Anatomy Flashcards
what are bronchopulmonary lymph nodes also known as
hilar lymph nodes
what is the path of the phrenic nerves
from C3-C5 descends across the lateral borders of the pericardium to the diaphragm
describe the positions of the phernic and vagus nerves in relation to the hilum
Phernic nerve anterior to hilum
Vagus nerve posterior to hilum
what internally lines the fibrous pericardium
lined internally by parietal serous pericardium
what covers the anterior surface of the heart
epicardium
what does the epicardium secrete
pericardial fluid lubricant
where is the pericardial cavity
located between the 2 layers of the serous pericardium
what is haemopericardium and what does it lead to
when pericardial cavity fills with blood, increasing pressure around heart and can prevent contraction = cardiac tamponade
what does the pericardial cavity contain
pericardial fluid
what is pericardiocentesis
drainage of fluid from the pericardial cavity
where is the needle inserted in a pericardiocentesis
into ‘bare area of pericardium’ via infrasternal angle and directed superoposteriorly, aspirating continuously
where is the bare area of the pericardium
below the sternal angle and costal cartilages
describe the transverse pericardial sinus
a space within the pericardial cavity, posterosuperiorly, lies posterior to the ascending aorta and pulmonary trunk
what vessels are enclosed within the pericardium
the most proximal segments of the ascending aorta and pulmonary trunk
how does the pericardium close around the ascending aorta and pulmonary trunk
blends with their adventitia
why is the transverse pericardial sinus clinically important
cardiac surgeons use this sinus to identify and isolate the great vessels in order to commence cardiopulmonary bypass (for open heart surgery)
where does a surgeons finger emerge from the TPS
anterior to the SVC
what are the three surfaces of the heart
anterior (sternocostal) surface, base (posterior) surface, inferior (diaphragmatic) surface
what are the borders of the heart
right and left (lateral)
what surface of the heart is in contact with the diaphragm
inferior
what vessel of the heart cannot be visualised anteriorly
left atrium
where can the apex beat normally be felt
5th left intercostal space in the midclavicular line (mitral area)
what does cardiac enlargement do to the heart what what is it AKA
cardiomegaly- often shifts the apex beat to the left
what does the coronary groove indicate
surface marking for the tricuspid valve (boundary between right atrium and right ventricle)
what does the anterior interventricular groove indicate
the boundary between the 2 ventricles
what combines to form the brachiocephalic veins
right and left internal jugular and subclavian veins
what combines t for the SVC
brachiocephalic veins
what is the right auricle
(ear like structure) extension of the right atrium
what is the left auricle
extension of the left atrium
where does the right coronary artery travel
within the coronary groove
what is the coronary sinus
short venous conduit which receives deoxygenated blood from most of the cardiac veins
where does the coronary sinus drain into
right atrium
where does the coronary sinus travel
within the atrioventricular groove posteriorly
what does the posterior interventricular groove contain
posterior interventricular artery (branch of right coronary artery) and posterior interventricular vein
what does the posterior interventricular groove indicate
the boundary between the 2 ventricles
what is the first branch off the aorta
coronary arteries
what connects the left and right coronary arteries
anastomoses
what is the septum between the 2 atria called and indicated by on the surface
interatrial septum- interatrial groove
what is the septum between the 2 ventricles called and indicated by on the surface
interventricular septum- interventricular groove
what can an atrial or ventricular septal defect cause
hypoxaemia due to mixing of atrial and venous blood
what does the mixing of arterial and venous blood do
reduces the oxygen content of systemic arterial blood in the aorta
what does the crista terminalis separate
rough and smooth textures
where is the tricuspid valve
