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52 Cards in this Set
- Front
- Back
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What rib level do the domes of the diaphragm lay?
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5th intercostal space during expiration
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Where do the intercostal arteries branch from?
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The aorta
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Where do the intercostal veins drain too?
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Azygous system of veins
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Where do the intercostal nerves come from?
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The thoracic spinal cord and pass through the sympathetic trunk
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At what spinal level does the trachea begin?
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Inferior border of the larynx at CV6
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What is anterior to the tracheal bifurcation?
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Manubriosternal joint.
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Where are inhaled objects more likely to be trapped?
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Right primary bronchi as it is shorter, wider and more vertically oriented.
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What is another name for secondary bronchi?
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Lobar bronchi
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What counteracts the thoracic wall tendency to expand and the lungs elastic recoil inwards?
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The fluid within the pleural cavity which keeps the two layers of the pleura in contact.
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Where do the lungs and visceral pleura receive innervations from?
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autonomic innervations from the vagus nerve, CN10, and the sympathetic trunk.
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Where does the parietal pleura receive innervationfrom?
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The intercostals nerves (from thoracic spinal cord) and the phrenic nerve.
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What innervates the diaphragm?
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Phrenic nerve, C3-5 (C-5, keeps the diaphragm alive)
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What are the accessory muscles of respiration?
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for inspiration the pectoralis minor, scalene, sternocleidomastoid, intercostals, for expiration the abdominal muscles can assist.
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When do you need to use accessory muscles of respiration?
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Times of increased oxygen requirement e.g. exercise, COPD etc or when forcing air out e.g. playing the trumpet.
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What is the mortality rate from thoracic trauma?
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10%, with chest injuries causing ¼ trauma deaths.
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What does assessment and management consist of in the treatment of an acute blunt trauma injury?
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Primary survey identifying life threatening chest injuries, initial resuscitation and restoration of vital functions, secondary survey with a detailed examination of chest and whole patient, definitive care.
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What are the causes and the clinical features in a patient with an acute airway obstruction and how should they be treated?
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Foreign body or inflammatory/structural narrowing/obstruction of the airway e.g. astha, leading to lack of O2 to the region downstream to the blockage. Patient will present with wheeze and acute breathlessness, secure airway patency and O2 supply with rigid bronchosopy, intubation, laryngeal mask airway; remove foreign body if visible, if asthmatic supply with salbutamol.
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What are the causes, clinical features and management options in a tension Pneumothorax?
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This is where trauma etc allows air into the pleural cavity, but the formation of a one way flap does not allow it to escape in expiration. Signs will be respiratory distress, tachycardia, hypotension, distended neck veins, trachea deviation, increased percussion with reduced breath sounds on affected side. Treatment is a bore needle into the midclavicular 2nd intercostals space, connected to a syringe with a plunger to allow suction of the air out, then chest drain insertion.
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What is cardiac tamponade?
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The accumulation of fluid or air in the pericardial space around the heart, leading to reduction in the expansion of the heart and its contractile function. If emergency and severe, treat by drainage.
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What is subcutaneous emphysema?
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Accumulation of air or gas in the subcutaneous layer of the skin, usually due to a puncture wound. On palpation, it feels ‘crackly’.
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What does pleura consist of?
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Thin (10-30um), double sided layer of connective tissue and mesothelial cells which on the parietal side have microvilli to enhance absorption and trap glycoproteins.
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What is the total volume of pleural fluid surrounding the lungs normally?
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2mL
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What is the pressure in the pleural space?
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-8.5 cm H20 at the top, -2.5cm H20 at the bottom of the lungs.
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What is compliance?
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Being more flexible/less stiff/less stretched, the ability to change volume with a pressure change.
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Which part of the lung expand more in inspiration?
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The lower parts as they operate on a more compliant part of the volume pressure relationship.
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What is the trend in the gradient of ventilation-perfusion down the lung?
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High at the apex to low at the base of the lung because the blood flow gradient is considerable steeper than the ventilation gradient.
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What mechanisms give rise to the negative pleural pressure gradient around the lung?
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1) alterable shape and mechanical properties of the chest wall 2) inherent stress-free shape of the lung 3) the weight of the lung 4) the elastic properties of the lung 5) possible pleural surface friction.
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What is starling’s law?
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the greater the stretch, the greater the force/ability to recoil, up until a certain point, or F = K[(Pc-Ppl) – (pc-ppl)], where F = Pressure moving fluid from pleural space into capillaries, Pc = hydrostatic pressure in capillaries, Ppl = pleural pressure, pv = osmotic pressure in capillaries, ppl = osmotic pressure in the pleural space, K = constant
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What are the net pressures and the net rate for the movement of fluid from parietal capillaries to visceral capillaries?
