1
Q
Which ribs are the true vertebrosternal ribs?
A
ribs 1-7
2
Q
Which ribs are the false (vertebrochondral) ribs?
A
ribs 8-10
3
Q
Which ribs are the floating ribs?
A
ribs 11-12
4
Q
What is the difference between vertebrosternal, vertebrochondral and floating ribs?
A
true ribs are bound to the sternum with costal cartilage at the costochondral joint
the costal cartilage of false ribs flows into costal margins that form the infrasternal (subcostal) angle. They do not articulate with the sternum
floating ribs have no costal cartilage and are only posteriorly attached to the vertbrae
5
Q
What is the order of the intercostal neurovascular bundles (superior to inferior)?
A
V-A-N
[posterior] intercostal vein
[posterior] intercostal artery
intercostal nerve
6
Q
where do the intercostal neurovascular bundles run on a rib (2)?
A
- beneath the inferior rim of the rib
- in the costal groove of the rib
7
Q
where are blood, pus or pleural effusions usual found in the lungs (2)?
A
In the costodiaphragmatic and costomediastinal recesses
8
Q
What is a pleural effusion
A
an abnormal collection of fluid in a pleural space.
*can be caused by cancer
9
Q
When blood, pus or a pleural effusions collects in a costodiaphragmatic or costomedistinal recess, what symptoms are seen in the patient?
How is it treated?
A
dyspnea: difficulty breathing or shortness of breath
treatment: thoracentesis
10
Q
Generally, how is a thoracentesis performed (2 steps)?
A
- locate collection on a CT/ultrasound
- tap the effusion with a needle (IOT draw the fluid out of the chest cavity/pleural space)
- patient will breath easier
11
Q
When the pleural space is broken, air flows _1_ the chest wound instead of through the _2_. Why does this happen?
A
- into
- lungs
This happenes because of the negative and positive pressures generated in the ventilatory cycle
12
Q
In exhalation, _1*_ in the lungs _2(increases/decrease), while _3*_ and _4*_ _5(increases/decrease).
*intrapleural pressures, tidal volume, intrapulmonary pressures
A
- tidal volume
- decreases
3-4. intrapulmonary/intrapleural pressures
- increases
13
Q
what is a pneumothorax?
what is the effect of a pneumothorax?
A
air fills the pleural space between the lungs and chest wall
the lung collapses
14
Q
what causes a sucking chest wound?
how do you treat a sucking chest wound (2 steps)?
A
pneumothorax
- treatment:
1. insert an emergency chest tube
2. place it on negative pressure (IOT re-expand the collapsed lung and drain blood)
15
Q
IOT treat a sucking chest wound, insert a __1__ and place it on _2 (+/-)_ pressure IOT _3_ the collapsed lung and to _4_ the blood.
A
- chest tube
- negative
- re-expand
- drain
16
Q
a chest tube is inserted through the layers of the _1_ space but close to the _2_ of the rib.
A
- intercostal
- superior margin
17
Q
When in the field, how can you provide negative pressure for a chest tube?
A
- in the field, seal the end of the tube by tying it or taping it with a rubber glove
- if on the ward, place the end of the tube under water in a bottle that is below the level of the patient (ex. put the bottle on floor next to patient)
18
Q
what are the muscles of the thoracic wall?
A
external intercostal
internal intercostal
innermost intercostal
transverse thoracis
diaphragm
19
Q
How do external intercostal muscles attach to ribs? What is their main action?
A
They originate from the inferior border of a rib and insert on the superior border of the next rib. The point diagonally towards the center of the thorax/abdomen.
The action is to elevate ribs during forced inspiration
20
Q
what is the attachment of the internal and innermost intercostal muscles?
what is their action?
A
- originate from the inferior border of ribs and insert on the superior border of the next rib. point away from the midline.
- the action during forced respiration is as follows:
- interosseous part: depresses ribs
- interchondral part: elevates ribs
21
Q
where does the transversus thoracis muscle originate and attach?
what is its action?
what is it innervated by?
A
- the transversus thoracis muscle originates on the **posterior surface of the lower sternum ** and inserts on the internal surfaces of costal cartilages 2-6
- the action of the transversus thoracis muscle is to weakly depress the ribs
- it is innervated by the intercostal nerves
22
Q
the internal thoracic arteries arise from which arteries? Where do they drain?
