Poisoning Roop/Jaffe Flashcards
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp. rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal- what are you trying to rule out here?
Stroke, tumor, brain bleed, etc.
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. What is an EMG and what is it able to diagnose?
Electromyography
Nerve/muscle conduction and muscle function
What can you expect from a nerve conduction study?
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. What is edrophonium and what do you hope to rule out with this test?
Its a muscle strengthener
Can rule out myasthenia gravis (MG)
How is a Tensilon Test given? Why is atropine needed on hand?
Atropine is needed on hand because Ach is apart of the parasympathetic NS → decreases HR and constricts airway/bronchioles
-Ach is a part of the SNS and controls skeletal m.
-Ach is also a part of ANS under the parasympathetic division
What happens if muscle strength is improved with a Tensilion Test? What happens if its not improved?
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. Upon further discussion with the patient, he states that on the day before he ate some green beans that were canned at home by his friends. So what’s the diagnosis?
Botulism
A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. Upon further discussion with the patient, he states that on the day before he ate some green beans that were canned at home by his friends. Doctor now thinks it’s botulism. Stool sample was positive for Clostridium botulinum. What type of organism is C. botulinum? How many different types of Clostridia are there?
-Gram-positive bacteria
-Anaerobic bacillus
-Spore-forming
-Produces the neurotoxin botulinum
-Theres 12 types
-People can still die from this because of home canning
Describe what happens at a motor neuron when an action potential arrives at the presynaptic terminal?
-Calcium influx
-Snare proteins helps vesicles to fuse to the presynaptic membrane
-In the case of botulinum toxin, it destroys Snare proteins → vesicles can’t fuse → no Ach release/exocytosis → cannot bind to receptors → flaccid paralysis
At the NMJ, ACh is stored in the vesicles of the presynaptic terminals. After the AP arrives, ________ enters the terminal causing the vesicles to migrate to the membrane.
calcium
The SNAP-SNARE proteins allow __________ of the vesicles with the cell membrane, fusion and then exocytosis of the ACh into the synaptic cleft
docking
BoNT- botulinum toxin destroys ____ of the family of proteins. ACh is not released and flaccid paralysis occurs
1+
Botulinum toxin will result in flaccid paralysis that first occurs in the _______ muscles and is symmetrical, and then will spread to other proximal muscles and then distal muscles
cranial
What muscle is paralyzed when a patient has droopy eyelids?
Levator palpebrae superioris m.
What muscle is affected that would cause a patient to have dysphasia?
Upper esophageal m. (sphincter)
What muscles are affected that would cause a patient to have double vision?
Any of the optic muscles
What is the time for symptoms to appear after ingestion of the food-borne toxin?
In foodborne botulism, symptoms generally begin 18 to 36 hours (on average) after eating a contaminated food.
How is botulism treated?
-Doctors treat botulism with a drug called an antitoxin, which prevents the toxin from causing any more harm.
-Antitoxin does not heal the damage the toxin has already done
-Fluid intake
-Induce vomiting with medication
-Antibiotics (difficult to treat anaerobic bacteria)
-Maintain airway (depending on how bad it is)
What would happen if a patient is not treated for botulism?
The disease may progress and symptoms may worsen to cause full paralysis of some muscles, including those used in breathing and those in the arms, legs, and trunk (part of the body from the neck to the pelvis area/torso)
Will affect the diaphragm muscles, so they are unable to breathe (ventilator may be necessary)
How long would a patient have to remain in the hospital when diagnosed with botulism and why? What are you trying to achieve physiologically?
Weeks to months → until all the symptoms disappear
You want the SNARE proteins to restore
The use of __________ toxin in the field of oral and maxillofacial surgery has been continuously evolving, for aesthetic and functional indications. There are the dermatological applications of botulinum toxin for cosmetology, as well as its varied therapeutic uses and its application in temporomandibular joint surgery, masseter muscle hypertrophy, bruxism, trismus, maxillofacial traumatology, salivary gland diseases, and facial palsy, among others. This should appeal to head and neck surgeons, oral maxillofacial surgeons, ENT surgeons and dermatologists in particular, and general surgeons and dentists in general.
botulinum
What is masseter muscle hypertrophy?
-rare condition
-mostly idiopathic
-enlargement of one or both masseter muscles
-facial asymmetry
What is bruxism?
Grinding of the teeth
What is Trismus?
Lockjaw, tetanic spasms of the muscles of mastication
What is the deadliest toxin in the world?
Botulinum neurotoxin
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). What do all these lab values mean?
Liver dysfunction
Bilirubin is the breakdown product of heme and is produced in the spleen then goes to the liver to be a part of bile
-All this bilirubin is too much, which means that there’s too much breakdown of RBCs and this can result in hemolytic anemia
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. What is chronic superficial non-atrophic gastritis?
