Blue Boxes Thorax

Front 1

Chest Pain

Back 1

most important symptom of cardiac disease

may also indicate intestinal, gallbladder, musculoskeletal, or pulmonary disorders

exam:
serious to minor causes

cardiac: freq. described as crushing substernal pain that does not disappear with rest

Front 2

Rib Fractures (p.54)

Back 2

1st rib rarely fractured b/c of protected position

frac. leads to risk of brachial plexus and subclavian vessel damage

frac. result from blows or crushing injuries; weakest part is anterior to angle

The middle ribs are the ones most commonly fractured (7th and 10th)

when several ribs are broken in several places a flail chest results

danger of damage to lung or spleen from broken end

diaphragmatic hernia is tear in diaphragm can be caused by rib fracture

painful b/c broken parts move during respiration

Front 3

Flail Chest (p.54)

Back 3

multiple rib fractures allow segment of t. wall to move freely

moves paradoxically to respiration (inward and outward on expiration)

diagram: A. Inspiratory phase. Chest wall collapses inward (a), forcing air out of bronchus of involved lung into trachea and bronchus to uninvolved lung and causing shift of mediastinum to uninvolved side (b). B. Expiratory phase. Chest wall balloons outward (a) so that air expelled from lung on uninvolved side (b) enters lung on involved side and mediastinum shifts toward involved side (a). This is a very inefficient form of respiration, and the patient will die of hypoxia and exhaustion if it occurs in an extreme phase and is not relieved.

extremely painful and impairs vent.
fixed by hooks and wires so it cannot move

Front 4

Thoracotomy, Intercostal Space Incisions, and Rib Excision (p.55)

Back 4

surgical creation of an opening through thoracic wall to access pleural cavity

anterior (H-shape) at the anterior chest wall - wide segment of rib removed allows entry through periosteal sheath, spares intercostal muscles can be used for pneumonectomy. also a critical maneuver in the management of traumatic cardiac arrest (wikipedia)

bone may be used as a graft in reconstruction procedures - will regenerate in periosteal sheath

posterior - 5th to 7th intercostal but can go up to 4th. lateral appproach gives best access- pt. lying contralateral, and upper limb fully abducted to change position of scapula for access to the 4th intercostal space. is considered the approach of choice for pulmonary resection (pneumonectomy and lobectomy)

complications: pneumothorax, infection, bleeding, air leaks, and resp. failure

Front 5

Supernumerary Ribs (p.54)

Back 5

usually have 12 ribs on each size

can have too many or failure of 12th pair to form

can confuse identification or numbering of levels on radiographs

Front 6

Protective Function and Aging of Costal Cartilages (p.54)

Back 6

costal c. contribute to elasticity for thorax and provide resilience to t. cage; prevent blows from fracturing sternum/ribs

chest compression can cause injury without fracture

in elderly, costal c. lose elasticiy from calcification and become brittle = radiopaque and less resilient

Front 7

Ossified Xiphoid Process

Back 7

normal in mid 40s to discover a hard lump in "pit of stomach"

patients may fear it's a tumor such as stomach cancer; just calcification at epigastric fossa

Front 8

Sternal Fractures (p.54)

Back 8

not common

can occur from crush trauma (ex. forced into steering column in crash)

usually "comminuted fracture"

most common site is at sternal angle - results in dislocation of the manubriosternal joint.

concern of possible heart damage with mortality ~25-45% chance

ALL patients with sternal injury should be evaluated for visceral trauma

Front 9

Median Sternotomy (p.54)

Back 9

to gain access to mediastinum by dividing sternum in median plane and retract.

(ex. for CABG surg., or removal of superior lobe tumors)

halves of sternum are reunited with wire sutures

Front 10

Sternal Biopsy (p.54)

Back 10

sternal body often used for bone marrow needle biopsy b/c of its breadth and subcutaneous position

obtain specimens for transplant or for detection of metastatic cancer and blood dyscrasias

Front 11

Sternal Anomalies (p. 54)

Back 11

sternal halves may not fuse in fetus = Sternal Cleft (above pic)

repair in infancy w/ direct apposition and fixation of cartilaginous sternal halves

sternal foramen due to incomplete fusion of plates (not clinically significant, except for misinterpretation on medical image as a bullet wound)

Front 12

Dislocation of Ribs (p.55)

Back 12

slipping rib syndrome or dislocation of a sternocostal join

displacement of a costal cartilage from the sternum

injury produces lump at dislocation site

common in body contact sports

can damage nearby nerves, vessels and muscles

Front 13

Thoracic Outlet Syndrome (p.55)

Back 13

involving compression at the superior thoracic outlet

Superior TA: Anatomically is called t."inlet", and Clinically is called t."outlet"