A
arise form the subclavian arteries. drain to the brachiocephalic vein.
23
Q
At which thoracic vertebral levels do the inferior vena cava, esophagus and aorta penetrate the diaphragm?
A
“8-10-12”
IVC penetrates at T8
Esophagus penetrates at T10
Aorta at T12
24
Q
How does the diaphragm contract? What is the result
A
Its domes are pulled inferiorly. As a result, the domes are flattened and abdominal viscera are pushed inferiorly therefore increasing the volume of the thoracic cavity and allowing more air into the lungs.
*also, blood in the IVC is pushed to the heart when the diaphragm contracts
25
describe the mvmts of the ribs and the sternum during respiration
ribs create a "**bucket** handle" mvmt
the sternum creates a "**pump **handle" mvmt
26
describe the mvmts of ribs during forced inspiration and force expiration.
in forced inspiration, the upper ribs moves **up** (bucket handle mvmt) and the lower ribs move **out** transversely IOT expand the thoracic cavity.
in forced expiration, the ribs move **down** and **in**.
27
what is dyspnea?
What are common causes of dyspnea?
what accomodation are made by the patient to breath?
* difficulty breathing, shortness of breath
* asthma, heart failure
* The patient will use accessorey respiratory muscles to help expand the thoracic cavity.
28
injury to the phrenic nerve will cause:
paralysis of half of the diaphragm (whether the R or L phrenic nerve is cut)
29
How do you diagnose a paralyzed diaphragm?
Radiographically or fluoroscopically.
During inspiration, the paralyzed dome will ascend as it is pushed up by the abdominal viscera (that are being compressed by the active dome).
During expiration, instead of ascending, the paralyzed dome withh descend due to the positive pressure of the lungs,
30
What are the branches of the aorta in order (3)?
brachiocephalic trunk (to the right)
left common carotid a.
left subclavian a.
31
what are the branches of the brachiocephalic trunk?
common carotid a.
subclavian a.
32
what are the branches of the subclavian artery?
vertebral a.
internal thoracic a.
thyrocervical trunk
axillary a.
33
the internal thoracic artery turn into which artery?
the superior epigastric artery
34
what are the six pleural layers and where are they located?
1. visceral pleura: aronud the lung
2. parietal pleura: lines the pleural cavity
3. costal pleura: against the ribs
4. diaphragmatic pleura: against the diaphragm
5. mediastinal pleura: against the mediastinum (i.e. the heart and trachea)
6. cervical pleura: top of the lung
35
what is the name of the lining of the thoracic cage?
endothoracic fascia
36
What is the difference between the hilum and the root of the lung?
the hilum is the dorrway while the root is the vessels and bronchi that go through th doorway and connect the lung to the mediastinum
37
what is contained in the root of the lung?
* pulmonary vessels (aa. and vv.)
* nerves
* bronchi
38
what are the five parts of the mediastinum?
1. superior
2. Inferior
* anterior
* middle
* posterior
39
what is located in the superior mediastinum (5)?
1. **t**hymus
2. great vessels (SVC, arch of Azygos, arch of Aorta)
3. **t**rachea
4. esophagus
5. **t**horacic duct
40
what is located in the anterior (inferior) mediastinum (1)?
THE THYMUS
41
what is located in the middle (inferior) mediastinum?
1. heart
2. pericardium
3. roots of the great vessels
42
what is in the posterior (inferior) mediastinum (4)?
1. thoracic aorta
2. thoracic duct
3. esophagus
4. azygous venous system
43
in a trauma patient, what does an abnormally widened mediastinum indicate?
a torn aorta
44
what is usually torn in a trauma patient when the aorta tears?
the ligamentum arteriosum
45
what is pneumothorax?
what is hydrothorax?
what is hemothorax?
entry of air into the pleural cavity
accumulation of fluid in the pleural cavity
blood entering the pleural cavity
46
1. what is a thoracentesis?
2. why is it performed?
3. what level is it performd at?
4. how is the needle angled?
1. insertion of a hypodermic needle through an intercostal space into the pleural cavity
2. to obtain a sample of fluid or to remove blood or pus
3. the 9th intercostal space (superior to T10 IOT avoid the collateral branches)
4. upward
47
1. why is a chest tube inserted?
