Anatomy - oxygen supply and exchange week 1 Flashcards
1
Q
which ribs are most commonly fractured?
A
4th-10th
2
Q
which ribs are least commonly fractured?
A
1-3 as they are protected by the clavicles
then 11-12 as they are mobile
3
Q
risk of rib fractures in children
A
less likely to sustain rib fractures because their ribs are more elastic
4
Q
what is the weakest part of the rib?
A
anterior to angle
5
Q
what are the contents of the superior thoracic aperture?
A
sternohyoid muscle sternothyroid muscle thymic remnants trachea recurrent laryngeal nerves oesophagus thyroid veins thoracic duct internal thoracic artery sympathetic trunk intercostal vessels ventral ramus of T1 common carotid artery subclavian arteries vagus nerves brachiocephalic trunk brachiocephalic vein phrenic nerves
6
Q
carina
A
division of trachea into 2 main bronchi
T4/5 level
7
Q
signs and symptoms of tension pneumothorax
A
pleuritic chest pain SOB hypotension tracheal deviation reduced breath sounds hyperresonance on percussion raised JVP diaphragm pushed down kinking of vena cava worsening signs haemodynamically unstable respiratory distress reduced chest expansion distended neck veins
8
Q
haemodynamically unstable
A
hypotension
tachycardia
elevated respiratory rate
9
Q
respiratory distress
A
cyanosis
restlessness
diaphoresis
10
Q
what is diaphoresis ?
A
excessive abnormal sweating
11
Q
what is a needle thoracostomy?
A
immediate insertion of large-bore needle into 2nd intercostal space along midclavicular line
12
Q
where should a chest tube be placed?
A
4-5th intercostal space
along nipple line
between anterior and median axillary line
always check CXR after insertion
13
Q
thoracic outlet syndrome
A
compression of certain anatomical structures within the thoracic aperture
14
Q
what is commonly compressed in thoracic outlet syndrome?
A
brachial plexus
subclavian artery/vein
15
Q
compression of brachial plexus
A
pain in neck and arm
atrophy of intrinsic hand muscles
16
Q
compression of subclavian vein
A
swelling venous distension diffuse hand/arm pain heaviness risk of thrombosis of arm
17
Q
compression of subclavian artery
A
mild arm ache fatigue pulselessness pain pallor paresthesia poikilothermia reduced BP >20mmHg in affected arm ischaemia - ulcerations and gangrene
18
Q
what is poikilothermia?
A
inability to control body temperature
19
Q
when does haemothorax require surgery?
A
if >1500ml of blood has accumulated or there is ongoing production of >200ml of blood per hour
when the haemothorax cannot be treated/bleeding stopped by catheter or chest drain
20
Q
most common cause of haemothorax?
A
penetrating trauma
gun/stab wounds
21
Q
thoracic-abdominal injury
A
any wound below nipple line or inferior to tip of scapula
22
Q
level of suprasternal notch
A
T2/3
23
Q
level of sternal angle/ angle of louis
A
T4/5
24
Q
level of inferior angle of scapula
A
T8
25
level of xiphisternum
T9
26
level of lowest part of costal margin
10th rib - L3
27
top part vs bottom part of rib
top part = blunt
| bottom part = groove for intercostal nerve, artery and vein
28
fracture of lower ribs
can penetrate liver, spleen, diaphragm, abdominal viscera or chest cavity
29
what can fracture of the first rib cause injury to?
brachial plexus
subclavian artery or vein
pleural covering of apex of lung
apex of lung - causing pneumothorax
30
pathological fracture
brought on by coughing
sign of underlying bone pathology
breast, renal, prostate or lung metastases to bones
31
what is flail chest?
bifocal fracture of 3 or more adjacent ribs
segment of chest wall becomes unstable and free from rest of chest wall
this segment will move in on expiration and out on inspiration
needs surgical treatment/ventilation
32
what is a tension pneumothorax?