Arteries/Viens, and brachial plexus nerves emerge trough aperture to enter lower neck and upper limbs

TOS (t. outlet syndrome) = implies thoracic location, obstruction is in root of the neck, manifestations of syndrome variably involve upper limb. (eg.: costoclavicular syndrome = diminished radial pulse resulting from compression of the subclavian artery b/w clavicle and first rib)

Front 14

Separation of Ribs (p.55)

Back 14

refers to dislocation of a costochonral junction between rib and its costal cartilage

if occurs in 3 - 10 = usually tears perichondrium and periosteum causing ribs to move superiorly, overriding rib above it and causes pain

Front 15

Paralysis of the Diaphragm (p.54)

Back 15

Innervated by cervical motor neurons C3-C5 via the phrenic nerves

hemidiaphragm paralysis as result of injury to its motor supply from phrenic nerve (each dome has separate nerve supply)

will move paradoxically when paralyzed

the affected dome descends during expiration as it is pushed down by the positive preassure in the lungs

Front 16

Dyspnea: Difficulty Breathing (p.64)

Back 16

when people with resp. problems (eg. asthma or CHF) struggle to breath, they use accessory respiratory muscles to assist expansion of t. cavity

leaning on chair or knees can "fix" pectoral girdle (clavicle and scapula) so these accessory muscles are better able to act on rib attachments and expand the thorax.

Front 17

(Extrapleural Intrathoracic Surgical Access)

Back 17

endothoracic fascia is a natural cleavage plane in surgery

separate costal parietal pleura from the thoracic wall = access to lymph nodes

can place instruments without risking opening of potential space of pleural cavity surrounding lungs

Front 18

Herpes Zoster Infection of the Spinal Ganglia (p. 64)

Back 18

shingles = viral disease of spinal ganglia

dermatomally distributed skin lesion

pathogenesis; 1)Entry through upper respiratory tract
10–21 day incubation 2)Travels to regional lymph nodes, liver and spleen (primary viraemia) 3) Travels to skin/mucous membranes: vesicular rash (secondary viraemia)
4) Replication in epidermal cells, entry into nerve endings and transport to dorsal root ganglia (DRG) where it establishes latency in sensory neurones 5)Reactivation in DRG → infection of nerves and dermatome → herpes zoster

the herpes virus invades a spinal ganglion and is transported along the axon to the skin.

causes red, vesicular rash confined to a dermatome; sharp burning pain in affected region

after a few days, the skin of the dermatome becomes red and vesicular eruptions appear

VZV (varicella-zoster virus) for shingles and small pox

Front 19

Intercostal Nerve Block (p.64)

Back 19

injecting a local anesthetic near intercostal nerves between paravertebral line and area of desired anesthesia

each area of skin gets innervation from two adjacent nerves so overlapping dermatomes occurs. therefore complete loss of sensation usually does not occur unless several intercostal nerves in adjacent intercostal spaces are anesthetized.

Herpes zoster or shingles pain in the chest is commonly treated with intercostal blocks

http://www.youtube.com/watch?v=BOLdHJC6_50

Front 20

Changes in the Breasts (p.58)

Back 20

branching of the lactiferous ducts may occur during menstruation or pregnancy

Colostrum = creamy white premilk; starts in last trimester; rich in protien, immune agents, growth factors

breasts increase in size with multiple pregnancies (multiparous)

breasts decrease in size wuth age and loss of fat and atrophy of glands

Front 21

Breast Quadrants (p.58)

Back 21

radial coordinate system to refer to location of tumors or cysts in breasts

divide into 4 equal quadrants, nipple as center reference point

Front 22

Carcinoma of the Breast (p.58)

Back 22

lymph drainage important (lymphogenic metastasis - metastasis of cancer by means of lymph); usually pass 2 or 3 sets of nodes before reaching venous drainage

Symptoms:
lymphedema, peau d'orange sign, dimples, breast elevation with pectoral contraction (if invading muscle)

most common site of metastasis is axillary lymph nodes since most of the lymphatic drainage of breast goes there.

usually adenocarcinomas (from epithelial cells of lactiferous ducts)

subareolar breast cancer - may cause inversion of the nipple

spread of cancer to cranium and brain through azygos/hemiazygos system of viens (where the posterior intercostal viens drain) p. 59

cancer can also spread by contiguity (invasion of adjacent tissue). see clinical sign of advanced cancer p. 59

Front 23

lymphedema (p.58)

Back 23

edema or excess fluid backup in breast upon blockage of lymph drainage by cancerous mass

Front 24

peau d'oragne sign (p.58)

Back 24

prominent / puffy skin between dimples pores

results from lymph backup in cancerous breast

Front 25

Mammography (p.59)

