Chest and Abdominal Trauma in Sport

Tension pneumothorax is the one to know. Air enters the pleural space and cannot leave, the lung collapses, the mediastinum shifts and venous return fails. The athlete is breathless and getting worse, and the injured side is quiet and barely moves. It is a clinical diagnosis, and waiting for a radiograph to confirm it is how people die of it.

Decompression is not automatic, and this is where people go wrong in both directions. It is indicated where a tension pneumothorax is suspected and there is severe respiratory compromise or haemodynamic instability, and it is performed by a clinician trained and equipped for it. A suspected pneumothorax in a stable athlete needs urgent transfer, not a needle.

Where a needle is indicated, the site is contested and the guidelines diverge, which is worth knowing on both counts. The European Trauma Course and the Royal College of Surgeons of Edinburgh continue to recommend the second intercostal space in the mid-clavicular line. Advanced Trauma Life Support moved in 2018 to the fourth or fifth intercostal space just anterior to the anterior axillary line, on the grounds that the chest wall is thinner there. The argument turns on chest wall thickness against what lies beneath, it varies with the athlete's build, and failure to reach the pleural cavity is common whichever site is used. The UK standard cannula is 14 gauge and 5 centimetres.

Cardiac tamponade after blunt trauma is rare. It presents as shock without an obvious cause, and distended neck veins are the classic sign but may be absent, particularly in an athlete who is also bleeding. It is not commotio cordis, which is an immediate electrical arrest following a blow to the precordium, with no structural injury at all, and which is covered on the Sudden Cardiac Arrest page.

Haemothorax gives a dull, quiet chest with shock, and the blood is inside the chest rather than on the grass where you would notice it.

Flail chest is a segment moving paradoxically, and the danger is not the flail but the pulmonary contusion beneath it, which worsens over hours.

Rib fractures matter for what they signal. The lower ribs on the left overlie the spleen and on the right the liver, so a fractured lower rib is a reason to look below the diaphragm rather than a diagnosis in itself.

The spleen is among the most commonly injured solid organs in blunt abdominal trauma and is frequently the only one hurt. A blow to the left flank or the lower ribs is the mechanism, and the presentation is unreliable: a substantial minority of splenic injuries have no obvious examination findings at all. A normal abdomen on the touchline excludes nothing, which is the most important sentence on this page.

Kehr's sign is worth recognising and not worth chasing. Blood irritating the underside of the diaphragm refers pain to the left shoulder tip, classically worse on inspiration. Its presence in an athlete who has taken a blow to the flank raises strong suspicion of splenic injury, and its absence reassures about nothing. Do not manoeuvre someone with a possible splenic bleed in order to provoke it. A left shoulder that hurts alongside a normal shoulder examination is the finding worth noticing.

The liver comes next, from a blow to the right upper quadrant, and the kidney from the flank. Dipstick the urine after any significant blow to the flank, loin or abdomen, because non-visible haematuria cannot be found any other way and it is what triggers assessment.

And the bleeding need not be now. Delayed splenic rupture is a real entity: a subcapsular haematoma that tears later, sometimes hours afterwards and occasionally days.

In hospital, computed tomography is the investigation for an athlete who is haemodynamically normal or who responds to resuscitation. Worth carrying into the referral conversation: a negative focused assessment with sonography for trauma does not exclude intraperitoneal or retroperitoneal bleeding, so a normal scan is not a discharge either.

Call 999. Give oxygen where there is hypoxaemia or severe respiratory compromise. Keep the athlete warm, keep them nil by mouth, and reassess in a structured way rather than simply watching them. If traumatic cardiac arrest occurs, the priority is treating the reversible causes, chest decompression among them where it is indicated.

Observations are serial or they are decoration. Respiratory rate, oxygen saturation, pulse, blood pressure, conscious level and the abdominal examination, repeated, are what show you a trend. One normal set at ten minutes shows you nothing.

The disposition is the point. Any athlete who takes a significant blow to the trunk comes off. 'Winded' is the word the culture uses and it is doing a great deal of work: it is a diagnosis of exclusion in anyone who has taken a blow to the trunk, and it is not one the athlete gets to make.

Anyone with pain, tenderness, referred shoulder pain, haematuria or any abnormal observation goes to hospital. Major trauma usually goes to a major trauma centre, but the destination is decided by ambulance triage against your regional trauma pathway, and occasionally the treatment cannot wait and a trauma unit is closer. That call is not yours, and the plan's job was to have agreed the pathway before the day.

They also go with someone, and with instructions about what would bring them back, because the athlete who deteriorates at eleven at night is the one who was told they were fine at four.

• •Current NICE guidance on major trauma covers assessment and initial management, imaging, and the trauma network pathway that determines destination.
• •The decompression site differs between guidelines: the European Trauma Course and the Royal College of Surgeons of Edinburgh recommend the second intercostal space in the mid-clavicular line, while Advanced Trauma Life Support moved in 2018 to the fourth or fifth intercostal space anterior to the anterior axillary line. Failure to reach the pleural cavity is common at either site.
• •The Faculty of Pre-Hospital Care sets the immediate care in sport standards that determine who at your venue is competent to decompress a chest.
• •The spleen is among the most commonly injured solid organs in blunt abdominal trauma, and a substantial minority of splenic injuries present without obvious examination findings.

• •Chest trauma can collapse breathing or circulation immediately; abdominal bleeding is often occult.
• •Tension pneumothorax is a clinical diagnosis, and decompression needs compromise, not just suspicion.
• •The European Trauma Course and Advanced Trauma Life Support recommend different decompression sites.
• •A normal abdominal examination does not exclude splenic injury.
• •Dipstick the urine after a flank blow; non-visible haematuria is invisible without it.
• •A negative scan does not exclude bleeding, and a normal examination is not a discharge.