3.2.1. ANATOMY - Internal and Clinical Anatomy of the Heart

Answer 4

Left Atrium

Question 6

What does JVD indicate? (What is happening, don’t list out possible diseases)

Answer 6

Backing up of blood, something is wrong in the chest!

Question 7

If the trachea is deviated to the right, what do you know?

Answer 7

There is some kind of pressure in the left side pushing the trachea to the right (like AIR!)

Question 8

If you percuss and you feel a dullness, what does this indicate?

Answer 8

Dull = blood below

(assume blood w/trauma, otherwise could just be watery fluid)

Question 9

Hyperresonating or echo like sound indicates what when percussing?

Answer 9

Air below

(like a drum)

Question 10

If you do not hear breath sounds, what does it mean?

Answer 10

That lung is not working, most likely due to blood/fluid buildup or lung collapse from air

Question 11

A patient presents to you with hypotension, cyanosis, and can’t breathe. X-ray shows a left-deviated mediastinum with a compressed left lung.

What caused the low blood pressure and how do you treat this?

Answer 11

This deviation causes the IVC to kink, so the blood can’t get to the right atrium. This is what causes the low blood pressure

Pressure buildup in the chest prevents the SVC from delivering blood to the RA

Treatment is a needle decompression or a chest tube to relieve the pressure

Question 12

Where do we insert the chest tube with respect to the rib?

Answer 12

ABOVE the rib, so as not to damage the neurovascular bundle on the inferior aspect of the rib

Question 13

What is the difference between a patient not being able to breathe and saying that they can not breathe?

Answer 13

Airway = Can’t breathe

Breathing issue = Patient tells you that they can’t breathe (complaints of dyspnea, as opposed to physical incapacity)

Question 14

A patient is shot in the right chest by a sniper - Dangerous due to bullet’s ability to break through the mediastinum.

Right sided chest pain, patient says they can’t breathe, cyanotic, low blood pressure.

Physical exam shows no breath sounds on the right side, percussion shows tympanic/hyperresonating sounds.

What is going on? How do we fix it?

Answer 14

“Sucking chest wound” - resistance of the hole is less than through the trachea, so the air rushes in, collapsing the lung.

COVER THE HOLE = allows you to breathe

Question 15

Why is the bandage for a sucking chest wound only sealed on 3 sides, not all 4?

Answer 15

3 sided bandage used with the top left open to allow air to leave the cavity. Covers the hole to prevent more air from coming in.

Question 16

Patient is shot by his friend, is not complaining of breathing issues.

Patient is cyanotic, tachycardic, and hypotensive.

X-ray shows blood in the right side of his chest with dull percussion and no breath sounds in the right chest.

What do you do?

Answer 16

Do a chest tube to let the blood out. After 1.5 liters, you need to have surgery

Question 17

32 y.o. woman shot in the left chest, hypotensive, cyanotic and tachycardic. Her exam yields Jugular neck vein distension, decreased heart sounds, normal percussion and normal breath sounds.

What does she have?

Answer 17

Cardiac Tamponade

Question 18

What is Beck’s Triad and which part is the most important diagnostically?

Answer 18

Beck’s Triad

1. Hypotension
2. JVD
3. Decreased heart sounds: most diagnostically important

Question 19

What is a pericardiocentesis? How do we deal with it?

Answer 19

Pericardiocentesis (aka pericardial tap) for blood buildup in the pericardium - Needle to drain excess fluid before the heart explodes since it cannot expand or stretch to accommodate the extra pressure.

Question 20

When draining blood from the pericardium, there is always the risk of piercing the heart itself.

How do you know if the blood you have removed is coming from a ventricle or from the pericardial sac?

Answer 20

Squirt the blood you just drew onto the table - if the blood clots, then you’re in the right spot! If not, you pierced the ventricle…

Blood that’s been resting in the pericardial space (re: “tamponade”) is more likely to have begun the clotting process and will more readily clot than circulating blood.

Question 21

A 66 year old male found unconscious after his truck hit a telephone pole. He was intubated rapidly by EMT and delivered to your ER. On exam, his GCS:6, BP 90/35, and he has dull breath sounds on left side

- Xray shows white on the left side of the chest. What does this mean?

Answer 21

white = no air in that lung

Question 22

What is the risk of soving an endotracheal tube in quickly?

Answer 22

Endotracheal tube can get shoved right down the right side of the lung TOO FAR, just pull the tube up a little bit if you see this.

-Straight shot to the right lung (left lung curves)

Question 23

Car accident patient - Painful percussion on right side with decreased breath sounds

Can’t breath, cyanotic, and tachycardic

Right chest wall sinks slightly with deep inspiration pain to right side.

What is going on here?

Answer 23

flail chest

Question 24

Discuss a flail chest and how it affects breathing

Answer 24

Fast compression of the lung usually due to heavy impact causing bruising of the lung. Usually accompanied by rib fractures (must have frx in at least two places to have a freely-floating rib segment, typically on the lateral/axillary aspects).

Has to be the side of the chest to be considered a flail chest

Can’t breathe because you can’t expand the chest

Question 25

34 y/o/ driver, telephone pole impacted the vehicle - Hypotensive, can’t breathe, cyanotic, tachycardic

Deviated trachea to left, JVD, no breath sounds to left, tympanic percussion on the right side

Tried a chest tube, but it comes out with bubbles in it. Try a couple more with all of the same result.

What has occurred in your patient? How do you fix it?

Answer 25

Bronchus has torn off (transection from violent needle decompression movement)

Usually occurs on the right side

Treat with stitches

Question 26

6 year old boy in an automobile accident complains of breathing difficulties and vomiting.

Physical exam yields tympanic left chest sounds.

What could be happening with this patient?

Answer 26

Diaphragm weakening, posterior side - Diaphragmatic hernia

Question 27

What side of the body can get a diaphragmatic hernia?

Answer 27

Left side only. Liver stops it from happening on the right.

Question 28

Truck accident 35 y.o.,drunk, seems normal on PE and vitals

Chest X-ray reveals widened mediastinum.

What is happening?

Answer 28

Aortic transection - very common in traumatic events ass’d w/rapid DECELERATION

Question 29

What are some signs of an aortic rupture/transection/dissection?

Answer 29

Things that can indicate this are

an enlargement of the aortic knob, hemothorax, tracheal displacement and esophageal displacement with a displaced bronchus

Question 30

What is dangerous about aortic dissection?

Answer 30

Recurrent laryngeal nerve paralysis associated with thoracic aortic aneurysm since this nerve wraps around the aortic arch

Question 31

Anterior spinal artery syndrome

Answer 31

Anterior spinal artery syndrome is a medical condition where the anterior spinal artery, the primary blood supply to the anterior portion of the spinal cord, is interrupted, causing ischemia or infarction of the spinal cord in the anterior two-thirds of the spinal cord and medulla oblongata.

Question 32

Who is more affected by CAD, men or women, and why?

Answer 32

Smoking in men is going down so we are seeing a decrease in CAD in men; female CAD is going up with an increase in smoking

For women, more women die of heart disease (356,000) than any other causes put together

Question 33

Why is CAD often not diagnosed in women?

Answer 33

Shoulder pain not felt in women - common reason for under-diagnosis