Back 25

radiographic breast examination

carcinoma appears as large jagged density in the mammogram

guide when removing breast tumors, cysts, and abscesses

Front 26

Supernumerary Breast and Nipples: Polymastia, Polythelia, and Amastia (p.58)

Back 26

supernumerary breasts (polymastia), or accessory nipples (polythelia) = occur superior or inferior to normal on mammary ridge

usually rudimentary = easily mistaken for mole until they change color during pregnancy

Front 27

Breast Cancer in Men

Back 27

1 in 100 breast cancers affect men and only about 10 in 1 million develop breast cancer (webMD)

usually metastasizes to lymph nodes (also to bone, pleura, lung, liver, and skin)

presents with visible or palpable subareolar mas or nipple secretion and tends to invade pectoral fascia

Front 28

Gynecomastia

Back 28

male breast hypertrophy after puberty - quite rare

may be age or drug related; or imbalance between estrogenic and androgenic hormones

treat as a symptom, check suprarenal and testicular cancer and cirrhosis

40% Klinefelter's (XXY) have gynecomastia

Front 29

Injuries to the Cervical Pleura and Apex of Lung (p.70 - 71)

Back 29

apex of lung (covered by cervical pleura) project through opening of the superior thoracic aperture into the base of the neck, just posterior to inferior attachment of sternocleidomastoid

risk of pneumothorax with penetrating wounds at base of neck

children are especially vulnerable

Front 30

Injury to Pleurae and Pleural Pain (p.78)

Back 30

visceral pleura - insensitive to pain
parietal pleura - sensitive to pain (esp. costal pleura = somatic intercostal and phrenic n.)

pain referred to dermatomes of same posterior root ganglia
costal / peripheral diaphragmatic pleura thoracic and abdominal walls

mediastinal / central diaphragmatic pleura = C3-C5 dermatomes

Front 31

Pulmonary Collapse (p.77)

Back 31

with penetrating wound, air will be sucked into pleural cavity and breaks surface tension adhearing visceral to parietal pleura, and the lung collapses because of its inherent elasticity (elastic recoil)

it's possible that only one lung can collapse because of the separation of pleural sacs

pressure in pleural cavities in subatmospheric (-2mmHg, during inspiration: -8mmHg)

eg. in open-chest surgery, maintain inflation with positive-pressure pump

leads to pneumothorax

Front 32

Pneumothorax

Back 32

if air enters the pleural space, the lung will collapse= pneumothorax.

If the chest wall is penetrated, which may occur as a result of an injury, air can enter the pleural space from the outside.

Air can also enter from the inside, from the lung itself, if the lung is torn or ruptured. One of the most common causes of spontaneous non-traumatic pneumothorax is a pulmonary bleb. This is a weakness and out-pouching of the lung tissue, which can rupture. This introduces air into the pleural space.

The immediate treatment for pneumothorax is tube thoracostomy, or the insertion of a chest tube

Pulmonary blebs are a common cause of spontaneous pneumothorax in young children and adults. They can be resected to prevent future pneumothorax

Front 33

Pneumothorax, Hydrothorax, Hemothorax, and Chylothorax (p.77)

Back 33

Air, Water, or Blood in the pleural cavity

pneumo = air from penetrating wound
hydro = fluid from from pleural effusion
hemo = blood injury to a major intercostal/internal thoracic vessel
chylo= chyle (pale white/yellow lymph fluid) from a torn thoracic duct

Front 34

Thoracentesis (p.78)

Back 34

insertion of hypodermic needle through intercostal space into pleural cavity to sample fluid or remove blood or pus

needle should be just superior to rib to avoid neurovascular bundle

pleural effusions accum. (when sitting) in costodiaphragmatic recess- space located between costal pleura and diaphragmatic pleura. used for thoracocentesis because of less risk of puncturing the lungs

insert needle at 9th intercostal space to avoid lung (& point up to avoid liver); also posterior superior to the rib, high enough to avoid the collateral branches. (posterior because the interspaces are wider. superior because neurovascular bundle is closer to the inferior margin of the rib posteriorly)

Front 35

Insertion of a Chest Tube (p.78)

Back 35

placed for removal of large amounts of air, blood, fluid, or pus

incision in 5th/6th intercostal space in midaxillary line

direct superior - remove air
direct inferior - drain fluid

connect outside end of tube with underwater drainage system with controlled suction (to prevent backflow)

Front 36

Thoracoscopy (p.78)

Back 36

diagnostic/therapeutic procedure for examination of pleural cavity for cancer

incisions in intercostal space allow placement of scope (take photos, biopsies; disrupt adhesions or remove plaques)

Front 37

Pleuritis (Pleurisy) (p.77)