opening in pleura acts as a 1-way valve so air comes in on inspiration but valve closes on expiration so air cannot escape again
positive intrapleural pressure collapses lung so hypoxia and mediastinal shift occurs
33
pulmonary collapse
pleural cavity becomes real space
diaphragm elevates on affected side
ribs come closer together and narrow intercostal spaces
mediastinal shift towards the affected side
collapsed lung appears dense
34
what is primary atelectasis
collapse of previously inflated lung
35
what is secondary atelectasis
where mucus plugs develop and cause additional collapse
36
treatment of tension pneumothorax
medical emergency
large bore cannula into mid clavicular line into 2nd costal space
when bubbles stop it is drained
risk of cardiac arrest
37
visceral pleura innervation
afferent nerves
nociception
sympathetic fibres of upper thoracic spinal nerve sensory ganglia - autonomic
38
what is the visceral pleura sensitive to
not pain
| sensitive to chemical burns
39
parietal pleura innervation
very sensitive to pain and supplied by intercostal nerves - somatic general sensory
irritation may produce local or referred pain
40
pain caused by irritation of phrenic nerve
referred to root of neck and over shoulder
41
where to give intercostal nerve block
just below rib
| to avoid the intercostal neurovascular bundle go above rib
42
how to give an intercostal nerve block?
just below rib
draw back to ensure not in vein/artery
anaesthetic injected around intercostal nerve trunk
complete loss of sensation not usually achieved - overlap between adjacent dermatomes
2 or more intercostal spaces/nerves need to be anaesthetised for complete loss of sensation at a particular region of thoracic wall
43
thoracocentesis
obtain fluid sample or remove blood/pus from pleural cavity
| hypodermic needle inserted superior to rib
44
where is a chest tube inserted?
incision into 5/6th intercostal space in mid-axillary line - nipple level
45
what is a haemothorax?
accumulation of blood and fluid in hemithorax
46
what does haemothorax do?
compresses lung
prevents adequate ventilation
can cause hypovolaemic shock
47
management of haemothorax?
simultaneous drainage and replacement of blood
chest drain required
thoracotomy
48
what is a thoracotomy?
anterior cur through costal cartilages or posterior/lateral cut between intercostal space and retractor - 5-7th intercostal spaces
49
rapid thoracotomy
clamshell
used in trauma - blunt trauma
gives good access to all parts of mediastinum
used in penetrating chest wound
50
uses of clamshell
cardiac tamponade release
to collapse and compress lung for haemostasis if unilateral lung injury
to compress thoracic aorta if exanguinating
51
apical lung cancer
tumours may disrupt recurrent laryngeal nerve and cause voice hoarseness
52
who is thoracic outlet syndrome most common in?
females 30-40 years old
53
symptoms/ signs of thoracic outlet syndrome
ulnar guttering
loss of intrinsics
loss of adduction and abduction of fingers
pain in neck and shoulder
weakness and paraesthesia over ulnar aspect of hand and forearm
axillary vein thrombosis
digital ischaemia
54
potential cause of thoracic outlet syndrome
cervical rib
55
diagnosis of thoracic outlet syndrome
neck x-ray
ultrasound arm
nerve conduction studies
venography
56
what makes up the thoracic cage?
12 pairs of ribs
rib costal cartilages
sternum
57
articulations of ribs
anterior and posterior
58
posterior rib articulations
all 12 articulate with vertebrae of spine
| each rib forms 2 joints = costotransverse and costovertebral joints
59
costotransverse joint
between tubercle of rib and transverse costal facet of corresponding vertebrae
60
costovertebral joint
between head of rib, superior costal facet of corresponding vertebrae and inferior costal facet of vertebrae above
61
anterior rib articulation
varies depending on which rib
ribs 1-7 = attach independently to sternum
ribs 8-10 = attach to costal cartilages superior to them
ribs 11 and 12 = no anterior attachment and end in abdominal musculature
62
what are the muscles of inspiration?
