8.3 Cardiovascular, Pulmonary, Abdominal & Dermatologic Assessment
Key Takeaways
- AHA 14-element PPE red flags include exertional syncope, family sudden cardiac death, Marfan stigmata, and a murmur that gets louder with Valsalva or standing — withhold and refer for hypertrophic cardiomyopathy concern
- Sudden cardiac arrest is instantaneous and unresponsive; commotio cordis is a chest blow inducing ventricular fibrillation; exertional sickling collapse is often still lucid in the first minutes of intense work — do not treat it as a cramp
- Unequal breath sounds and late tracheal deviation suggest tension pneumothorax; vocal cord dysfunction is inspiratory stridor that does not behave like asthma; anaphylaxis needs epinephrine, not another albuterol trial
- McBurney and rebound point to appendicitis/peritonitis; Kehr is referred left-shoulder pain from the spleen; testicular torsion is a time-critical surgical emergency
- NFHS wrestling skin rules disqualify contagious herpes, tinea, and bacterial/MRSA lesions until treatment and lesion criteria are met — wet herpetic or draining bacterial lesions cannot be covered to compete
PA8 Domain II task 0202 is not only joints. Athletic trainers recognize and evaluate cardiovascular, pulmonary, abdominal, endocrine, and dermatologic presentations — then refer or activate EMS. Full medical treatment belongs to the physician; missing the red flag belongs to you.
Cardiac Red Flags (AHA 14-Element PPE)
The American Heart Association 14-element preparticipation screen is history plus exam, not a mandatory population ECG (ECG may be added in structured programs; universal ECG screening of all young people is not the AHA population recommendation).
Personal history (items 1–7): exertional chest pain or pressure; unexplained syncope or near-syncope; exertional dyspnea, fatigue, or palpitations; prior heart murmur; elevated blood pressure; prior restriction from sport; prior cardiac testing ordered by a physician.
Family history (items 8–10): premature sudden death before age 50 from heart disease in a relative; disability from heart disease in a close relative under 50; known family hypertrophic or dilated cardiomyopathy, long-QT or other channelopathy, Marfan syndrome, clinically important arrhythmia, or related genetic cardiac disease.
Physical exam (items 11–14): heart murmur (auscultate supine and standing, with Valsalva); femoral pulses (coarctation); Marfan stigmata (arm span > height, arachnodactyly, pectus, kyphoscoliosis, high-arched palate, myopia, and related findings); brachial blood pressure sitting, preferably both arms.
A murmur that increases with Valsalva or standing (maneuvers that decrease left-ventricular volume) is a hypertrophic cardiomyopathy (HCM) / dynamic-obstruction concern (also consider mitral-valve prolapse patterns). Most innocent flow murmurs soften with those maneuvers. Withhold sport and refer — do not “clear the PPE” around that murmur.
Exertional syncope is never a vasovagal shrug until a physician says so. Family sudden cardiac death plus Marfan habitus plus a Valsalva-louder murmur is a stop-the-workout cluster.
HCM Versus Commotio Cordis Versus Sudden Cardiac Arrest
| Condition | What it is | Recognition | Immediate action |
|---|---|---|---|
| Hypertrophic cardiomyopathy | Pathologic LV hypertrophy with possible outflow obstruction and arrhythmia risk | PPE murmur ↑ Valsalva/standing, exertional syncope, family SCD | Withhold, refer cardiology; not a sideline “play through” |
| Commotio cordis | Blunt chest blow at a vulnerable repolarization instant inducing ventricular fibrillation in a structurally normal heart | Collapse immediately after a chest impact (baseball, lacrosse, hockey puck, etc.) | CPR + AED; survival is time-to-shock |
| Sudden cardiac arrest (SCA) | Abrupt cessation of effective cardiac output (VF/pVT or asystole/PEA) | Instantaneous collapse, unresponsive, agonal or absent breathing, no pulse | Activate EAP, CPR, AED, EMS — seconds, not a history retake |
SCA is unresponsive. If the athlete is talking, you are not looking at classic SCA — keep the differential open (sickling, heat, asthma, head injury) while you still check pulse and breathing, because deterioration can be fast.
Pulmonary: Asthma, Vocal Cord Dysfunction, Anaphylaxis, Pneumothorax
Asthma / exercise-induced bronchoconstriction: expiratory wheeze, chest tightness, cough, known history, usually responds to a short-acting beta-agonist (albuterol) when the athlete can cooperate. Status asthmaticus that is silent, hypoxic, or tiring is EMS, not “one more inhaler.”
Vocal cord dysfunction (inducible laryngeal obstruction): typically inspiratory stridor, throat tightness, and poor response to albuterol. It can mimic asthma on the field. Calm the athlete, remove from play, consider referral for laryngoscopy; do not stack beta-agonist doses as if more drug will open the cords.
Anaphylaxis: urticaria, angioedema, wheeze or stridor, hypotension, GI symptoms after a sting, food, or unknown exposure. Intramuscular epinephrine (auto-injector) first, then EMS. Albuterol can help bronchospasm but does not replace epinephrine.
Spontaneous or traumatic pneumothorax: sudden pleuritic pain and dyspnea. Unequal breath sounds are the early lung finding. Tracheal deviation away from the injured side is a late tension-pneumothorax sign (with JVD and shock). Needle decompression is an advanced/EMS skill under protocol; the AT’s job is high-flow oxygen as available, EAP/EMS, and not packing the athlete off to the bus because “it is a side stitch.”