Back 37

normally respiration/expiration produces no detectable noise from pleurae (by asucultaion)

but with inflammation, this makes the lung surfaces rough = pleural rub and can be heard with stethoscope

acute pleuritis = sharp, stabbing pain

friction = "pleural rub" this is audible with stethoscope

Front 38

Lung Resections (p.78)

Back 38

pneumonectomy = whole lung
lobectomy = a lobe
segmentectomy = one or more bronchopulmonary segments

for tx. for lung cancer/tumor, or abscesses (collection of pus)

understand bronchopulmonary segments and their relationship to the bronchial tree for plan of drainage and clearance techniques (especially for pts. with pneumonia or cystic fibrosis)

tumors often localize in a bronchopulmonary segment, when resecting a bp. segment, surgeons follow the interlobar veins to pass between the segments.

Front 39

Variations in the Lobes of the Lung (p.77)

Back 39

can have extra fissure or one may be absent

azygos lobe = most common accessory lobe, appears in RL 1% of pop.

azygos vein arches over apex, not hilum, creating new (azygos) lobe in medial part of apex

Front 40

Inhalation of Carbon Particles (p.78-79)

Back 40

lungs are light pink in children, non-smokers in clean environment

foreign bodies most likely enter the right main bronchus

commonly dark / mottled in adults in urban / agricultural areas as a result of inhaled particles (smoker's cough)

lymph carries "phagocytes" that phogocytose carbon particles. These particles color the surface of the lungs gray to black.

Front 41

Auscultation of the Lungs and Percussion of the Thorax (p.78)

Back 41

listening with steth; tapping to detect sounds

A: asses airflow in lungs. also used to detect heart murmurs. use steth.

P: percussion of the lungs - tapping the chest over the lungs with the finger = establishes state of underlying tissue = air filled (resonant), fluid (dull), or solid (flat)

some places should be flat b/c of bone structure.

Always include root of the neck (apicies); base of lung refers to inferoposterior part, listen at inferoposterior aspect of thoracic wall = T10

Front 42

Lung Cancer and Mediastinal Nerves

Back 42

involvement of phrenic nerve may paralyze diaphragm

apical cancers may involve recurrent laryngeal nerve (branch of vagus); presents as hoarseness due to paralysis of vocal cored

Front 43

Aspiration of Foreign Bodies (p.78)

Back 43

R bronchus is wider, shorter, and runs more vertically than L

foreign bodies tend to lodge in the R main bronchus or one of its branches

dentists may insert a rubber dam in oral cavity to prevent aspiration during procedures

Front 44

Bronchoscopy (p.79)

Back 44

uses bronchoscope

carina (keel) = ridge seen between orifices of main bronchi; lays in sagital plane and has definite edge

carina will be distorted with enlarged lymph nodes in angle - morphologic changes important for diagnosis from a bronchogenic carcinoma

mucus membrane covering carina associated with cough reflex

Front 45

Segmental Atelectasis

Back 45

blockage of segmental bronchus prevents air from reaching supplied segment

air will be gradually absorbed and segment will collapse (does not require compensating space in pleural space; adjacent segments expand)

Front 46

Pulmonary Embolism (p.79)

Back 46

embolus forms when blood clot, fat globule, or air bubble travels to lung from a leg vein

embolus travels through the R heart to pulmonary artery and to the lung.

may block artery or one of it's branches:
Pulmonary embolism blocks a pulmonary artery = leads to partial or complete obstruction of blood flow = acute respiratory distress

right side of heart may become dilated (inc. venous return
collateral circulation can compensate for PE in younger people

pulmonary infarct = medium size embolus blocks an artery supplying bronchopulmonary segment, and results in an area of necrotic lung tissue = tx. resection.

Front 47

Lymphatic Drainage after Pleural Adhesion

Back 47

lymphatic vessels in lung and visceral pleura drain to axillary lymph nodes

presence of C particles is evidence of pleural adhesion

Front 48

Bronchogenic Carcinoma

Back 48

usually squamous or small-cell carcinoma arising from bronchus (now refers to any lung cancer)

main cause: cigarette smoking

most arise in mucosa of large bronchi; present w/ persisten, prouctive cough

metastises to blood, bone, lymph, adrenal

Front 49

Mediastinoscopy and Mediastinal Biopsies

Back 49

incision approximately 1 cm above the suprasternal notch of the sternum, or breast bone

used to conduct minor surgical procedures

or biopsy of lymph nodes to test for bronchiogenic carcinoma

Front 50

Widening of Mediastinum

Back 50

often observed after trauma from lacerated great vessels/ serious hemorrahge

also indicates:
malignant lymphoma
enlargement of heart (hypertrophy) with CHF

Front 51

Surgical Significance of Transverse Pericardial Sinus (p.82)