```
accessory = sternocleidomastoid, scalenes group, pectoralis minor
principal = external intercostals, diaphragm and interchondral part of internal intercostal muscles
```
63
what are the muscles of expiration?
quiet breathing = expiration results from passive, elastic recoil of the lungs, rib cage and diaphragm
active breathing uses muscles
64
what muscles are used in active expiration?
internal intercostals
| abdominals
65
what is the intercostal space?
space between 2 ribs
66
how many intercostal spaces are there?
11
67
what are the contents of the. intercostal space?
```
essential respiratory muscles
intercostal muscles - external, internal and innermost
intercostal nerves
intercostal arteries
intercostal veins
investing fascia
```
68
where is the intercostal neurovascular bundle found?
just below the rib
69
what are the compartments of thoracic cavity?
left pleural cavity
right pleural cavity
mediastinum
70
what are the divisions of the mediastinum?
```
anterior
posterior
inferior
middle
superior
```
71
what is the pleural cavity?
potential space between parietal and visceral pleura of lungs
contains pleural fluid, pleura and lungs
72
contents of superior mediastinum
```
thymus
trachea
oesophagus
aortic arch
brachiocephalic trunk
left common carotid artery
left subclavian artery
internal thoracic arteries
superior vena cava
left superior intercostal vein
brachiocephalic veins
phrenic nerves
vagus nerves
left recurrent laryngeal nerve
thoracic duct
lymph nodes
lymph vessels
```
73
contents of anterior mediastinum
```
portion of thymus
adipose and connective tissue
lymph nodes
branches of internal thoracic vessels
sternopericardial ligaments
```
74
contents of middle mediastinum
```
pericardium
heart
pulmonary trunk
ascending aorta
pulmonary veins
superior vena cava
inferior vena cava
tracheal bifurcation
main bronchi
```
75
posterior mediastinum contents
```
oesophagus
oesophageal plexus
thoracic aorta and its branches
azygos and hemiazygos venous systems
thoracic duct
sympathetic trunk
thoracic splanchnic nerves
```
76
what makes up the thoracic wall?
```
ribs
associated costal cartilages
thoracic vertebrae
sternum
intercostal muscles
external, internal and innermost intercostal muscles
internal and external membranes
subcostal muscles
transversus thoracis muscles
serratus posterior
levatores costrum muscles
subcutaneous tissues
skin
```
77
what are the joints of the thoracic wall?
```
costovertebral joints
sternocostal
costochondral
sternoclavicular
manubriosternal
xiphisternal
interchondral
```
78
costovertebral joints
between head of ribs and vertebral bodies/ intervertebral discs
costotransverse joints - between tubercle of rib and transverse process of vertebrae
79
sternocostal joint
sternum and costal cartilages
80
costochondral joint
costal cartilages and ribs
81
what makes up the thoracic cage?
12 pairs of ribs
rib costal cartilages
sternum
82
articulations of ribs
anterior and posterior
83
posterior rib articulations
all 12 articulate with vertebrae of spine
| each rib forms 2 joints = costotransverse and costovertebral joints
84
costotransverse joint
between tubercle of rib and transverse costal facet of corresponding vertebrae
85
costovertebral joint
between head of rib, superior costal facet of corresponding vertebrae and inferior costal facet of vertebrae above
86
anterior rib articulation
varies depending on which rib
ribs 1-7 = attach independently to sternum
ribs 8-10 = attach to costal cartilages superior to them
ribs 11 and 12 = no anterior attachment and end in abdominal musculature
87
what are the muscles of inspiration?
```
accessory = sternocleidomastoid, scalenes group, pectoralis minor
principal = external intercostals, diaphragm and interchondral part of internal intercostal muscles
```
88
what are the muscles of expiration?
quiet breathing = expiration results from passive, elastic recoil of the lungs, rib cage and diaphragm
active breathing uses muscles
89
what muscles are used in active expiration?
internal intercostals
| abdominals
90
what is the intercostal space?
space between 2 ribs
91
how many intercostal spaces are there?