between right atrium and right ventricle
where is the pulmonary valve
between the right ventricle and pulmonary trunk
where is the mitral (bicupsid) valve
between the left atrium and left ventricle
where is the aortic valve
between the left ventricle and the aorta
describe the pulmonary valve
has anterior right and left cusps
describe the aortic valve
has right, left and posterior cusps and sinuses (spaces within cusps)
describe the tricuspid valve
has anterior, posterior anf septal cusps
describe the mitral valve
has anterior and posteroir cusps
what attached the valve leaflets to papillary muscles
tendinous chords
what causes the first heart sound
mitral and tricuspid valves closing closing
what causes the second heart sound
the closure of the aortic and pulmonary valves
what are the sinuses within the aortic valves for
the coronary arteries
what are semilunar valves
cusps look like half moons; pulmonary and aortic
what are leaflet valves
have valve leaflets held down with teninous chords which attach to papillary muscles, prevent reflux, mitral and tricuspid
what does the fibrous skeleton do to the valves
provides them with stability
what does a moderator band do
carries fibres of right bundle branch to the papillary muscle of the anterior cusp (shortcut for electrical activity to make sure all cusps contract and close tricuspid at same time
what is a foetal remnant that can be seen in the right atrium
foramen ovale
where do you auscultate for the aortic valve
2nd right ICS sternal edge
where do you auscultate for the pulmonary valve
2nd left ICS sternal edge
where do you auscultate for the tricuspid valve
4th left ICS sternal edge (lower left sternal edge)
where do you auscultate for the mitral valve
5th left ICS midclavicular line
describe diastole
blood returns via vena cave to RA and pulmonary veins to LA
Tricuspid & mitral valves open so blood drains into RV & LV
Impulse originates at SA node and spreads across atria
Atrial contraction completes ventricular filling
describe systole
Impulse spreads across ventricles
Ventricles begin to contract – once pressure in ventricles > pressure in atria tricuspid & mitral valves snap shut
Ventricles continue to contract – once pressure in ventricles > pressure in PT & aorta pulmonary and aortic valves forced open and blood ejected into great arteries
Impulse spreads across ventricles
Ventricles begin to contract – once pressure in ventricles > pressure in atria tricuspid & mitral valves snap shut
Ventricles continue to contract – once pressure in ventricles > pressure in PT & aorta pulmonary and aortic valves forced open and blood ejected into great arteries
how does autonomic innervation and visceral afferent nerves reach the heart
via cardiac plexus
what are the two components of the visceral afferent nerves
pain fibres travel to spinal cord alongside sympathetic nerves
(visceral) reflex afferents (e.g. from baroreceptors) travel mainly in the vagus nerve (some in CN XI)
what do pain fibres travel to the spinal cord in
cardiopulmonary splanchnic nerves and cardiopulmonary plexus
where is the cardiac plexus located
behind the great vessels of the heart
what connects the CNS to the ganglion (synapse)
presynaptic fibre/ preganglionic fibre
what connect the ganglion to the organ
postsynaptic fibre
what is a ganglion
collection of nerve cell bodies outside the CNS
what are the neurotransmitters of the sympathetic ganglion and post synaptic fibres
ganglion=acetyl choline
PSF= noradrenaline
how do sympathetic signals leave the CNS
- travel inferiorly within spinal cord tracts and then…
2. exit the spinal cord in one of T1-L2/3 spinal nerves (thoracolumbar)
what are the 3 most likely options for a sympathetic signal once it leaves the CNS
go into the ganglion of that level & synapse
travel superiorly in the sympathetic chain to another ganglion & synapse
travel inferiorly in the sympathetic chain to another ganglion & synapse
what do the cardiopulmonary splanchnic nerves supply
sympathetic nerves to heart and lung from spinal cord
what type of innervation will a midline organ (e.g. the heart) have
bilateral sympathetic innervation
what three types of nerve fibres make up the cardiac plexus and where do they come from?