Back 51

after the pericardial sac has been opened anteriorly, a finger can be passed through the TPS posterior to the aorta and pulmonary trunk.

must ligate these vessels during cardiac surgery (eg. CABG)

Front 52

Pericarditis and Pericardial Effusion (p.83)

Back 52

inflammation of pericardium = chest pain

no detectable sound during auscultation but causes pericardial friction rub (pericarditis makes surface rough which results in friction) = sounds like the rustle of silk with steth.

results in compressed heart - unable to expand and fill fully and ineffectual

Front 53

Pericardial Friction Rub p.83

Back 53

inflammation causes friction along roughened surfaces

sounds like rustle of silk, hairs rubbing together

Front 54

Pericardial Effusion p.83

Back 54

("fluid around the heart") is an abnormal accumulation of fluid in the pericardial cavity

leaky pericardial capillaries or pus accumulation during inflammation

also occurs during CHF without inflammation

negative effect to heart = cardiac tamponade!

Front 55

Cardiac Tamponade p.84

Back 55

heart compression caused by tough and inelastic pericardium. consequently, heart volume is compromised by the fluid outside the heart.

occurs when the pericardial space fills up with fluid faster than the pericardial sac can stretch

caused by a large or uncontrolled pericardial effusion, (eg. the buildup of fluid inside the pericardium)

slow increase in size of hear = cardiomegaly

hemopericardium = blood enters the pericardial cavity, caused by trauma (eg. stab wounds)

pericardiocentesis = drainage of serous fluid from pericardial cavity

Front 56

Pneumopericardium

Back 56

air from pneumothorax dissecs percardial sac

Front 57

Pericardiocentesis

Back 57

drainage of fluid from pericardial cavity

insert needle in left 5th or 6th intercostal space near sternum
("bare area of pericardium")

Front 58

Positional Abnormalities of the Heart

Back 58

dextrocardia : apex directed right instead of left

mirror image positioning of great vessels

Front 59

Percussion of the Heart p.91

Back 59

]defines the density and size of the heart.

percuss at 3rd, 4th, and 5th intercostal spaces from left anterior axillary line to right anterior axillary line.

change from resonance to dullness indicates edge of heart

Front 60

Atrial Septal Defects (ASDs) p. 91

Back 60

congenital anomalies of interatrial septum- usually related to incomplete closure of the ovale foramen after birth

small-size ASDs have no clinical significance

large-size allow O2 rich blood from lungs to be shunted from the LA thorugh the defect into the RA, causing enlargement of the RA and ventricle and dilation of the pulmonary trunk

Front 61

Ventricular Septal Defects (VSDs) p.91

Back 61

commonly on membranous part of IV septum

25% of all forms of congenital heart disease

size of defect 1 to 25mm

causes LV to RV shunt of blood through the defect.

increases pulmonary blood flow (hypertension) and may cause cardiac failure

much less common for the muscular part of the septum to remain open (usually closes in childhood)

Front 62

Thrombi / Stroke / CVA p.91

Back 62

"cerebral vascular accident" aka stroke

thrombi (clot) detach and pass into systemic circulation, occluding peripheral arteries

occlusion of an artery supplying brain = CVA

affects vision, cognition, sensory and/or motor fxn. previously controlled by the now damaged area of the brain

Front 63

Valvular Heart Disease p.91

Back 63

VHD produces either stenosis or insufficiency

stenosis = valve cannot fully open slowing blood flow from a chamber
insufficiency / regurgitation = valve cannot fully close. cusps do not meet or align, allowing blood to flow back

both result in increased workload, produce audible turbulence (murmurs or thrills)

turbulance sets up eddies (small whirlpools) that produce vibrations that are audible as murmurs

thrills = superficial vibratory sensations, that may be felt on the skin over an area of turbulance

vulvuloplasty = surgery can replace valves with artificial valve prostheses (synthetic or xenografted from other species)

Front 64

Mitral Valve Insufficiency / Prolapse p.91

Back 64

valves are "floppy" - where one or both leaflets are enlarged/redundant and extending back into the LA during systole.

blood regurgitates back into LA when the LV contracts, produces a characteristic murmur

freq. present w/out clinical significance

Front 65

Pulmonary Valve Stenosis p.92

Back 65

narowed central opening - the valve cusps are fused

infundibular pulmonary stenosis : conus arteriosus is underdeveloped, producing a restriction of RV outflow during diastole

Front 66

Aortic Valve Stenosis p.92

Back 66

most frequent valve abnormality

often results in LV hypertrophy

freq. degenerative calcification, appears after 60 y/o

Front 67

Aortic Valve Insufficiency

Back 67

produces a heart murmur and collapsing pulse (a forcible impulse that rapidly diminishes)