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6cm H20 from parietal capillaries into pleural space, 13cm H20 from pleural space to being absorbed by visceral pleural capillaries, 100mL fluid/hr flow.
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What mechanisms can cause fluid build up in the pleural space?
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Pleural Effusion is caused by: Increase in visceral hydrostatic pressure e.g. left heart failure, increase in visceral hydrostatic pressure e.g. leak of proteins into the space due to trauma, inflammatory or malignant processes, or a decrease in nplasma osmotic pressure e.g. hypoalbuminaemia.
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What are important attributes of the doctor’s demeanour in emergencies?
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Calm, competent, compassionate, unhurried.
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Are you able to tell family members details about a patient’s medical progress in emergency situations?
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Yes, where possible prior patient consent should be obtained, but if not possible, it should be considered, but is usually not an overriding concern when advising relatives in emergency settings.
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What are some ways in which bad news should be approached?
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empathetic, acknowledgement, simplistic, clarity, absence of jargon, provision of space for venting, emphasising any positive providing ongoing support, with the presence of relatives/close friends.
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What are some ways in which anger should be dealt with in the context of a doctor giving bad news to a family member?
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Not reacting, providing space for ventilation, acknowledging anger, acknowledging concerns, facilitating communication by inquiry and making arrangements for concerns to be addressed.
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Can you give details about a patient’s medical condition to the police?
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Only with the patient’s written informed consent.
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What is post traumatic stress disorder?
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Development of characteristic psychological symptoms that follow exposure to an extremely stressful event that involved actual or threatened death or serious injury. When the responses occur to such an extent that it begins to interfere with the person’s normal functioning, it moves from a syndrome into a disorder.
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What is an adult’s response in PTSD?
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Intense fear, helplessness, horror, re-experiencing of the event through images or dreams, persistent avoidance of associated stimuli, numbing of emotions, anxiety and arousal/irritability.
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How might a 5 year old present with PTSD?
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Reliving the incidence through repetitive play.
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What are the factors affecting likelihood of developing PTSD?
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severity, duration, proximity of exposure to traumatic event, subjective fear of death, mental disorders and poor social supports.
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What are some techniques for treating PTSD which have shown some efficacy?
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re-exposure to the trauma and processing of associated feelings by imaginal recall of the event, graded in-vivo exposure to feared situation, cognitive therapy where the patient’s unhelpful beliefs are identified and modified, psychotherapy exploring the even’t meaning to the individual, medications such as SRI’s.
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Should all people mandatorily debrief after a traumatic event?
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No, it is only a useful prophylaxis if the patient feels like they are ready to discuss the event, some people may need further time to process or may need a different way of resolving the emotional impact of the event.
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region of the brain controls the ANS?
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Diencephalon and brain stem.
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Where does the peripheral part of the sympathetic division of the ANS arise from?
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Preganglionic cell bodies arise from the lateral horns of the thoracic and upper lumbar spinal cord, and form the sympathetic trunk running parallel to the spinal cord where they meet the postganglionic cell bodies, unless they are associated with peripheral ganglia. The nerves then distribute by peripheral nerves, splanchnic nerves and along blood vessels.
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Where does the peripheral part of the parasympathetic nervous system arise from?
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brain stem or sacral spinal cord segments. The cranial preganglionic cell bodies are in cranial nerve nuclei and distributes through CNIII, VII, IX, X, the sacral preganglionic cell bodies are in the intermediate region of sacral spinal cord grey matter semnets 2 – 4,and travel along peripheral nerves, splanchnic nerves or along blood vessels. Postganglionic cell bodies are near the organ of innervations.
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What are the peripheral neurotransmitters for the ANS?
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NA for SNS (except sweat glands = Ac/mAch-R), Ach (mACH-R) for PNS, Ach (nACH-R) for preganglionic to postganglionic synapses.
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What spinal cord segments supply SNS fibres to the heart and lungs, and for what purpose?
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T1 – T5, dilate respiratory airways, increase heart rate and force of contraction.
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What organs do the PNS fibres from the vagus nerve supply and what results from stimulation?
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oesophagus (peristalsis), lungs (airway narrowing), heart (decrease rate).
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Where are thoracic ANS plexuses found?
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around the oesophagus, arch of the aorta, and root of lungs.
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What type of ANS innervation do most muscular arteries and arterioles receive?
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Sympathetic for vasoconstriction
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What is elasticity in reference to the lungs?
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the tendency to recoil inwards, the ability to change pressure with a volume change
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When is a spontaneous Pneumothorax more likely to happen?
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In young, tall males, or in association with lung disease such as asthma or COPD, mechanical ventilation.
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What are the typical signs and symptoms of Pneumothorax?
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pleuritic chest pain, dyspnoea, tachypnoea, hyper-resonance, diminished breath, tracheal deviation, mediastinal shift, CXR with no lung markings between bone and chest wall.
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