Abdominal and Genitourinary Red Flags
Palpate all four quadrants after trauma and in unexplained visceral pain. Auscultate bowel sounds before deep palpation when you are doing a medical exam.
| Finding | Implication | Action |
|---|---|---|
| McBurney point tenderness (one-third of the way from the right ASIS to the umbilicus) | Appendicitis until proven otherwise | NPO, refer/ED |
| Rebound tenderness / rigid board-like abdomen | Peritoneal irritation | EMS/ED, not a return-to-play trial |
| Kehr sign (left shoulder pain after left-upper-quadrant trauma) | Splenic irritation of the diaphragm (phrenic, C3–C5) | Assume spleen injury; monitor vitals; EMS if unstable |
| Hematuria after a flank blow | Kidney (or lower tract) trauma | Refer; do not wrestle/contact until cleared |
| Sudden severe unilateral scrotal pain, nausea, high-riding testis, lost cremasteric reflex | Testicular torsion | Time-critical surgical emergency (hours, not next clinic day) |
Left-shoulder pain after a left-upper-quadrant blow is Kehr, not automatically an AC joint. Do not send torsion “ice and elevate until morning.”
Diabetes: Glucometer, Hypo Versus Hyper
Know the athlete’s plan and use the glucometer rather than guessing.
| Hypoglycemia | Hyperglycemia (and possible ketosis) | |
|---|---|---|
| Typical | Shaky, sweaty, hungry, confused, can progress to seizure | Thirst, polyuria, fatigue, nausea, fruity breath if ketoacidosis |
| Field action | Rapid carbohydrate if conscious; glucagon per plan if unconscious; EMS if not recovering | Hold intense exercise if glucose is markedly high or ketones are present per the diabetes plan; fluids; physician/EMS if vomiting or altered |
Do not give insulin for a suspected low. Document the number, the treatment, and the response.
Sickle Cell Trait and Exertional Collapse
NATA sudden-death guidance and inter-association statements treat exertional collapse associated with sickle cell trait (ECAST / exertional sickling) as a leading killer in conditioning, especially the first minutes of all-out work, heat, dehydration, altitude, or illness. The athlete often slumps, has weakness out of proportion to focal cramp, muscles that look and feel normal (not rock-hard heat cramps), and is typically still lucid and talking — unlike SCA, which is unresponsive from the instant of collapse. Core temperature is usually not in the exertional-heat-stroke range.
Exam trap: treating that collapse as “just cramping.” Stop activity, high-flow oxygen, cool and hydrate as indicated, and activate EMS. Do not stretch a “cramp” while the athlete is sickling. Heat cramps hobble and yell with a hard muscle; sickling slumps with a soft muscle and a still-talking athlete who can deteriorate within minutes.
Dermatologic: MRSA, Herpes Gladiatorum, Tinea, NFHS Wrestling
Contact sport, especially wrestling, is a skin-infection amplifier. NFHS (Sports Medicine Advisory Committee skin statements and the wrestling skin-lesion form) requires a health-care professional clearance; ATs screen and disqualify until criteria are met.
| Infection | Typical look | Participation rule of thumb (NFHS SMAC teaching) |
|---|---|---|
| Herpes gladiatorum (HSV) | Grouped vesicles on an erythematous base; primary outbreak may add fever and lymphadenopathy | Disqualify. Primary outbreaks: oral antiviral and minimum ~10 days (often 14 if systemic symptoms). Recurrent: typically 120 hours (5 days) of antiviral. Lesions must be dried/crusted, no new vesicles for 72 hours, no systemic symptoms. Active wet lesions cannot be covered to allow competition. |
| Tinea (corporis/gladiatorum) | Annular scaly plaque | Antifungal therapy, commonly 72 hours for body lesions before return; tinea capitis needs a longer oral course (classically 2 weeks). Body lesions may be coverable once treated per form. |
| Bacterial / MRSA | Furuncle, carbuncle, impetigo, “spider bite” abscess | 72 hours of antibiotics, no new lesions for 48 hours, no moist/exudative lesions. Active bacterial lesions may not be covered to compete. |
Hygiene (shower immediately, launder gear, no sharing razors) is prevention; the skin form is the RTP document. When in doubt, hold out and refer — one wrestler with herpes can seed a duals meet.
Mononucleosis and the Spleen
Infectious mononucleosis (EBV) produces fatigue, pharyngitis, lymphadenopathy, and splenomegaly. The spleen can rupture with modest trauma while enlarged. Contact/collision athletes stay out of play until a physician documents recovery; many protocols use about 3 weeks from symptom onset as a minimum before even considering return, and longer if the spleen remains enlarged. Left-upper-quadrant pain or Kehr sign in a recently mono-positive athlete is a rupture workup, not a side stitch.
General-medical Domain II in one line: if it can stop a heart, a lung, a viscus, or a tournament, you evaluate it — you do not stretch it.
During a PPE, a murmur is louder and longer with Valsalva and with standing from a squat, and the athlete reports exertional near-syncope. Family history includes an uncle who died suddenly at 34. What is the athletic trainer’s best action?
A football player with known sickle cell trait slumps to the ground in the first minutes of a conditioning gasser. He is still talking, complains that his legs will not hold him, and his thigh muscles look and feel normal rather than rock-hard. What is the correct interpretation?
A wrestler presents the morning of a dual with clustered vesicles on the shoulder, low-grade fever, and swollen cervical nodes. The coach wants the lesions covered with tape. What should the athletic trainer do under NFHS skin guidance?