Front 68

Coronary Artery Disease (CAD) p.100

Back 68

leading cause of death

occlusion of major artery resulting in reduced blood supply to myocardial tissue (MI or coronary atherosclerosis)

m. infarction - sudden occlusion of major artery by embolus = vessel bloodless (infarcted)
leads to necrosis - pathological tissue death

common sites: Anterior IV LAD branch of the LCA, RCA, and circumflex branch LCA

Front 69

Myocardial Infarction (MI) p. 100

Back 69

area of myocardium has undergone necrosis due to sudden occlusion of major artery

common locations:
LCA (left main coronary artery)
RCA (right main coronary artery)
Circumflex branch
1) LAD branch (left anterior descending)

Front 70

Coronary Atherosclerosis p. 100

Back 70

the most common cause of ischemic heart disease

atherosclerotic process = lipid accumulations in the intima (lining layer), or on internal walls of arteries eventually results in stenosis

collateral channels may compensate, but may not be able to provide enough O2

insufficiency of blood supply to heart leads to myocardial ischemia/infarction

Front 71

Angina Pectoris

Back 71

transient, but moderately severe pain / tightness in thorax

caused by ischemia of myocardium

results from narrowed/hardened coronary arteries
anaerobic metabolism of myocytes produces lactic acid -pain receptors sensitive to drop in pH

treat w/ sublingual nitroglycerin to dilate coronary arrteries

Front 72

Coronary Bypass Graft (CABG) p. 101

Back 72

segment of artery or vein connects proximal part of artery to ascending aorta, distal to blockage/stenosis

great saphenous vein is often used b/c 1) has the same or greater than diameter than of the coronary arteries. 2)it can be easily dissected from the lower limb. 3) it offers relatively lengthy portions with a minimum occurrence of valves or branching.

can also use radial artery

revascularization of the myocardium may also be achieved by surgically anastomosing an internal thoracic artery with a coronary artery.

Front 73

Coronary Angioplasty p. 101

Back 73

percutaneous transluminal coronary angioplasty = catheter with small inflatable balloon flattens plaque against vessel wall to increase lumen size to improve blood flow

in other cases thrombokinase (enzyme) is injected trhough the catheter, to dissolve blood clot

intravascular stent - introduced to maintain dilation

Front 74

Coronary Occlusion and Heart Conduction Effects

Back 74

LAD supplies AV bundle

RCA supplies SA and AV nodes

heart block may occur upon occlusion of these vessels

Front 75

Artificial Cardiac Pacemaker

Back 75

implanted to induce heart contraction at a predetermined rate

electrode passed through SVC into RA, through tricuspid to RV and firmly fixed to traveculae carnae in ventricular wall

Front 76

Restarting the Heart

Back 76

CPR -- firm pressure over thorax forces blood into systemic circulation, release of pressure allows for refilling

Front 77

Fibrillation of Heart

Back 77

multiple, rapid, circuitous contractions or twitching of muscle fibers

atrial fibrillation : rapid, irregular uncontrolled twitchings of atrial walls

ventricular fibrulation : twitchings do not pump / maintain circulation. most disorganized of all dysrhythmias; fatal if persistant

Front 78

Defibrillation of Heart

Back 78

electric shock causes cessation of all cardiac movements to induce normal beating

Front 79

Cardiac Referred Pain p. 102

Back 79

actual heart insensitive to touch, pain, or temp.

ischemia and metabolic products stimulate pain endings in myocardium, through T1-T5 axons (left side)

noxious stimuli in heart perceived as pain on superficial part of body (i.e. left upper limb)

visceral pain = transmitted by visceral afferent fibers accompanying sympathetic fibers

anginal pain = radiates from substernal and left pectoral regions to left shoulder and medial aspect of upper limb

Front 80

Age changes in Thymus

Back 80

thymus replaced by adipose tissue in adults, but continues to be important

number one source of T cells in body

(that's why immune defense of older people go down)

Front 81

Aneurysm of Ascending Aorta p. 112

Back 81

aneurysm = localized dilation

evident on a chest film (radiograph) or a magnetic resonance angiogram

results from force of LV contraction and a localized dilation

symp: chest pain that radiates to back

aneurysm of arch of aorta may exert pressure on the trachea, esophagus, and reccurent laryngeal nerve, and results in difficulty breathing and swallowing

Front 82

Variations in the Great Arteries p. 112

Back 82

most superior part of the aorta = ~2.5 cm inferior to the superior border of the manubrium.

different branch patterns of aortic arch (in 35% of people)

R. arch or the aorta = over R lung
double arch or retroesophageal right subclavian artery = vascular ring around the esophagus and trachea.