sympathetic fibres from the cardiopulmonary splanchnic nerves
parasympathetic fibres from the vagus
visceral afferent fibres (pain fibres ect)
what are the neurotransmitters for the ganglion and post synaptic fibres of the para system
both acetylcholine
what are para posr sympathetic fibres very short in the innervation of the heart
as ganglion on heart wall so PGF dont have to travel very far
how do Parasympathetic Signals Reach the Organs
via Cranial Nerves III, VII, IX & X
what is CN III
oculomotor nerve
what is CN VII
facial nerve
what is CN IX
glossopharyngeal nerve
what is CN X
vagal nerve
describe the nerve fibres within the CN X nerve
presynaptic parasympathetic fibres in vagus nerve then synapse onto postsynaptic neurones
(with short axons in ganglia within the walls of the organs of the chest & upper abdomen e.g. heart, lungs)
what does the vagus nerve supply
heart and other thoracic organs
what spinal nerves do para also travel in
sacral spinal
what reflex afferents are in the vagus nerve
aortic arch baroreceptor reflex afferents in vagus nerve
what are the somatic causes of pain in the central chest and what is it like
Muscular Joint Bony Intervertebral disc (Fibrous) pericardial nerve
typically sharp, stabbing and well localised
what are the potential visceral causes for central chest pain and what is it like
Heart & Great vessels
Trachea
Oesophagus
Abdominal viscerae
typically more dull, aching, nauseating, poorly localised
describe radiating pain
Pain felt in centre of chest AND felt spreading from there
- Upper limbs
- Back
- Neck
describe referred pain
Pain ONLY felt at site remote from area of tissue damage in the chest
- Upper limbs
- Back
- Neck
where does sensation reach consciousness
cerebral cortex
what is stimulate in dermatomes to produce sensations
skin mechanoreceptors
describe the path of pain
sensor- AP propagated centrally- crosses spinal chord- CNS (e.g. Anterior ramus, spinal nevre posterior root, crosses side of spinal chord and then comes into contact with cerebral cortex)
why is somatic pain well localised
due to precisely (somatotopically) organised pathways from periphery and projections to cortex
what is the somatosensory part of the brain and what does it do
postcentral gyrus of parietal lobe- APs arriving here bring body wall (somatic) sensations into “consciousness”
what is the somatomotor part of the brain and what does it do
precentral gyrus of frontal lobe- APs originating here bring about contractions of body wall (somatic) skeletal muscle
what are sources of sharp, somatic central chest pain
herpes zoster (shingles), muscle joint and bone, parietal pleura and fibrous pericardium
what could cause dull, visceral central chest pain
trachea- tracheitis aorta- ruptured aneurysm of aortic arch abdominal viscerae- infections oesophagus-oesophagitis heart- angina and MI
what sub division of the mediastinum are the great vessels in
superior
where does the phrenic nerve run in relation to the hilar
anterior
where is the vagus nerve always found on the RHS
on surface of the trachea, passing posterior to the root of the lung then follows the oesophagus to the diaphragm
what does the azygous vein drain into
SVC
what is the path of the vagus nerve on the left hand side
crossing left side of aortic arch heading posterior to the lung hilum towards the oesophagus
where is the thoracic duct
left side of upper oesophagus
from what side of mediastinum can the aorta be visualised
left hand side
what creates the recurrent layrngeal nerve
branch of left vagus nerve that cross the trachea
what part of the aorta lies in the posterior mediastinum
thoracic aorta
describe the path of visceral afferent APs
pass bilaterally to thalamus & hypothalamus then diffuse areas of the cortex
alongside what do visceral pain afferents travel alongside going to the organs
alongside the sympathetic (motor)
where do visceral pain afferents from the heart enter the spinal chord
via posterior roots in the cervical ganglia and T1-T5
how does the route visceral afferents lead to radiating chest pain
as Route visceral afferents take from heart via neck & upper thoracic regions of trunk/cord leads to radiating and referred pain from the heart – due to lack of precision in route taken by visceral afferents to the spinal cord
(cant decide between visceral or somatic as they synapse at ganglion in same place)
where do somatic sensory neurons enter the spinal chord in relation to visceral afferents
in same place (via posterior roots)
if pain is originating in a somatic structure the radiation of pain is where
along the affected dermatome(s)
if pain is originating from the heart where is the radiating pain and why
radiation is to the dermatomes supplied by the spinal cord levels at which the cardiac visceral afferents enter the sympathetic chain/spinal cord i.e. BILATERALLY to cervical and upper thoracic dermatomes
what is referred pain
the sensation of pain is “felt” ONLY at a site remote from the actual area of injury or disease
what causes referred pain
Due to afferent (sensory) fibres from soma and afferent (sensory) fibres from viscera (visceral afferents) entering the spinal cord at the same levels