-Influx of neutrophils and lymphocytes → still see fundal glands
-Epithelium shedding
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. Pt.’s pain began to worsen and doctors delved deeper into his history. They found that his occupation was a warehouse guard. This warehouse stores old books and the building is old. Doctors did a more extensive physical exam and found the patient’s gums to have Burton’s lines. What are these lines and what do they indicate? What tests do you do to verify?
-Sign of chronic lead poisoning
-Lead levels should be less than 10 micrograms (his blood lead level was found to be 52.8ug/dl- BLOOD TEST)
-Burton’s lines is due to precipitation of lead sulfide
»It’s a blue-purplish line on the gums
»Caused by reaction between circulating lead with sulfur ions released by oral bacterial activity, which deposits lead sulfide at the junction of the teeth and gums
-Hematological smear would show basophilic stippling of RBCs indicative of heavy metal poisoning
A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. Pt.’s pain began to worsen and doctors delved deeper into his history. They found that his occupation was a warehouse guard. This warehouse stores old books and the building is old. Doctors did a more extensive physical exam and found the patient’s gums to have Burton’s lines, which means chronic lead poisoning. What is the treatment?
Chelating agents
-Will be excreted in urine
-Examples:
»succimer and penicillamine are given orally
»dimercaprol and edetate (EDTA) calcium disodium (CaNa2 EDTA) are administered parenterally
Lead can cross the blood brain barrier and result in what? How?
seizures
Edema = increased ICP → encephalopathy
Left untreated can result in irreversible brain damage
How does lead affect the blood?
-Can block enzymes in heme synthesis pathway → anemia
-Basophilic stippling → RNA left back in RBC (not cleared because enzyme is inhibited)
-Attaches to RBC = hemolysis is easier
The 2 enzymes that are blocked by lead in ________ __________ pathway is aminolevulinate dehydratase and ferrochelatase
heme synthesis
Basophilic stipplingIs due to Pb inhibiting the ez 5’-nucleotidase which clears….
clumps of degraded RNA
Pb attaches to RBCs membrane making hemolysis much easier– hence the increase in bilirubin levels. Additionally, it reacts with sulfur ions released due to oral bacterial activity. This deposits lead sulfide at the tooth-gum junction as…
Burton’s Lines
A 58 year old man came to the ED complaining of bleeding in his mouth. It began 24 hours ago and has been continuous even with compression. He suffered an MI 18 months ago and stopped smoking after the MI. Began exercising moderately after the MI. He started taking warfarin after MI. Vital signs show normal temp., pulse= 85/min, resp.= 18/min, BP=95/65 mmHg. Lab studies show Hct= 35% (low), stool sample test was positive for blood (likely has internal bleeding), PT was 35 seconds and PTT was 48 seconds (both high, indicating clothing dysfunction). What do his blood results indicate?
Something is wrong with clotting cascade
What are the 2 major components of hemostasis?
Platelet plug formation and clotting cascade
Bleeding of the oral mucous membranes could also indicate internal bleeding, e.g. GI system. Would this be indicated in vital signs? How?
Low BP, pulse/respiration are high because body is compensating
What are platelets also known as? What are they derived from?
Thrombocytes, derived from megakaryocytes
What is the platelet lifespan?
7-10 days
Platelet formation is regulated by the hormone ___________
Thrombopoietin
Platelets have three different types of granules. What are they and what do they contain?
Alpha
-Contains adhesion proteins like fibrinogen and vWF
Dense
-Contains bioactive amines like serotonin and histamine, and also contains nucleotides like ADP/ATP
Lysosomes
-Contains degenerative enzymes
What is the mechanism of action of warfarin?
Inhibits vitamin K clotting factors
Clotting factor II = prothrombin
A 58 year old man came to the ED complaining of bleeding in his mouth. It began 24 hours ago and has been continuous even with compression. He suffered an MI 18 months ago and stopped smoking after the MI. Began exercising moderately after the MI. He started taking warfarin after MI. Vital signs show normal temp., pulse= 85/min, resp.= 18/min, BP=95/65 mmHg. Lab studies show Hct= 35% (low), stool sample test was positive for blood (likely has internal bleeding), PT was 35 seconds and PTT was 48 seconds (both high, indicating clothing dysfunction). Upon further examination and workup, the patient is found to be on the best dose of warfarin. Medical personnel again begin to question further into his history and ask about anything additional he might be taking including any supplements. Pt reveals that he began to take garlic and ginkgo biloba supplements one month ago. What are the effects of these herbal extracts?