-coarctation of aorta : abnormal narrowing, producing obstruction to blood flow
*most commonly near ligamentum arteriosum; collateralization provides many years of life

Front 83

Injury to Recurrent Laryngeal Nerves p.112

Back 83

supply all intrinsic muscles of larynx, except one

affected by bronchial/esophageal carcinoma, enlargement of mediastinal lymph nodes, or an aneurysm of aortic arch (the nerve may be stretched by the dilated arch of the aorta)

Front 84

Laceration of Thoracic Duct p.112

Back 84

vulnerable to inadvertent injury during investigative / surgical procedures because it's thin walled and colorless

results in lymph escaping into thoracic cavity at very high rates, and pleural cavity causing chylothorax

fluid may be removed by thoracentesis and ligation of duct may be necessary

Front 85

Alternate Venous Routes to the Heart

Back 85

azygos, hemiazygos, and accessory hemiazygos all offer alternate means of venous drainage to heart if there is obstruction of the IVC

Front 86

Subarealoar breast cancer (p. 58)

Back 86

may cause inversion of the nipple by similar mechanis involving the lactiferous ducts

Front 87

surgical incision of breast (p.59)

Back 87

placed in the inferior quadrants when possible since they are less vascular

Front 88

Mastectomy (p.59)

Back 88

breast excision

not as common as it once was

simple mastectomy = breast is removed down to the retromammary space.

radical mastectomy = more extensive that involves removal of the breast, pect. muscles, fat, fascia, and many lymph nodes

lumpectomy or quadrantectomy aka breast-conserving surg. = often only remove the tumor and surrounding tissues - followed by radiation therapy

Front 89

Role of costal cartilages p. 50 & 54

Back 89

contribute to the elasticity of the t. wall

in elderly people, the costal cartilages undergo calcification, making them radiopaque and less resilient

Front 90

Dyspnea p.64

Back 90

shortness of breath (SOB), or air hunger

may be caused by asthma or emphysema or with heart failure

fix pectoral girdles (clavicle and scapula) to expand thorax.

Front 91

Muscles of thoracic wall (link)

Back 91

http://home.comcast.net/~wnor/thoraxmuscles.htm

Front 92

Bones of the thorax (link)

Back 92

http://home.comcast.net/~wnor/thoraxbones.htm

Front 93

Arterial Blood and Nerves supply to the thorax (link)

Back 93

http://home.comcast.net/~wnor/thoraxves&nerofwall.htm

Front 94

Lung Dissection (link)

Back 94

http://home.comcast.net/~wnor/thoraxlesson2.htm

Front 95

Pleura (link)

Back 95

http://home.comcast.net/~wnor/thoraxlesson3.htm

Front 96

The Heart (link)

Back 96

http://home.comcast.net/~wnor/thoraxlesson4.htm

Front 97

Posterior Mediastinum (link)

Back 97

http://home.comcast.net/~wnor/thoraxlesson5.htm

Front 98

Superior Mediastinum (link)

Back 98

http://home.comcast.net/~wnor/thoraxlesson6.htm

Front 99

The Mediastinum p. 80

Back 99

Superior Mediastinum: suprior thoracic aperture to the sternal angle (T4-T5)

Inferior: anterior, middle, and posterior mediastinum

Front 100

Inferior mediastinum p. 80

Back 100

Anterior contains: thymus, lymph noes, fat, and connective tissue

Middle contains: pericardium, heart, roots of the great vessels, arch of the azygos vein, main bonchi

Posterior contains the : esophagus, thoracic aorta, azygos and hemiazygos veins, thoracic duct, vagus nerves, SVC, sympathetic trunks, and splanchnic nerves

Front 101

Nerve supply of the pericardium p. 82

Back 101

Phrenic nerves (C3-C5) - primary source of sensory fibers; pain sensations - skin of top of the shoulder of the same side

Vagus (CNX) - fxn uncertain.

Sympathetic trunks - vasomotor

Front 102

apex beat p. 92

Back 102

impulse that results from the apex being forced against the anterior thoracic wall when the left ventricle contracts

the location of the apex beat (mitral area) varies in position; it may be located in the 4th or 5th intercostal spaces.

Front 103

Areas of auscultation p. 94

Back 103

Aortic valve; second intercostal space to the right of the sternal border

Pulmonary valve; second intercostal space to the left of sternal border

Tricuspid valve; near left sternal border in fifth or sixth intercostal space

Mitral valve; apex of the heart in fifth intercostal space in midclavicular line


SEE p. 93

Front 104

The cardiac cycle p.98 (link)

Back 104

http://www.youtube.com/watch?v=jLTdgrhpDCg

Front 105

Conducting system of the heart p. 97 (link)

Back 105

http://www.youtube.com/watch?v=te_SY3MeWys&feature=related

Front 106

Dissection (link)

Back 106

http://www.youtube.com/watch?v=87iMg1dMXiA&feature=related

Front 107

Coarctation of Aorta p. 113

Back 107

the arch of the aorta or descending aorta has a abnormal narrowing (stenosis) that decreases the size of its lumen.

most common site is near the ligamentum arteriosum.

