chapter 15. Chest problems
MH Vioreanu and SP Gaine
INTRODUCTION
Three main scenarios may arise:
APPROACHING THE PLAYER WITH BREATHING/CHEST PROBLEMS
What should I check for?
Speak to the player
• ‘Can you tell me what happened?’
• ‘Were you hit?’
• ‘Do you have any pain?’
• ‘Where is the pain?’
• ‘Does the pain go anywhere else?’
• ‘Is it worse on breathing?’
• ‘Do you feel short of breath?’
• ‘Has this ever happened before?’
• ‘Do you have any breathing problems?’
• ‘Are you asthmatic?’
• ‘Do you have any heart problems?’
• ‘Are you taking any medications?’
Problem identification
• The mechanism of injury will give a good clue as to the cause of the problem
• By speaking with the player you can get a good indication of how serious the problem is
If a player can’t speak or is extremely out of breath it is a serious condition (Red Zone Injury)– go to the ABC chapter (p. 21).
• Contact – ‘I was hit’ – more than likely a muscular or bony injury
• No contact – ‘I was not hit’ – WARNING – There may be a breathing condition or heart condition. Take extreme caution!
• The site of the pain will give a clue as to the cause
• Central Chest Pain – Behind the breast bone – Is likely to be from the heart or lungs, but can also be from the stomach or be caused by anxiety
• Pain to either side to rib cage – Most likely to be from the lung
• Type of pain
• Crushing pain – constant, unrelenting – likely to be from the heart
• Pain on breathing likely to be from the lung or ribs
• Does the pain go anywhere?
• A pain running down the left arm or into the jaw – always think Heart Attack!
• Tightness across the chest going into the back may be from the lungs or heart – Caution!
• Other illnesses or medications
• It is very important to know if a player has a known condition
• Find out about any medication – the player may have it with them and it may be very useful to treat them
Signs and symptoms of ‘breathing problems’
• Rapid deep breathing
• Noisy breathing
• Flaring nostrils
• Dizziness or faintness
• Anxiety or confusion
• Straining muscles: neck, face, chest, abdomen
• Blue discoloration – lips, face
• Numbness or tingling – hands/feet
• Spasm of fingers and toes If player has one of the above problems treat them as an emergency – see the ABC chapter (p. ••).
Observe
• Look at the player’s general appearance, position, ability to breathe and speak
Rule out serious injury
Airway problem or respiratory arrest (Red Zone Injury):
• If player is able to speak normally, the airway is probably OK
• Establish if the player is able to breathe on their own
• Make sure to check the airway if they are unable to speak – go immediately to the ABC chapter (p. 21)
Touch for tenderness
• Feel for point tenderness of the chest
• Place your hand on either side of the chest wall to confirm they are moving equally with each breath
• Feel over the airway to make sure it is in the centre of the neck
• If an injury is located, feel the ribs to check for any breaks or abnormality – if found, this is a Red Zone Injury
Skills assessment
• Assess the player’s ability to breathe while exercising, preferably on the side of the pitch
• If the player continues to struggle to breathe, and is not just winded or ‘out of puff’, they must come off to be assessed further
If a breathing problem is identified, remove player from the play immediately.
What should I do?
A player with a serious breathing problem or chest injury needs to be removed immediately from the field of play for assessment and treatment. These are Red Zone Injuries until proven otherwise!