2. where is the incision made for the tube?
3. where is the tube inserted:
* for air removal?
* for fluid drainage?
1. to remove large amounts of air, blood, serious fluid, pus
2. the 5th or 6th intercostal space @ the midaxillary line (close to the nipple)
3. to remove air: direct the tube superiorly toward the **cervical pleura. **To remove fluid, direct the tube inferiorly to the costodiaphragmatic recess
48
what does "coarctation of the aorta" mean?
a segment of the aorta is stenotic (narrow or constricted)
49
when is "coarctation of the aorta" usu diagnosed?
where does it usu occur?
congenital condition the exists at birth
usu in the thoracic aorta, distal from the branch of the L subcalvian artery
50
what is the result of "coarctation of the aorta"?
* enlarged intercostal arteries (IOT bypass the constriction and supply the LE)
* enlargement leads to notching and remodeling of the growing ribs
* notching leads to **high** blood pressure in the UE and **low **bp in the LE
51
How is coarctation of the aorta fixed?
it is repaired surgically
52
what is pectus excavatum? what usu causes it?
receding sternum (funnel chest)
overgrowth of ribs
53
what is pectus carinatum?
projecting sternum (pigeon breast- sticks/puffs out)
54
What is the defect in Poland syndrome?
* the pectoralis major (sternocostal head) and minor are absent
* incomplete sternal ossification leading to a hole or "sternal foramen"
55
how can you tell the difference between a congenital hole and a fracture?
a sternal foramen is smooth and not tender to the touch
this means it is not a fracture that has jagged edges and is tender to palpation
56
What are the levels of the right tracheobronchial tree?
1. Trachea
2. Right main bronchus
3. Right superior lobar bronchus
4. Right middle lobar bronchus
5. Segmental bronchus
6. Right lower lobar bronchus
57
What are the levels of the left tracheobronchial tree?
1. trachea
2. left ain bronchus
3. left superior lobar bronchus
4. left inferior lobar bronchus
58
What are the segments of the right superior lobe?
apical, posterior, anterior
59
what are the segments of the right middle lobe?
lateral and medial
60
what are the segments of the right inferior lobe?
superior, anterior basal, medial basal, lateral basal, posterior basal
61
what are the segments of the left superior lobe?
* apical, posterior (usu apicoposterior segment)
* anterior
* superior lingular
* inferior lingular
62
what are the segments of the left inferior lobe?
* superior
* anterior basal and medial basal (usu anteriomedial basal)
* lateral basal
* posterior basal
63
what are the three levels of brionchioles?
Conducting
Terminal
Respiratory
64
What are the tertiary structures of the bronchioles?
pulmonary artery
bronchiole
bronchial artery
65
name the next three levels after the terminal bronchiole
* respiratory bronchiole
* alveolar duct
* alveolar sac
66
What is the eponym for the sternal angle? Name the vessels at the sternal angle (4):
the Angle of Louis
1. brachiocephalic vein
2. brachiocephalic trun
3. L common carotid
4. L subclavian
67
kidneys are at what vertebral level?
T12
68
the mediastinum is a what vertebral level?
T4-T5 (T5 vertebral disc)
69
what are the two joints at the thorax?
sternomanubrial joint
scapulothoracic joint
70
the phrenic nerve is right against what tissue?
The pericardium
71
atmospheric pressure is (higher/lower) than pleural pressure? This is why air flow into the lungs (path of least resistance) in a pneumothorax.
higher
72
percussion of a pneumothorax sounds like what?
of a hemothorax?
* a pneumothorax sounds hollow like a drum (tympany)
* a hemothorax sounds dull
73
what vital sign change happens as a result of a flail chest fracture?
what happens when they expire?
decreased tidal volume
on expiration, air pooches out to exhibit a **paradoxical chest motion**
74
what is the biggest concern with a flail chest fracture
pulmonary contusion and bleeding into the lung
75
What is located in the root of the lung (include location in hilum)?
bronchus (feel cartilaginous)- located posteriorly
pulmonary artery- located anteriorly and superiorly
pulmonary vein- located anteriorly and inferiorly
lymph
76
what nerve is located between the trachea and the arch of the aorta?
the left recurrent laryngeal nerve
77
what structures run parallel as they traverse the superior thoracic aperture?
think TELT
Trachea, Esophagus, Left Recurrent Laryngeal Nerve, Thoracic
78
what does aberrant mean?
departing froman accepted standard
79
what is hemoptysis?
coughing up blood
(*hem*- blood + Greek *ptysis *act of spitting)
80
what is the carina? What reflex is it associated with?
the cartilaginous projection of the last tracheal ring that sits between the orifices of the right and left main bronchi.
associated with the cough reflex
81
how many segmental bronchi does the right lung have?
