Blue Boxes Flashcards
Causes of chest pain
pulmonary disease, cardiac disease, intestinal, gallbladder, or musculoskeletal disorders
What disorder causes crushing substernal pain?
heart attack
Multiple rib fractures may allow segment of anterior and/or lateral thoracic wall to move freely. Loose segment of wall moves paradoxically (in on inspiration and out on expiration). Extremely painful, impairs ventilation and thereby oxygenation of blood. During treatment loose segment may be fixed by hooks
Flail chest
Least frequently fractured rib and why?
short, broad, 1st rib, posteroinferior to clavicle so its protected and hard to palpate, if it is broken structures crossing over superior aspect may be injured (brachial plexus and subclavian vessels)
Most commonly fractured rib or ribs?and how?
middle ribs, usually from blows and crushing injuries, weakest part is anterior to its angle, broken end may injure internal organs (lungs or spleen)
Fractures of lower ribs may tear diaphragm this is called?
diaphragmatic hernia
What is a thoracotomy?
surgical creation of an opening through the thoracic wall to enter pleural cavity
Sometimes a wide segment of rib is excised during a thoracotomy. This is sometimes needed to remove a lung. This is called?
pneumonectomy
usually have 12 ribs, number is increased by presence of cervical or lumbar ribs, or decreased failure of 12th to form. extra ribs are called?
supernumerary ribs
Costal cartilage can become ____ as they age and ____ making them more brittle.
radiopaque, calcification
In 40’s some patients consult physician about hard lump in there upper abdomen, (epigastirc fossa)
ossified xiphoid process
Sternal fractures are not common. Can be caused by what?
Crush injury after traumatic compression, like the chest being forced into the steering column. air bags have reduced this.
A fracture of the sternal body is called what?
comminuted fracture (break resulting in several pieces) displacement uncommon because of deep fascia
What causes a dislocation in the manubriosternal joint in the elderly?
a fracture at the sternal angle where the joint is fused.
What is the biggest concern in a sternal injury?
likelihood of heart injury i.e. myocardial contusion, cardiac rupture, tamponade) or lung injury. Mortality rate 25-45% largely due to the above
To gain access to thoracic cavity for procedures the sternum is split in half in median plane and retracted. This is called?
median sternotomy, flexibilty of ribs and cartilage allow for this.
Because of breadth and subcutaneous position the sternum is often used for?
bone marrow needle biopsy, commonly used for transplantation and for detetction of metastatic cancer and blood dyscrasias (abnormalities)
Sternum develops through fusion of bilateral and vertical condensation of precartilaginous tissue what?
sternal bands or bars
Halves of the sternum of fetus may not fuse. If complete what happens?
sternal cleft. heart may protrude (ectopia cordis)
Sometimes a sternal perforation remains in sternal body because of incomplete fusion. This is called?
sternal foramen, not clinically significant
What is pectus excavatum or funnel chest?
receding sternum
What is pectus cavinatum or pigeon breast?
projecting sternum
Another name for superior thoracic aperature.
Anatomists say thoracic inlet, clinicians say sometimes the thoracic outlet
An obstruction outside the aperature in the root of the neck and the manifestation of syndromes of upper limbs. usually damage to arteries and/or t1 spinal nerves as the exit the thoracic aperature. This is referred to sometimes as?
thoracic outlet syndrome
What is a rib dislocation or slipping rib?
dislocation of sternocostal joint or the interchondral joints. Common in body contact sports. usually unilaterally and involves 8,9, and 10.
What complications can accompany rib dislocations?
pressure on or damage directly to vessels and nerves and muscles, also injury to diaphragm or liver, severe pain, produces lump like deformity in dislocation site.
Seperations of 3rd -10th rib at the costochondral junction may result in what?
tearing of perichondrium and periosteum. as a result rib may move superiorly overriding the rib above.
What happens if phrenic nerve is damaged?
paralysis of diaphragm. if one sided results in paradoxical movement. instead of the diaphragm descending on inspiration the paralysed half ascends as it is pushed superiorly by abdominal viscera.
People with respiratory problems or with heart failure have difficulty breathing will use accessory breathing muscles. What is this called and what muscles are being used?