Talk to the player
• Reassure the player, explain what is happening
• By talking to the player, establish their capacity to breathe
Remove the player safely from the field of play
• The player should walk off the pitch with assistance
• If the player is seriously injured they should be taken off on a stretcher
Emergency transfer to hospital
• Any serious chest injury should be transferred to hospital by ambulance if available or as soon as possible by other means
Avoid further injury
• Remove the player from any environment that could worsen the breathing problem, e.g. smoke, cold air, fog
• Perform ongoing assessment of the player’s state
• DO NOT leave the player alone
Treatment
• Keep player at rest in a comfortable environment
• Place player in a sitting position. It helps if the player can support themselves on their forearms when sitting – this eases their efforts to expand the chest
• Continue to talk with the player
• If a player stops speaking or is unable to speak, check that the airway is open
• If in doubt at any stage, go to the ABC chapter (p. 21)
• Administer oxygen if available
• Assist player with medication (beta-agonist inhaler – salbutamol, etc.) if they are familiar with it (Fig. 15.4)
 |
| Fig. 15.4 |
• Cover the player to conserve body heat
• Continue to monitor the player and provide emotional support
‘I CAN’T BREATHE –I WAS NOT HIT’
Red Zone
• Severe asthma attack
• Anaphylaxis
• Collapsed lung (Spontaneous pneumothorax) (Fig. 15.1)
• Epiglottitis
Amber Zone
• Mild or moderate asthma attack
• Chest infection/bad cough
• Hyperventilation
Green zone
• Athlete out of shape
Severe asthma attack
Exercise induced asthma is very common. The asthma attack usually occurs in the first 5-10 minutes after starting exercising or 5-10 minutes following exercise, and may last up to 30 minutes. Fast, hard breathing, coughing, wheezing and a tight chest are signs of an asthma attack, which can be very serious, even life-threatening. As many as 10-20% of all athletes will experience some form of asthma attack when exercising in cold, dry air (e.g. cross-country skiing, ice-hockey).
What should I check for?
Speak to the player
• What happened?
• Did you get hit?
• Are you having trouble breathing?
• Do you have asthma?
• Where’s your inhaler?
• Do you have any pain?
• Does it hurt to take a deep breath in?
Problem identification
By talking to the player, decide upon the severity of the attack
• A player severely out of breath, unable to speak, extremely agitated or panicking is likely to be having a serious attack. They need to calm down, take their medication and be sent to hospital
Observe
• Observe the way the player is breathing
• The player is anxious and in obvious respiratory distress
• The player is breathing rapidly (fast rate) – easy inhalation and forced, noisy expiration (wheezing)
• The player is using other muscles to breathe – abdominal breathing, straining of neck muscles, and sucking in of cheeks
• The player may have a bluish tint to their skin, especially around the lips
Rule out serious injury
• Make sure the airway is open
• Ensure that the player is able to speak
If the airway closes or the player can no longer breathe, go immediately to the ABC chapter (p. 21).
Skills assessment
If the player is suffering from a chest injury, it is advisable to remove them from competition. Only players with minor injuries should be allowed to return to action.
What should I do?
Talk to the player
Breathing difficulties and chest pain cause extreme anxiety and distress.
• Act calmly and with assurance – tension and anxiety makes an asthma attack worse
• Try to focus the player on calm, controlled breathing
Remove the player safely from the field of play
Avoid further injury
• Stopping activity will reduce the stress on the heart and lungs
• Remove the player from an environment that may cause breathing difficulties – cold, dry, foggy air
Emergency transfer
Call for an ambulance if necessary.
Treatment
• Give oxygen
• Place the player in a seated position
• Attempt to give an inhaler – salbutamol or equivalent (Fig. 15.4)
• Send patient to the hospital by ambulance, or get the player to hospital by the quickest means possible if an ambulance is not available
• Encourage slow deep breaths
Do not leave the player unattended!
Anaphylaxis/anaphylactic shock (see also Ch. 6)
Anaphylaxis is an extreme allergic reaction that can be life-threatening. Anaphylaxis may be associated with widespread itching and the same signs and symptoms as asthma. Although not commonly encountered, athletes may have an anaphylactic reaction to a substance – an allergen – which could be anything from eating certain nuts through being bitten or stung by an insect to receiving antibiotic medication.
What should I check for?
Speak to the player
• Make sure the player can speak! A player who cannot speak indicates a swollen airway. This is a Red Zone Injury – go immediately to the ABC chapter (p. 21)
• ‘What happened?’
• ‘Are you having trouble breathing?’
• ‘Did you get stung by anything?’
• ‘Did you eat anything strange?’
• ‘Do you have any known allergies?’
• ‘Do you have any itching sensation?’
• ‘Has this ever happened before?’
• ‘Do you take any medications?’