TEN!
82
How many segmental bronchi are in the left lobe?
eight
83
what is a pulmonary embolism?
Obstruction of a pulmonary artery by a blood clot (embolus)
84
what is a thrombus?
what is an embolus?
a blood clot
any intravascular mass (gas, solid, liquid) detached and in circulation
85
what happens as a result of pulmonary embolism?
the patient suffers from acute respiratory distress
86
why does pulmonary embolism cause acute respiratory distress?
* because blood flow is blocked in the lungs, there is a decrease in oxygenated blood, increase in CO2 (therefore increase in acidity) in blood. The lungs try to compensate with tachypnea but if they cannot expel the CO2, the heart and brain start to fail (arrythmias/unconsiousness then death)
* also a rise in pulmonary pressure can lead to failure of the right ventricle
* pulmonary infarct is produces (an area of necrotic (dead) lung tissue)
87
lymph from the bronchomediastinal lymph nodes drain to the inferior \_1\_ (carinal) nodes and then to the \_2\_ (hilar) nodes
1. (inferior) tracheobronchial
2. bronchopulmonary
88
What is pleurisy? What effect does it have on the lungs?
Pleuritis: inflammation fo the lung. Makes the lungs rough.
89
is the lung tissue (visceral pleura) sensitive to pain? Is the parietal pleura? why or why not?
no, it is not innervated, therefore not sensitive to pain
yes! very sensitive. It is innervated by nerves deried from the intercostal and phrenic nerves.
90
what parts of the parietal pleura do the phrenic nerves supply?
* the central part of the diaphragmatic pleura
* the mediastinal pleura
91
what parts of the parietal pleura do the intercostal nerves supply? What are the sensations?
* the costal pleura
* the peripheral part of the diaphragmatic pleura
mediates sensations of touch and pain
92
what is hemopericardium? What does it cause?
blood in the paricardial cavity
produces cardiac tamponade
93
what is pericardiocentesis? what level is the wide-bore needle placed into?
drainage of fluid from the paricardial cavity
the 5th or 6th intercostal space
94
where do you listen to pleural rubs on a patient (be specific)?
in the triangle of ausculatation: bordered by trapezius, latissimus dorsi and rhomboid major (or medial border of scapula)
95
the phrenic nerve is sourced by which parts of the cervical nerve?
"C3, 4, and 5 keep the diaphragm alive."
96
what is the difference between pneumothorax and tension pneumothorax?
in tension pneumothorax, the air is not excaping the pleural space wheras in pneumothorax, air is flowing freely through a hole in the pleura
97
What are the major landmarks for parietal pleura and visceral pleura at terminal exahalation?
- midclavicular line
- midaxillary line
- paravertebral line
- midclavicular line: VP-6 PP-8
- midaxillary line: VP-8 PP-10
- paravertebral line: VP-10 PP-12
(VP is higher and two above PP)
98
At the 6th intercostal space, what does the internal thoracic (mammary) artery split into?
the musculophrenic and superior epigastric
99
what are the two layers of the pericardial sac?
the outer fibrous pericardium and inner serous pericardium
100
what is the function of intercostal muscles?
pull adjacent ribs together and assist in **active respiration**
101
what are the boundaries of the mediastinum (5)?
1. anterior: sternum and costal cartilages
2. posterior: thoracic vertebrae bodies
3. superior: superior thoracic aperture
4. inferior: diaphragm
5. lateral: mediastinal pleurae on each side
102
what do the left and rigth recurrent laryngeal nerves innervate?
the musculature of the vocal cords
103
\_1\_ vein and \_2\_ \_1\_ veins receive most of the left posterior intercostal veins and lie along the left side, posterior to the aorta.