Dyspnea, esternal intercostal, internal intercostal, innermost intercostal, subcostal, scalenes,
During surgery what can be peeled from the wall of the thoracic cavity?
parietal pleura
These structures extend above the level of the clavicle into the base of the neck, are often found higher in children and damage can result in pneumothorax or lung damage
parietal pleura, visceral pleura, and the lung
Name three places an abdominal incision can cause a pneumothorax.
right part of infrasternal angle, right and left costovertebral angles inferomedial to the 12th ribs (posterior to the superior poles of the kidney
pneumothorax
entry of air into pleural cavity caused by penetrating wound or rupture of a lesion, or a broken rib
bronchopulmonary fistula
rupture of pulmonary lesion into the pleural cavity
hydrothorax
accumulation of significant amount of fluid in the pleural cavity
pleural effusion
escape of fluid into the pleural cavity
hemothorax
blood in the thoracic cavity
hemopneumothorax
air and blood in pleural cavity; characterized on film by an air fluid line, sharp horizontal line irregardless of patient position
thoracentisis
obtain a sample of fluid, or remove blood or pus from pleural cavity,
what do you want to avoid in a thoracentisis and how is this acheived?
lung= enter costodiaphragmatic recess 9th ICS
intercostal nerve and vessels= insert above the rib high enough to avoid collateral branch
deep side of recess ( liver, diaphragm, other pleural layer)- angle needle upward
Important points of inserting a chest tube
for removal of major amounts of air, blood, serous fluid pus etc.
incision in 5th or 6th ICS, midaxillary line tube directed superiorly to cervical pleura for air, and to costodiaphragmatic recess for fluid, suction or underwater drainage to prevent air backflow
lung decrotication
removal of resistant fibrous covering inhibiting expansion after fluid in pleural cavity
pleurisy
inflammation of pleura, pleuritis, marked by sharp stabbing pain esp. on exertion, lung surface rough, pleural rub is detectable via auscultation sounds like a clump of hairs being roled between fingers. may cause adhesion
pleurectomy
excision of part of pleura
pleurodesis
adherence of parietal and visceral pleura induced by covering apposing layers of pleura with irritating powder or sclerosing agent
spontaneous secondary atelectasis
spontaneous lung collapse, caused by chronic pneumothorax, malignant effusion resulting from lung disease, perform a pleurectomy or pleurodesis
Thorascopy
diagnostic, sometimes therapueutic, pleural cavity examined with scope. used for observation, biopsy, disrupting adhesions or removing plaques
common accessory lobes
incomplete or extra fissures, superior left lobe may lack lingua, azygos lobe in right lung usually small and superior to hilum, large azygos may appear to be bifurcated apex
what cell in the lymph system of the lungs remove carbon from gas-exchanging surface and deposit it in “inactive” connective tissue?
phagocytes
Aspiration of foreign bodies is more likely to end up where in the lungs? Why?
right main bronchus, it is wider, shorter, and runs more vertical
What might cause the carina to be distorted, widened posteriorly, and immobile?
metastasized cancer from bronchogenic carcinoma into tracheobronchial lymph nodes
What is the most sensitive area of tracheobronchial tree and is associated with cough reflex?
mucous membrane covering the carina
What is the difference between a pneumonectomy, a lobectomy, and a segmentectomy?
removal of a lung, removal of a lobe, removal of a bronchopulmonary segment
What is segmental atelectasis?
blockage of segmental bronchus prevents air from reaching bronchopulmonary segment, air in segment gradually be absorbed into blood causing collapse, adjacent segments will expand to fill space
what is and what causes a pulmonary embolism?
obstruction of a pulmonary artey, blood clot, fat globule, or air bubble travels in blood ( can happen after compound fracture of leg)
Acute respiratory distress causes?
major decrease in oxygenated blood owing to blockage of blood flow through the lung, right side of heart may become acutely dilated, death may occur in minutes
What is a pulmonary infarct?
are of necrotic lung tissue, may be due to blocked artery supplying bronchopulmonary segment, in physically active a collateral supply exists or develops further with a PE to prevent infarction
If there is a lung adhesion where might the lymphatics of the lungs drain? Why?
an anastomosing of vessels may occur between visceral and parietal, parietal drains to the axillary nodes
What is hemoptysis? Name some causes.
