic the acid gastric juices digests the dead tissue just like a piece of meat causing a hole that extends into the wall of the stomach or duodenum. Most ulcers in the past have been associated with high-strung, nervous, irritable, prone to worry, and stressful people, however recent research has shown most ulcers to be caused by a bacterial infection instead of stress. Ulcer pain often relieved by taking food, but pain returns in an hour. Also relieved by neutralizing the acid with sodium bicarbonate.
       11. Colitis - inflammation of the colon. Ulcerative colitis, a common cause of bowel disease, affects all age groups & commonly begins young in life. Begins with acute attack of abdominal pain accompanied by diarrhea & passage of blood, mucus, and pus in the feces. Fever & malaise also are often present. Usually becomes chronic characterized by alternating periods of exacerbations & remissions.
       12. Hemorrhoids - piles, condition in which veins at the lower end of the rectum become varicose (swollen) and enlarged. Internal hemorrhoids are those covered by the mucous membrane at lower rectum and may come down through the anal opening & appear on the surface, although they can be replaced by pressure. External hemorrhoids are covered by the skin in the anal area. Caused by straining due to bowel movements, chronic constipation, & heredity. Result can be a protrusion and/or bleeding of the veins of the anus. Most are self limiting, but occasional referral for surgery may be necessary sometimes.
       13. Pancreatitis - inflammation of pancreas, can be mild & lead to vague abdominal symptoms or severe with intense pain often referred to as an acute abdomen. Can be caused by infectious agent & often appears due to sudden release of active pancreatic enzymes within the organ itself. Attacks occur after a large meal or alcoholic spree with the outstanding symptom being intense pain. More painful than ulcers, patient appears to be in shock, remains motionless, turns blue on face. Immediate medical referral is necessary.
       14. Hepatitis - inflammation of the liver, commonly results from viral infection, but ay be secondary to bacterial, fungal, or parasitic infection, toxic exposure, side effect of prescribed medication, or consequence of immunologic disorder. Symptoms vary from malaise, fever, loss of appetite, jaundice, followed by diarrhea, nausea, vomiting, and abdominal discomfort. Jaundice-yellow coloring of skin & sclera. Infectious hepatitis is extremely contagious.
       15. Sickle cell anemia - condition of the blood with abdominal symptoms & possible involvement of the spleen. Hereditary, genetically determined, sometimes fatal, characterized by an abnormal type of hemoglobin, and mostly confined to black population. Some may never experience any symptoms or problems but an acute crisis, which may be a recurrent, painful, and frustrating problem. Precipitating factors include high altitude, fever, infections, cold exposure, and stress. Symptoms include muscle weakness, pallor, fatigue, severe pain often in abdomen, chest, back, and extremities. May mimic an acute abdomen. Most severe cases may result in death.
   21. Non-traumatic genitourinary injuries/conditions
   22. 1. Perineal lacerations - referred for suturing, even small lacerations should be referred
       2. Vaginitis - common, usually caused by a yeast or parasitic infection
       3. 1. Gradual onset
          2. Dysuria - painful urination
          3. Vaginal discharge, odor & itching
       4. Testicle contusion - mild to extremely painful, nauseating, & disabling
       5. 1. Direct blow to scrotum
          2. Usually short-lived symptoms
          3. Occasional bleeding
          4. Drawing sensation with muscles attached to testes going into spasm
          5. 1. Relieved by drawing knees up to chest or Valsalva maneuver
          6. Examine for normal positioning & appearance
       6. Testicular torsion - torsion of the spermatic cord
       7. 1. Scrotum appears to be cluster of swollen veins
          2. Dull pain combined with heavy dragging sensation in scrotal region
          3. Immediate medical attention is required
       8. Hydrocele - fluid in tunica vaginalis (membrane covering front & sides of testis & epididymis)
       9. 1. Caused by inflammatory condition of testis or epididymis, tumor, or trauma
       10. Hematocele - same condition as hydrocele except blood is present
       11. Varicocele - varicose condition of the veins from the testicle & the epididymis forming a swelling that feels like a "bag of worms". May appear bluish through the skin of the scrotum & may e accompanied by a constant pulling, dragging, or dull pain in the scrotum.
       12. Testicular cancer - most common type of tumor in men 15 to 35. 12% of all cancer deaths in U.S. Painless scrotal mass most common symptom. Other symptoms are:
       13. 1. Slight enlargement of one of the testes or a change in its consistency
           2. Dull ache in the lower abdomen
           3. Sensation of dragging or heaviness in the scrotum
           4. Self-examination & education is most important
       14. Menstrual dysfunctions
       15. 1. Amenorrhea - absence or abnormal cessation of the menses
           2. Oligomenorrhea - abnormally infrequent or scanty menstruation. Primary amenorrhea is the delay in menarche beyond 16. Secondary amenorrhea is the absence of menstruation in women who previously menstrual.
           3. Dysmenorrhea - Pain associated with menstruation.
       16. Sexually Transmitted Diseases - any athlete with a urethral discharge should be referred.
       17. 1. Chlamydia - intracellular parasites that cause wide variety of diseases. Chlamydia trachomatis causes genital infections in males & females, most commonly sexually transmitted pathogen. In males inflammation occurs with pus discharge 1 to 4 weeks after intercourse. Occasionally, dysuria & traces of blood are found in urine. Most common cause of urethritis in the male. In females, infection is often asymptomatic, but may cause a vaginal discharge, dysuria, and a painful pelvis.
           2. Gonorrhea - "clap" caused by gonococcal bacteria, usually spread through sexual intercourse. In male acute urethritis occurs 2 to 8 days after infection. Main symptom is purulent discharge and is combined with difficulty & pain in passing urine. If untreated it may pass to seminal vesicles & epididymis. Treatment results in quick resolution. In female, it causes acute urethritis & cervicitis, symptoms or frequently ignored, absent, or unnoticed. Infection can spread to fallopian tubes and lead to peritonitis.
           3. Syphilis - caused by the spirochete Treponema pallidum, a slender, spiral parasitic microorganism. A small papule develops at site of inoculation 10 to 90 days after exposure, which becomes painless ulcer, or chancre sore. It heals without treatment within 4 to 5 days without much scarring. Its appearance may be missed, particularly in women when the lesion is on the cervix or in the vaginal vault. Within 2 to 3 months disease becomes clinically generalized and rash of secondary syphilis appears, a non-itching rash possibly affecting the whole body, including palms & soles. Slight fever, headaches, and joint pain may be noted at this stage.
4. Immediate Referral with the following signs & symptoms
5. 1. Vomiting or coughing up blood
   2. Signs of shock
   3. Severe abdominal pain
   4. Signs of acute abdomen
   5. 1. Rebound tenderness
      2. Rigidity
      3. Guarding
   6. Blood in the urine or stool
   7. Prolonged discomfort, sensation of weakness, or pulling in groin
   8. Superficial protrusion or palpable mass
   9. Increasing nausea
   10. Presence of fever
   11. Presence of radiating or referred pain
   12. Doubt regarding the nature and severity of the chest injury
6. Referral
7. 1. Signs/Symptoms of veneral disease
   2. Testicular contusions that do not resolve or that have significant bleeding

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