1. hemiazygous
2. accessory
104
what is the sinus venarum?
the smooth part of the right atrial wall that is derived from the sinus venosus
105
what is the sulcus terminalis?
the groove between the sinus venarum and the rest of the right atrium
(\*separates the rest of the atrium from the sinus venarum)
106
what is the crista terminalis?
the ridge deep to the sulcus terminalis
107
what is the musculi pectinati?
the pectinate muscles. The are found in the anterior wall as muscular ridges.
**(pectin**= comb)
108
what is the fossa ovalis?
a remnant of the foramen ovale that is now simply a depression (in the righ atrium)
109
what is the infundibulum in the right ventricle?
the conus arteriosus
*infundibulum* is latin for funnel. It is a narrowing of the r.ventricle before the pulmonary semilunar valve.
110
what are the trabeculae carnae?
meaty columns that **are not** musculi pectinati
also, pillars of cardiac muscles
111
what are the papillary muscles connected to?
the chordae tendineae
112
what is the function of papillary muscles?
the contract early in the cardiac cycle IOT anchor the cusps of the atrioventricular valve and prevent regurgitation or backwards flow of blood into the atrium.
113
what are the chordae tendineae and what is their function?
* tendinous cords that attach the leaflets of the tricuspid valve to the papillary muscles
* they assist the papillary muscles in preventing regurgitation
114
what is the moderator band? What is significant about it
septomarginal trebeculae
this band of muscle connects the interventricular septum to the papillary muscles.
the moderator band contains electrical conducting fibers
115
where is the atrioventricular node located?
between the valve of the coronary sinus and the tricuspid valve
116
where is the SA node located?
between the SVC and the Right atrium
117
the right recurrent laryngeal vein loops around what structure?
the right subclavian **artery**
118
the transverse pericardial sinus runs under what two structures?
the ascending aorta and the pulmonary trunk
119
the roght coronary artery runs in what feeature of the heart?
the coronary sulcus
120
the fibrous skeleton wraps around what structures?
the 4 valves: semilunar (aortic and pulmonary) and atrioventricular (mitral and tricuspid)
121
identify one feature of the heart that makes it susceptible to blockage
the vessels do not *highly *anastomose (feed into each other)
122
list the vessels, chambers and valves a drop of blood would flow through beginning at the **R atrium**:
through the **tricsupid valve **to the **R ventricle** through the **pulmonary valve** into the **pulmonary trunk ** into the **pulmonary arteries **to the lungs back through the **pulmonary veins **into the **L atrium** through th **mitral valve** into the **L ventricle ** through the **aortic valve** into the **ascending aorta**, to the **arch of the aorta** to **systemic circulation** via the brachiocephalic trunk (R subclavian and common carotid arteries) , L common carotid, L subclavian and thoracic aorta, to the arterioles, into the capillaries of organs out through the venules, into the IVC, (if on the left side) hemiazygous and accessory hemiazygous veins, (if on the right side) azygous vein, SVC (fed from the R and L brachiocephalic vein), and coronary sinus (from the heart) and back into the **R atrium.**
123
what is an aortic lunule? an aortic nodule?
the lunule is the thickened edge of a valve cusp while the nodule is the apex of the angulated lunules (free edges)
124
what does the right coronary (RCA) artery supply (4)?
right atrium
SA and AV nodes
the posterior interventricular sulcus
125
what is the artery to the SA node called?
the SA nodal artery
126
what does the right marginal artery supply?
the right ventricle and the apex of the heart
127
what does the posterior interventricular artery supply?
the right and left ventricles and the posterior third of the interventricular sulcus
128
what does the circumflex artery supply? What artery does it branch from?
the left atrium and ventricle
LCA
129
what does the left marginal branch supply?
left ventricle
130
what are the branches of the left ccoronary artery?
the anterior interventricular artery or LAD (left anterior descending)
left circumflex
left marginal
131
what are the branches of the right coronary artery?
sinuatrial (SA/AV nodes)
right marginal
posterior interventricular
132
what is the dividing point between the great cardiac vein and the coronary sinus?
the oblique vein of Marshall (aka the oblique vein of the left atrium)
133
what is a myocardial infarction? What happens?
necrotic myocardium
a heart attack: when an embolus occludes a vessel and _blocks blood flow_ to the heart (ie. in a coronary artery) thus leading to necrosis of that part of the heart due to lack of oxygen
134
what are the three most common sites of coronary artery occlusion?