The brain chooses to believe that the pain signals coming from the organ, are actually coming from the soma
what is a heart attack
Myocardial infarction (MI) – irreversible death (necrosis) of part of the myocardium due to occlusion of it’s arterial blood supply
what are the types of MI
according to which SURFACE of the heart has been affected, e.g.:
Anterior MI
Inferior MI
Anterolateral MI
where do the coronary arteries arise from
right and left aortic sinuses of the ascending aorta
what are common sites for coronary atheroscleorosis (narrowing and occlusion especially)
(4 in order of likely hood)
anterior interventricular branch (LAD) of LCA
RCA
circumflex branch of LCA
left (main stem) coronary artery
what is triple vessel disease
narrowing or occlusion in three coronary arteries, treated by triple bypass
where are coronary artery grafts anastomosed proximally
to the ascending aorta
where are coronary artery grafts anastomosed distally
to coronary artery distal to narrowing
what are three commonly used grafts
radial artery/internal thoracic (mammary) artery; great saphenous vein
what artery is grafted in pedicle and what does this mean
internal thoracic artery graft (by pedicle meaning a segment not cut from vessel but instead the distal end of the vessel is anastomosed distal to the narrowing leaving the proximal end in situ and receiving blood as normal via the subclavain artery
what happens if the blood supply to the conducting system of the heart is reduced= tissue damaged by ischaemia
arrhythmia
what blood supply feeds the SA node
RCA nears in origin
what blood supple feeds the AV node
RCA near origin of PIV artery (posterior interventricular artery)
what supplies blood to the interventricular septum
dual supply;
LAD (left anterior descending) or anterior interventricular artery
and
posterior interventricular artery
what happens is the blood supply to the interventricular septum is compromised
arrhythmias
what is right and left co dominance
territory supplied by left and right coronary arteries
right-dominant pattern in ~70%; in up to 35% LCA is dominant and in approx. 20% there exists a co-dominance : i.e. both supply branches that run in the posterior interventricular groove)
which coronary artery gives rise to the posterior interventricular artery
right CA
what is dysphagia
difficulty swallowing
what is the mediastinum
area between the lungs
what divides the superior and inferior mediastinum
sternal angle (in between t4 and t5)
what structures surround the thoracic inlet
ribs 1, T1 vertebra and jugular notch
how is the mediastinum divided
superior, inferior; anterior, middle and posterior
what is the anterior mediastinum between
sternum and the fibrous pericardium
what gland in contained within the anterior mediastinum
thymus
what is the role of the thymus is children and adults
children- produces T lymphocytes
adults- replaced with adipose tissue
what is contained within the middle mediastinum
pericardium, heart, parts of the great vessels
what great vessels attach to the heart and pass through the middle mediastinum
inferior part of SVC, superior part of IVC, pulmonary trunk anf arteries, pulmonary veins, ascending aorta
what is contained within the posterior mediastinum
azygous vein, vagus nerves, 2 main bronchi, thoracic aorta, oesophagus, vagal trunks, thoracic duct, sympathetic chains/ trunks
what is the role of the azygous vein
conveys blood from the intercostal veins to the SVC
what is the role of the thoracic duct
carries lymph to the left venous angle
what is the path of the vagal trunks
pass through the diaphragm with the oesophagus onto the stomach
what part of the aorta lies within the posterior mediastinum
the thoracic part
where does the trachea bifurcate
at the level of the sternal angle (so in the superior mediastinum)
describe how and where the vagus nerves exist
as plexus within posterior mediastinum
what nerves are the most lateral
sympathetic trunks
what can rupture the azygous vein
chest trauma
describe the path of the azygous vein
arches anteriorly, superior to the lung root to drain into the SVC
where do the intercostal veins drain into
drain posteriorly into the analogous vein
where is the azygous vein in relation to the lung root
posterior and superior to it
when does the descending aorta become the abdominal aorta
after it passes through the diaphragm
what part of the aorta do the carotids come from
ascending aorta
what are the mediastinal branches of the aorta
coronary arteries,
brachiocephalic trunk- common carotids and left subclavian,
posterior intercostal ateries (one for each intercostal space),
branches from the thoracic aortas anterior surface;
- bronchial arteries
- oesophageal arteries
- mediastinal arteries
- pericardial arteries
- phrenic arteries (for the diaphragm)
where does the right subclavian artery come from
right brachiocephalic artery
what is the role of the bronchial arteries
arterial blood for the lung tissue
what is the aortic hiatus
opening in the diaphragm for the aorta
what drains into the right venous angle
right lymphatic duct
what drains into the left venous angle
thoracic duct
what do the lymph vessels accompany
veins
how does the lymph drain from the nodes