spitting of blood or blood stained sputum derived from lungs or bronchial tree due to bronchial or pulmonary hemorrhage, bronchitis, lung cancer, pneumonia, bronchiectasis, pulmonary embolism, and TB
What is bronchogenic carcinoma?
specific designation for squamous cell carcinoma arising in bronchus, metastasis to bronchopulmonary lymph nodes and subsequently to other thoracic lymph nodes,
What nerves may be affected by lung cancer?
recurrent laryngeal if at apex, phrenic
Which pleural layer feels pain?
parietal via phrenic ad intercostal, visceral has no sensory innervation, may get referred pain to dermatome
What is the transthoracic plane?
imaginary line between sternal angle and between T4 and T5
Where are these structures located in relationship to vertebra and the trans thoracic plane in the supine position? ( aortic arch, bifurcation of trachea, central tendon of diaphragm)
arch of aorta superior to transverse thoracic plane
bifurcation transected by transverse thoracic plane
central tendon at level of xiphasternal junction and T9
Where are these structures located in relationship to vertebra and the trans thoracic plane in an upright position? ( aortic arch, bifurcation of trachea, central tendon of diaphragm)
arch of aorta transected by transverse plane
tracheal bifurcation inferior to transverse plane
central tendon of diaphragm xiphoid process and t9-t10 disc
Mediastinoscopy is used for what? Where do surgeons enter?
minor surgical procedures, biopsy a lymph node to check for metastasizing from a bronchogenic carcinoma;
incision at the base of neck just superior to jugular notch into potential space anterior to trachea; also via anterior thoracotomy
Name some conditions that can cause widening of mediastinum on radiograph.
malignant lymphoma, hypertrophy of heart often in congestive heart failure, head on collision producing a hemorrhage
Why is the transverse pericardial sinus important during surgery?
by passing a surgical clamp around the vessels anterior to sinus to insert tubes and tighten ligature for cardiac bypass
Pericarditis
inflammation of the pericardium, usually causes chest pain. chronic inflammation can lead to calcification hampering cardiac efficiency
pericardial rub
can hear the friction between pericardium during auscultation, sounds like rustling of silk
pericardial effusion
product of inflammatory disease, passage of fluid from pericardial capillaries into pericardial cavity or accumulation of pus, heart is compressed and ineffective
Congestive heart failure
causes noninflammatory pericardial effusion, venous blood returns to heart at rate that exceeds cardiac output producing right cardiac hypertension
Cardiac tamponade
fibrous pericardium is tough inelastic layer. if too much pericardial effusion, the compromised volume does not allow for full expansion of the heart.
Hemopericardium
blood in pericardial cavity, produces cardiac tamponade, may result from weakened area of heart muscle owing to previous MI. Especially lethal because of high pressure and rapid accumulation of fluid heart increasingly compressed and circulation fails
pneumopericardium
a patient with a pneumothorax can have air dissect connective tissue planes and enter the pericardial sac
What is a pericardiocentesis and where whould you perform it?
drainage of fluid from pericardial cavity, insert needle thru 5th or 6th intercostal space near sternum, be careful of lung here. or insert needle in infrasternal angle avoid internal thoracic artery or terminal branches here
How would you establish homeostasis of hemorrhage in hemopericardium?
perform an emergency thoracotomy ( rapid opening of thorax) so pericardial sac may be incised to immediately relieve tamponade
Dextrocardia
abnormal folding of embryonic heart may cause position of the heart to be completely reversed so apex is to the right. most common positional abnormality of the heart. associated with mirror imaging of great vessels
Situs inversus
general transposition of thoracic and abdominal viscera
isolated dextrocardia
transposition only effects heart only, congenital anomaly is complicated by severe cardiac anomalies
Name two procedures to study flow of blood through the heart and great vessels
cardiac catheterization, and cineradography or cardiac ultrasonography
Atrial Septal defect if large enough what would you expect to find clinically?
oxygenated blood from lungs being shunted from left atrium to right atrium causing enlargement of right atrium and ventricle and dilation of pulmonary trunk leads to hypertrophy of right atrium and ventricle.
Ventricular septal defects what is the most common site?
no connection between membranous and muscular portion.