11
92
typical intercostal nerves
3rd-6th intercostal nerves
confined within their own intercostal space
connection with corresponding sympathetic trunk
93
where is the intercostal neurovascular bundle found?
just below the rib
94
what are the compartments of thoracic cavity?
left pleural cavity
right pleural cavity
mediastinum
95
what are the divisions of the mediastinum?
```
anterior
posterior
inferior
middle
superior
```
96
what is the pleural cavity?
potential space between parietal and visceral pleura of lungs
contains pleural fluid, pleura and lungs
97
contents of superior mediastinum
```
thymus
trachea
oesophagus
aortic arch
brachiocephalic trunk
left common carotid artery
left subclavian artery
internal thoracic arteries
superior vena cava
left superior intercostal vein
brachiocephalic veins
phrenic nerves
vagus nerves
left recurrent laryngeal nerve
thoracic duct
lymph nodes
lymph vessels
```
98
contents of anterior mediastinum
```
portion of thymus
adipose and connective tissue
lymph nodes
branches of internal thoracic vessels
sternopericardial ligaments
```
99
contents of middle mediastinum
```
pericardium
heart
pulmonary trunk
ascending aorta
pulmonary veins
superior vena cava
inferior vena cava
tracheal bifurcation
main bronchi
```
100
posterior mediastinum contents
```
oesophagus
oesophageal plexus
thoracic aorta and its branches
azygos and hemiazygos venous systems
thoracic duct
sympathetic trunk
thoracic splanchnic nerves
```
101
what makes up the thoracic wall?
```
ribs
associated costal cartilages
thoracic vertebrae
sternum
intercostal muscles
external, internal and innermost intercostal muscles
internal and external membranes
subcostal muscles
transversus thoracis muscles
serratus posterior
levatores costrum muscles
subcutaneous tissues
skin
```
102
what are the joints of the thoracic wall?
```
costovertebral joints
sternocostal
costochondral
sternoclavicular
manubriosternal
xiphisternal
interchondral
```
103
costovertebral joints
between head of ribs and vertebral bodies/ intervertebral discs
costotransverse joints - between tubercle of rib and transverse process of vertebrae
104
sternocostal joint
sternum and costal cartilages
105
costochondral joint
costal cartilages and ribs
106
sternoclavicular joint
clavicle and sternum
107
manubriosternal joint
manubrium and body of sternum
108
xiphisternal joint
sternum and xiphoid process
109
interchondral joint
costal cartilages and lower ribs
110
directions of internal and external muscles
external = inspiration
internal = expiration
perpendicular to each other
111
contents of intercostal space
intercostal muscles
intercostal muscle membranes
main and collateral intercostal vessels and nerves
112
naming of intercostal spaces
according to rib forming superior border of space
| space below 12th rib doesn't lie between ribs so = subcostal space
113
rhizotomy
posterior and anterior roots and rootlets are the only sites where motor and sensory fibres of a spinal nerve are segregated
nerve roots could be selectively sectioned to relieve intractable pain or spastic paralysis
114
how many intercostal nerves are there?
12 pairs of thoracic spinal nerves
11 intercostal nerves
anterior rami of T1-11 form intercostal nerves within intercostal spaces
115
subcostal nerve
anterior ramus of T12 runs inferior to 12th rib
116
what are the types of intercostal nerves?
typical and atypical
117
what do the typical intercostal nerves supply?