Front 108

septomarginal trabecula p. 89

Back 108

moderator band

significance: it carries part of the right bundle branches of the AV bundle of the conducting system of the heart and the anterior papillary muscles

this facilitates conduction time, allowing coordinated contraction of the anterior papillary muscle.

Front 109

Mediastinoscopy

Back 109

a procedure that enables visualization of the contents of the mediastinum, usually for the purpose of obtaining a biopsy.

often used for staging of lymph nodes of lung cancer or for diagnosing other conditions affecting structures in the mediastinum such as sarcoidosis or lymphoma.

involves making an incision approximately 1 cm above the suprasternal notch of the sternum, or breast bone
A scope (mediastinoscope) is then advanced into the created tunnel which provides a view of the mediastinum

Front 110

Pulmonary valve stenosis p.92

Back 110

valve cusps are fused, forming a dome with a narrow central opening.

Front 111

Vagus Nerve Pathways aka Pneumogastic nerve/ Cranial Nerve X

Back 111

The vagus nerve supplies motor parasympathetic fibers to all the organs except the suprarenal (adrenal) glands, from the neck down to the second segment of the transverse colon. The vagus also controls a few skeletal muscles

The vagus nerve is responsible for such varied tasks as heart rate, gastrointestinal peristalsis, sweating, and quite a few muscle movements in the mouth, including speech (via the recurrent laryngeal nerve) and keeping the larynx open for breathing (via action of the posterior cricoarytenoid muscle, the only abductor of the vocal folds).

Parasympathetic innervation of the heart is controlled by the vagus nerve. To be specific, the vagus nerve acts to lower the heart rate.

Effects of Vagus nerve lesions:The patient complains of hoarse voice, difficulty in swallowing (dysphagia), and choking when drinking fluid. There is also loss of gag reflex. Uvula deviates away from the side of lesion, and there is failure of palate elevation

Front 112

Phrenic Nerve

Back 112

originates mainly from the 4th cervical nerve, but also receives contributions from the 5th and 3rd cervical nerves (C3-C5)

contain motor, sensory, and sympathetic nerve fibers

provide the only motor supply to the diaphragm as well as sensation to the central tendon. In the thorax, each phrenic nerve supplies the mediastinal pleura and pericardium

Path : Found in the middle mediastinum, both phrenic nerves run from C3, C4 and C5 along the anterior scalene muscle deep to the carotid sheath.
- The right phrenic nerve passes over the brachiocephalic artery, posterior to the subclavian vein, and then crosses the root of the right lung anteriorly and then leaves the thorax by passing through the vena cava hiatus opening in the diaphragm at the level of T8. The right phrenic nerve passes over the right atrium.
- The left phrenic nerve passes over the pericardium of the left ventricle and pierces the diaphragm separately.

phrenectomy will paralyze half of the diaphragm

Front 113

Azygos venous system

Back 113

Azygos vein= runs to R of T4-T12, arches on root of R lung, and empties into SVC. Serves to drain most of the posterior intercostal veins on the right side of the body,

hemiazygos vein and the accessory hemiazygos vein drain most of the posterior intercostal veins on the left side of the body

Accessory hemiazygos =
drains the fifth through eighth intercostal spaces on the left side of the body. Joins hemiazygos v. or runs sup to join brachiocephalic v.

Hemiazygos v. = runs superiorly in the lower thoracic region, just to the left side of the vertebral column.

Front 114

Heart valves

Back 114

The four valves are known as:

The tricuspid valve

The pulmonic or pulmonary valve

The mitral valve

The aortic valve

Front 115

Heart Vascular supply (ant.)

Back 115

Front 116

Heart vascular supply (post)

Back 116

Front 117

Sympathetic chain

Back 117

The sympathetic trunk is a fundamental part of the sympathetic division of the autonomic nervous system. It allows nerve fibers to travel to spinal nerves that are superior and inferior to the one in which they originated. Also, a number of nerves, such as most of the splanchnic nerves, arise directly from the trunks

Front 118

the nervous system

Back 118

Front 119

Muscles of the thoracic wall

Back 119

Front 120

Posterior Thorax dissection (link)

Back 120

part1 : http://www.youtube.com/watch?v=YathjWGgmEc&feature=related

part 2 : http://www.youtube.com/watch?v=4J-fgyb4spk

Front 121

Circulatory Sys.

Back 121