What is the clinical significance of a ventricular septal defect?
shunt from left to right of blood, increases pulmonary blood flow causing severe pulmonary disease
Thrombi
clot
cerebrovascular accident
also called stroke, occlusion of an artery supplying the brain, commonly a clot from the wall of the left ventricle knocked loose. may affect vision, cognition, or other motor function of parts of the body
Where does the coronary arteries arise from specifically?
right sinus of valsalva (associated with right valve cusp) has opening for right coronary
left sinus of valsalva ( associated with left valve cusp) has opening of left coronary. posterior sinus has nothing
stenosis of valve
failure of valve to open fully, slowing blood flow from a chamber, causes turbulent flow causing eddies that produce vibrations that are audible, valve problem and almost always aquired
insufficiency of a valve
also called regurgitation, is failure of valve to completely close, usually due to a nodule formed on the cusp. may also be defect in supporting structure ( papillary muscle, chordae tendonae, annulus etc) can be congenital or aquired
Valvuloplasty
replacement of a cardiac valve, can use pig or prostheses
What is a mitral valve prolapse? Its significance?
an insufficient or incompetent valve with one or more leaflets enlarged, redundant or floppy and extending back into left atrium during systole, 1 in 20, mostly young women, clinical importance in a small number suffering from chest pain and fatigue
What is pulmonary valve stenosis? it’s significance?
valve cusps fused forming a dome with a narrow opening, in infundibular pulmonary stenosis the conus arteriosis is underdeveloped. both restrict right ventricular outflow and may occur together. cause right ventricular hypertrophy
What is pulmonary valve incompetence and what causes it?
lunules of semilunar valve thicken and become less flexible or are damaged by disease, valve will not close completely, backrush of blood into rt ventricle during diastole
What is aortic valve stenosis and its significance?
most frequent valve abnormality, those born in early to mid 20th century common cause was rheumatic fever now < 10 %, now mostly from degenerative calcification significant in 6th decade of life, causes extra work for left ventricle causing hypertrophy
What is aortic valve insufficiency?
results in aortic regurgitation producing a murmur and collapsing pulse forcible impulse that rapidly diminishes
echocardiography
ultrasonic cardiography, graphically record position and motion of the heart, can detect as little as 20 mL of fluid in pericardial cavity
Doppler echocardiography
a technique that demonstrates and records the flow of blood through the heart and great vessels
Coronary angiography
produces coronary arteriograms, long catheter inserted into femoral artery in the inguinal region, tip of catheter placed just inside the opening of a coronary artery, release radiopaque dye
Coronary artery disease
one of the leading causes of death, has many causes, all of which result in a reduced blood supply to the vital myocardial tissue
What is a myocardial infarction and how does it happen?
a region of myocardium becomes rendered virtually bloodless from an occlusion of the artery supplying the area, tissue undergoes necrosis
Which coronary arteries are typically occluded?
Anterior IV 40-50%, RCA 30-40%, Circumflex branch of LCA 15-20%
Ischemic heart disease
coronary artery insufficiency resulting from atherosclerosis, main cause of myocardial infarction
Angina pectoris is what? Name some causes.
pain that originates in the heart, narrowed coronary artery, less oxygen is delivered, when heart activity increases due to stressor (ie exercise, cold etc.) the occluded vessels cannot supply enough O2, lactic acid builds up in the muscles triggering a pain response
Atherosclerotic process
characterized by lipid deposits in the intima of coronary arteries, slowly results in stenosis of the lumina of the arteries
Myocardial ischemia
insufficiency of blood supply to the heart, collateral supply tries ompensate but is not always capable
What is clinically significant about slowly progressive coronary artery disease?
collateral circulation has time to increase so there is adequate perfusion to myocardium, however if in a large coronary branch some infarction is probably inevitable, extent of damage dependent on the collateral supply, connect with small arteries in tunica adventitia of aorta, pulmonary arteries, and branches of internal thoracic, bronchial, and phrenic arteries
What does sublingual nitroglycerin do?
dilates the coronary arteries and others, increasing blood flow, to heart while decreasing workload of heart and the hearts need for oxygen, plus dilated vessels accommodate more blood, so less arrives back relieving congestion.
What is percutaneous transluminal coronary angioplasty?
a catheter with small inflatable balloon attached to its tip, balloon inflates to stretch the vessel wall to improve blood flow
What is thrombokinase?
an enzyme to dissolve blood clots, injected through a catheter
What role do small cardiac veins play in collateral circulation?
can carry blood directly from heart chambers (luminal blood) to capillary beds of myocardium in some regions, unlikely to be sufficient without a pre-existing ischemic heart disease especially in conjunction with physical training
What is an ECG?
electrocardiography, measure passes of impulses over the heart from the SA node used in functional testing of heart.