```
intercostal muscles
serratus posterior
parietal pleura
skin of thoracic and abdominal walls
anterior aspect of thorax and abdomen
```
118
atypical intercostal nerves
not confined to intercostal space
supply structures outside the intercostal space
1st,2nd and 7-11th intercostal nerves
119
T1 intercostal nerve supply
brachial plexus
| skin of axilla
120
T2 intercostal nerve supply
intercostobranchial nerve
| floor of axilla and upper medial aspect of arm
121
7-11th intercostal nerve supply
lateral cutaneous branches
| anterior abdominal wall skin and muscles and parietal peritoneum via sensory branches
122
arterial supply of typical intercostal space
large posterior intercostal artery from thoracic aorta
| small pair of anterior intercostal arteries from internal thoracic/ mammary artery
123
venous drainage of intercostal space
intercostal veins accompany intercostal arteries and nerves
124
intercostal neurovascular bundle
life inferior to the rib along costal groove
vein, artery, nerve, with nerve most inferior
and nerve artery vein of superior border of the rib below
125
cutaneous innervation of anterior thoracic wall
supraclavicular nerves - C3 and 4
126
T4 dermatome
nipple
127
T10 dermatome
umbilicus
128
what is referred pain?
pain felt away from site of cause
129
referred pain from coronary artery disease
medial side of arm
130
referred pain from disease of thoracic wall
dermatome that extends across the costal margin into the anterior abdominal wall
131
referred pain from PE/pneumonia
if costal parietal pleura involved abdominal pain and tenderness and rigidity of abdominal musculature
132
uses of intercostal nerve block
repair of thoracic or abdominal wall lacerations
relief from rib fracture
to allow pain free respiratory movements
thoracostomy tube insertion
133
herpes zoster infection/ rash distribution
infection of spinal ganglia
sensory neuropathy with dermatomally distributed skin lesions - shingles affects the dermatome of the infected spinal nerve
134
innervation of thoracic viscera
autonomic
135
sympathetic supply of thoracic viscera
cardiac branches = T1-5
| T1-L2 sympathetic chain
136
what does sympathetic innervation of thoracic viscera do?
increases rate and strength of cardiac contraction
| dilates coronary arteries
137
parasympathetic supply of thoracic viscera
craniosacral outflow
cranial nerves 10,9,3,7 and S2-4
main contributor is vagus nerve
138
what does parasympathetic innervation of thoracic viscera do?
decreases rate and strength of cardiac contraction
| constricts coronary arteries
139
lateral horn of spinal cord
autonomic horn
| gives rise to sympathetic and parasympathetic nerves
140
innervation of heart
cardiac plexus
| sympathetic supply
141
innervation of SAN and AVN
cardiac plexus
142
visceral afferent fibres
convey reflexive.subconscious sensation and nociceptive sensation fibres from heart
detect stretch and chemical irritation
143
what makes up the cardiac plexus?
sympathetic, parasympathetic and visceral afferent fibres
144
what does atropine do?
speeds up heart rate in bradycardia
| parasympathetic antagonist
145
innervation of lungs and visceral pleura
vagal, sympathetic and visceral afferent fibres contribute to anterior and posterior pulmonary plexuses
146
parasympathetic fibres to lungs and visceral pleura
motor to smooth muscle of bronchi
inhibition to pulmonary vessels
secretomotor innervation to glands
147
parasympathetic effect on lungs
bronchoconstriction
vasodilation
increased gland secretion
148
sympathetic fibres to lungs and visceral pleura
inhibition to bronchial smooth muscles
inhibition to alveolar glands
motor to pulmonary vessel smooth muscles
149
sympathetic effect on lungs
bronchodilation
decreased secretions
vasoconstriction
150
what innervates the parietal pleura
intercostal nerves
151
what innervates intercostal muscles?
intercostal nerves
152
sympathetic innervation of pulmonary vs coronary vessels
vasoconstriction of pulmonary and vasodilation of coronary
153
what is pleurisy?
sharp pain due to irritation of peripheral parietal pleura
154
irritation of diaphragmatic pleura
referred pain to neck and shoulders
155
parasympathetic antagonists
used in asthma
bronchodilator
ipratropium - anticholinergic
156
damage to phrenic nerve
traumatic injury above C3 = bilateral phrenic nerve paralysis and respiratory arrest
mediastinal/lung tumours may involve the phrenic nerve and cause unilateral diaphragmatic paralysis
new raised hemidiaphragm on CXR may indicate mediastinal malignancy