anterior IV (LAD) branch of the LCA (aka the "widow-maker")
right coronary artery (RCA)
circumflex branch of the LCA
135
How can a coronary occlusion affect the conducting system?
if the RCA is blocked, blood supply to the SA and AV node could be dirupted and cause a *heart block *(a problem with the heart's electrical system)
136
what is a heart block? what is the resulting effect?
damage to the heart's electrical system
it can change the rate and rhythm of the heart rate
137
what is myogenic conduction? What does it produce? How is it regulated?
muscle propagated conduction
produces a **late asynchronous contraction**
regulate/fix with a cardiac pacemaker
138
if you were to injure yourself through the sternum, which part of the heart would be damaged?
the right ventricle
139
What connects the aorta to the pulmonary artery?
the ligamentam arteriosus (previously the ductus arteriosus)
140
if you sweep your hand up and behind the heart but stop right behind the veins, there is your hand located?
in the oblique pericardial sinus
141
(T/F) The pulmonary valve is attached to the cardiac skeleton.
False. the pulmonary valve is not attached.
142
In the aortic valve, there are ostiums that lead to what to arteries?
the left and right coronary arteries
143
the heart has four valves. which are passive and which are active?
the semilunar valves are passive and the aorticoventricular valves are active
144
what is Virchow's triangle for thrombosis?
* Hypercoagulability (risk for blood clots)
* Endothelial injury (intima of blood vessels)
* Hemdynamic changes (blood flow)
145
Thrombosis is more common in the L or R heart? If there is a clot in the Left heart, what could it lead to?
Right heart. There is a lot of empty space in the left heart.
stroke
146
What muscular structure is the first thing activated by the AV node? What does it do (what is the muscle's function)?
the moderator band
it closes the AV valve
147
How does angina present in men?
as cardiac referred pain in the left shoulder
148
How does the thymus change with age? Does it have any function past puberty?
initially it helps to develop and support the immune system.
at puberty, it begins to shrink
in adulthood, it is replaced with fat but **continues to produce T-lymphocytes**
149
What are the 5 auscultatory areas of the chest? Where are they located?
1. Mitral area (5th left intercostal space-5LICS)
2. Tricuspid area (4LICS)
3. Secondary pulmonic area (3LICS)
4. Pulmonic area (left upper sternal border-LUSB)
5. Aortic area (RUSB)
150
what is valvular stenosis?
the failure of a valve to fully open so that blood flow is slowed
151
what is valvular insufficiency?
the valves do not shut completely therefore blood flow regurgitates.
Nodule formation also arises along with scarring or conrtaction of the cusps. This prevents the valve from sealing properly.
152
When valvular insufficiency or stenosis is present, what effect does it have on the heart?
The heart has an increased workload
153
what is a murmur? what causes it?
murmurs are audible vibrations caused by small whirlpools (eddies) resulting from turbulence. turbulence usually arises from stenosis or regurgitation)
154
What is a thrill?
a superficial vibratory sensation felt on the skin over an area of **turbulence**
155
what separates the trachea from the esophagus?
the tracheoesophageal septum
156
what is a transesophageal fistula? What is the most common form?
an abnormal connection (fistula) between the trachea and esophagus.
the proximal part of the esophagus has a blind end and the distal part has a narrow opening right at the bifurcation of the trachea
157
what are the 7 branches of the thoracic aorta?
ascending aorta
arch of aorta
thoracic (descending) aorta
posterior intercostal
bronchial (1-2 branches)
esophageal (4-5 branches)
superior phrenic
158
what is the ligament of Treitz?
The suspensory muscle of the duodenum
159
why is the ligament of Treitz important?
It demarcates the duodenum from the jejunum
160
what are the three normal constrictions of the esophagus?
cervical (upper esophagela sphincter)
thoracic (broncho-aortic)
diaphragmatic
161
where does the thoracic duct originate from
the cisterna chyli
162
the right lymphatic duct drain lymph from where?
the body's right upper quadrant (R-side head, neck, thorax and right limb)
163
where is the right lymphatic duct located
in the right venous angle at the root of the neck
164
what does the thoracic duct drain?
what the right thlymphatic duct doesnt: the left upper quadrant and regions of the thorax
CPR-Week 1
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