What is heart block?
part of the conducting system of heart has a cut off in blood supply
Bundle Branch block results in?
one ventricle beating at a slower rate than the other which is still in sync with the atria
What is myogenic conduction?
muscle propagated conduction in the heart
An electrode with a catheter connected is inserted into a vein its progression through the venous pathway is followed with what device?
fluoroscope, device for examining deep structures in real time by means of radiographs
What is atrial fibrillation?
rapid irregular uncoordinated twitching of different parts of the atria, circulation is usually ok
What is ventricular fibrillation?
rapid irregular twitching movements that do not pump blood into systemic or coronary circulation, most disorganized of all arrhythmias, no cardiac output in its presence, fatal if persists, need to fibrilate
Heart is insensitive to what sensations?
touch, cutting, cold, and heat
Heart is sensitive to what?
ischemia and accumulation of metabolic products stimulate pain endings in myocardium
What is cardiac referred pain? Name areas it is likely to occur?
phenomenon where stimuli originating in the heart are perceived as pain arising superficially; sternal, shoulders, deltoid region, medial side of arm, left pectoral region, diamond shape mid back, 2 in above and below nipple line across entire front, abdomen medial and inferior to ribs until umbilicis, up both sides of the neck and jaw
What is angina pain?
left pectoral, left substernal, medial side of left arm
What is visceral referred pain?
transmitted by visceral afferent fibers accompanying sympathetic fibers, and is referred to somatic structures
Name some common variations of branching off the arch of aorta.
left common carotid off brachiocephalic trunk, no brachiocephalic trunk, rt and left common carotid and subclavian off of arch, left vertebral off of the arch, retroesophageal right subclavian as fourth branch off the arch, accessory artery to thyroid gland from arch or brachiocephalic trunk
Name some anomalies of the arch of aorta.
arch curves over right root of lung and passing posteriorly on the right creating a right arch of aorta, double arch of the aorta
What can cause an ascending aortic aneurysm? What structures are at risk? list some symptoms.
distal part receives strong thrust of blood, not yet reinforced by fibrous pericardium may have dilation; trachea, esophagus and recurrent laryngeal, chest pain radiating to the back
What is coarctation of the aorta?
abnormal narrowing or stenosis, dimishes caliber of lumen, producing obstruction, most common site of coarctation is near ligamentum arteriosum
Impressions in the esophagus are clinically significant how?
can be a site for food to get lodged or a stricture develop after eating or drinking something caustic
What may happen of the thoracic duct is lacerated?
lymph or chyle may enter pleural cavity, producing chylothorax.
What is the space of Bogros?
between transversalis fascia and parietal peritoneum, placemnt site of mesh during hernia repair
Name the six common causes of abdominal protrusion.
food, fluid, fat, feces, flatus, fetus
Umbilical hernias are most common in what patient population? Why?
neonates, anterior abdominal wall is relatively weak in umbilical ring, esp. low birth weight.
Acquired Umbilical hernias are most common in what patient population? Why?
most commonly in women and obese, extraperitoneal fat and or peritoneum protrude into hernia sac.
Where in the abdomen can hernias occur?
lines along which fibers of abdominal aponeurosis interlace are potential sites, umbilicis, inguinal region
An epigastric hernia occurs where?
along linea alba between umbilicis and xiphoid process.
Spigelian hernias occur where?
along the semilunar lines
What are involuntary muscles spasms in the abdomen called?
guarding, illicitated by cold hands, or inflamed organ being palpated
How is the superficial abdominal reflex tested?
quickly stroking lateral to medial toward umbilicis
What two nerves run on the anterolateral abdominal wall? When are they at risk and what may result from their injury?
iliohypogastric, ilioinguinal, surgery or trauma, weakening of muscles which may lead to a hernia
Give two examples of high risk incisions and explain why they are high risk.
pararectus because may cut nerve supply to abdomen and inguinal because may injure ilioinguinal nerve
Endoscopic surgery reduces the risk of what?
potential for nerve injury, incisional hernia or contamination through open wound