via the bronchopulmonary lymph nodes
where are the bronchopulmonary lymph nodes
surround the main bronchus at the lung root
how can pulmonary malignancies metastasise
via the lymphatics
where are the tracheo-bronchial lymph nodes
around the bifurcation of the trachea
what is the cisterna chyli
swollen start of thoracic duct in abdomen
how does the oesophagus pass through the diaphragm
oesophageal hiatus
where is the right vagus nerve in the mediastinum
sits on lateral surface of the trachea and passes posterior to the root of the lung
the right phrenic nerve pass through the _____ with the _____ to supply the _____ from the ______ aspect
passes through the diaphragm with the IVC to supply the diaphragm from the inferior aspect
where is the left vagus nerve in the mediastinum
closely associated with the aorta, lies on top of it then passes posterior to root of lung
what is the ligamentum arteriosum
remnant of the ductus arteriosus
where is the liganentum arteriosum
between the aortic arch and pulmonary trunk
the right phrenic nerve pass through the _____ to supply the _____ from the ______ aspect
left dome of the diaphragm
diaphragm
inferior aspect
what is a role of the recurrent laryngeal branch of the left vagus nerve
allows us to talk
what is the course of the left recurrent laryngeal branch of the left vagus nerve
left RLN originates from the left vagus nerve as it crosses the aortic arch. It then passes posteriorly under the arch and the ligamentum arteriosum then travels back up to larynx
list the structures within the superior mediastinum from anterior to posterior
brachiocephalic veins and SVC, arch of aorta, trachea, oesophagus, thoracic duct
list the structures within the superior mediastinum from lateral to medial
phrenic nerves, vagus nerves, recurrent laryngeal nerves
the pressure inside which veins reflect the pressure in the right atrium
central veins
what are the central veins
internal jugular, subclavian, brachiocephalic, superior vena cava, inferior vena cava illiac, femoral
what causes the double pulsation in the JVP
atrial contraction and then filling of the right atrium against a closed tricuspid valve
how high should the JVP be normally at 45 degrees
no more than 3cm above the sternal angle
what does the right recurrent laryngeal nerve hook under
the right subclavian artery
do either of the reccurent laryngeal nerves enter the chest
no
what are the phrenic nerves made up of
combined anterior rami of the cervical spinal nerves 3, 4 and 5 ( keep the diaphragm alive)
what does the phrenic supply somatic motor to
the diaphragm
what does the phrenic supply somatic sensory to
mediastinal parietal pleura,
fibrous pericardium,
diaphragmatic parietal pleura,
diaphragmatic parietal peritoneum
describe referred pain from the diaphragm
something (liver abscess/ inflammation) irritates parietal peritoneum lining the inferior surface of the diaphragm, which is supplied by the phrenic nerve (C3,4,5). The supraclavicular nerves (c3,4) supply the dermatomes over the “shoulder tip” and enter the spinal cord at the same levels as the phrenic nerve. Brain refers pain to skin over the shoulder tip
what does the vagus nerves contain
somatic sensory nerves, somatic motor nerves, autonomic parasympathetic nerves
what structures are supplied with the somatic sensory nerves within the vagus nerves
palate, laryngopharynx and larynx
what structures are supplied with the somatic motor nerves within the vagus nerves
pharynx and larynx
what structures are supplied with the autonomic parasympathetic nerves within the vagus nerves
thoracic and abdominal organs
what do the vagus nerves contain after the recurrent laryngeal branches branch off
only parasympathetic fibres
where do the anterior intercostal arteries come from
thoracic artery
where do the posterior intercostal arteries come from
thoracic arota
what is the superficial vein of the upper limb
cephalic vein
where do the anterior intercostal veins drain into
thoracic vein
where do the posterior intercostal veins drain into
azygous veins
what is the peripheral pulse in the neck and where is it found
bifurcation of the common carotid- anterior to sternocleido-mastoid muscle at level of superior border of thyroid cartilage
what peripheral pulses are in the upper limb and where are they found
brachial- medial to biceps brachii tendon in the cubital fossa
radial- lateral to tendon of flexor carpi radialis
what peripheral pulses are in the lower limb and where are they found
femoral artery
-inferior to midpoint of inguinal ligament
popliteal artery
-in popliteal fossa (immediately posterior to knee joint)
posterior tibial artery
-between the posterior border of the medial malleolus & the achilles tendon
-dorsalis pedis artery (dorsal artery of the foot)
medial to tendon of extensor hallucis longus on the dorsum of the foot
what are allows arterial access to the (left side) of the heart and their uses
radial artery (cannulation for ABP/ABG)
femoral artery (intravascular interventions)
subclavian artery (ccardiac pacing wire)
what are allows venous access to the (right side) of the heart and their uses
inferior jugular vein (central line)
femoral vein (central line and intravascular interventions)