Problem identification
• Anaphylactic reactions are not always very obvious
• A player will often complain of feeling very hot and bothered
• They may complain of swelling and feeling congested
• They are often agitated and irritable
Observe
• The player may be anxious – this could be respiratory distress
• Their breathing may be noisy or ‘whistling’
• If they complain of an itch or soreness on their skin – check for an insect bite or rash
• Sometimes the rash is on the player’s chest or back and is not very obvious. Remove the player from the field of play and check these areas if they complain of itchiness there
• Look out for raised areas of skin, redness, blotchiness, blistering or swelling
Rule out serious injury.
• Make sure airway is open
Touch for tenderness
• Feel the player’s forehead to see if they have a temperature
• Touch any area of skin that feels itchy
• Feel for swelling
• Feel for any raised areas on the skin which may indicate a rash
• Feel under the angle of the jaw for any swelling of the glands
Skills assessment
The player is not able to continue physical activity.
What should I do?
Talk to the player
Act calmly and with assurance.
Tension and anxiety makes breathing worse.
Remove the player safely from the field of play
Emergency transfer Call for an ambulance.
Avoid further injury
• Stopping activity will reduce the stress on the heart and lungs
• Remove the player from an environment that may cause breathing difficulties – cold, dry, foggy air
• Remove the allergen (the stinger of an insect bite) – take care not to harm yourself!
Treatment
According to the severity of an anaphylaxis attack, treat as follows:
• If the player has difficulties breathing, generalized rash and swollen lips
• Call for an ambulance
• Give the player oxygen if available
• Use injectable adrenaline if available (see Fig. 6.3, p. 43)
• Reassess frequently – if the player stops speaking or the airway closes go immediately to the ABC chapter (p. 21)
• A player with anaphylaxis but no breathing difficulties
• Place athlete in sitting position
• Give antihistamine medication if available
• Observe every 15 minutes
Insect bites and stings
• The swelling associated with an insect bite may be dramatic and frightening
• Because the sting of a bee remains in the skin, it can continue to inject venom for up to 20 minutes after the bee has gone
• You should gently attempt to remove sting attached to the skin/muscle by scraping the skin with the edge of a sharp, stiff object such as a credit card.
• Do not leave the player unattended.
Collapsed lung (Spontaneous pneumothorax)
Spontaneous pneumothorax is a collection of air between the outside surface of the lung and the inside surface of the chest wall causing the lung to collapse (Fig. 15.5). Spontaneous means there is no injury to the chest or lung. It usually occurs in tall, thin men between the ages of 20 and 40. Competition at high altitude may be a contributory factor. Symptoms often begin suddenly and can occur while exercising or resting. This is a potentially life-threatening condition for the athlete and needs to be dealt with urgently by a doctor.
What should I check for?
Speak to the player
• ‘What happened?’
• ‘Are you having trouble breathing?’
• ‘Did you get hit?’
• ‘Do you have any pain in the chest?’
• ‘Where is the pain?’
• ‘Does it hurt to breathe in?’
• ‘Has this ever happened before’
Problem identification
• The player will complain of a sharp pain and localize it to one side of the chest
• The pain is worse on taking a deep breath
• Tall males are more likely to develop spontaneous pneumothorax
• This problem can be recurrent, so it is important to determine whether it has happened before. If it has, the player will know all about it!
Observe
Observe the way the athlete is breathing:
• May be anxious and in respiratory distress
• Watch the movement of the rib cage – one side will not move compared to the other
• Watch to see if the player is using other muscles to breathe – straining of neck muscles, sucking in of the cheeks and tummy as they try to get more air in!
• Look for a bluish tint to the skin, especially around the lips – this indicates low oxygen levels in the blood
Rule out serious injury.
• Make sure airway is open
Touch for tenderness
• Feel player’s ‘wind pipe’. In severe cases this is not in the middle
• Feel both sides of the player’s chest to see if they are moving equally with each breath. No movement on one side would suggest a collapsed lung on that side
Skills assessment
• The player is not able to continue physical activity
What should I do?
Talk to the player Act calmly and with assurance – Tension and anxiety makes breathing worse
Remove the player safely from the field of play
Emergency transfer
Call for an ambulance
Avoid further injury
• Stopping activity will reduce the stress on the heart and lungs
• Remove the player from an environment which may cause breathing difficulties – cold, dry, foggy air
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