Garlic inhibits platelet adhesion
Ginkgo biloba
-Potentiates warfarin effects (increases activity of warfarin)
-Vasodilator (for peripheral vascular disease)
Side effects: massive headaches
Most metals that cause poisoning are in a microscopic (molecular) form when they enter your body. Heavy metals can enter your body by three different systemic routes. What are they?
1) Absorbing through your skin (subcutaneous/topical)
2) Inhaling into your lungs
3) Ingesting into your digestive tract organs (orally)
What makes intact skin a good barrier?
Has layers, and the top layer sheds off (desquamates)
Normal skin should have a neutral pH (approx 7.35)
-Moderately acidic (5.5) acid mantle
Contains sweat glands and sebaceous glands
Secretions can kill bacteria
The pigment melanin provides a chemical pigment defense against UV light
What are the regions of the integument?
Epidermis, dermis, and subcutaneous tissue
What are the layers of the epidermis of thick and thin skin?
Thick skin is only on palmar and plantar regions and contains 5 skin layers
The 5 layers are: (“come lets get sun burnt”)
-stratum basale (deep)
-stratum spinosum
-stratum granulosum
-stratum lucidum
-stratum corneum (superficial)
Thin skin does not contain the stratum lucidum layer
Classify the epidermis as a specific tissue type
Keratinized stratified squamous epithelium
What are the layers of the dermis?
Thin upper layer called the papillary dermis, and a thick lower layer called the reticular dermis
-Deep reticular layer is the “leathery part” and is about 80% of the dermis
-Papillary layer makes up about 20% of dermis
-Basement membrane separates the basal layer of epidermis from the papillary layer of dermis
Contains connective tissue, blood vessels, oil and sweat glands, nerves, and hair follicles
Classify the dermis as a specific tissue type
Dense irregular connective tissue (contains reticular, collagen, and elastin fibers)
What are the accessory organs of the integument?
Hair
Nails
Sweat glands
-Eccrine sweat glands (also called sudoriferous or sudoriparous glands, and they secrete salt water)
-Apocrine sweat glands (open on hair follicle and secretes amino acids that can cause BO)
Sebaceous glands (secretes sebum/oil)
What structures are found in the hypodermis/subcutaneous tissue?
-Adipose tissue
-Blood vessels
-Superficial fascia (areolar connective tissue, adipose tissue, arteries and nerves)
Cells are born in the basal layer of the ________ and migrate up. This process takes about a month. What happens if they migrate too quickly to the top? Or are too slow?
epidermis
If it happens too quickly then its most likely psoriasis (about 10 days)
If it takes longer than 4-5 weeks then its most likely an occlusion
The papillary layer houses small projections called the __________ ___________. They contain small and large blood vessels and nerve endings. They give us our fingerprints and footprints and it causes the dermis to twist and turn to give us our print morphology
dermal papilla
The breast started off embryologically as a….
modified sweat gland
What is the preferred cavity for breathing?
nose
What tissue type is the nose lined with? What does this do?
ciliated pseudostratified columnar epithelium that moistens and sanitizes air
How many tonsils are there along the breathing route?
3
What makes the respiratory tract a good barrier?
The ciliated pseudostratified columnar epithelium has mucus that can capture and trap foreign entities
Foreign entities stick to the mucus membrane (mucus pathways: respiratory, GI, reproductive, urinary tracts)
the 3 tonsils in breathing pathway (palatine, pharyngeal/adenoids, and lingual tonsils)
Where can you find the palatine tonsils?
Under the palatoglossal arches
Say “ahh” and you can see them
Located in oropharynx
What is the histology of palatine tonsils?
nonkeratinized stratified squamous epithelium
Where can you find the pharyngeal/ adenoid tonsils?
Superior to the palatine tonsils, and located in the nasopharynx
What is the histology of the pharyngeal/ adenoid tonsils?
ciliated pseudostratified columnar epithelium
Where can you find the lingual tonsils?
at the root of tongue and in laryngopharynx
What is the histology of the lingual tonsils?
nonkeratinized stratified squamous epithelium
What are the 2 clinical divisions of the respiratory tract?
Upper and lower respiratory tracts
upper= go to ENT
lower= go see pulmonologist
Which part of the throat is common to air & foods?
Oropharynx and laryngopharynx
Laryngopharynx openings
-Anterior opening →Larynx (glottis: opening into our voice box) → Trachea.
»Intubation tube goes here
-Posterior opening → esophagus.
Follow the air from your nose into your lungs through the respiratory tract identifying the organs and tubes a molecule of air passes across until it reaches the lungs starting with the external nares and ending with the alveoli
Air enters through the nostrils (external nares) → nasal septum separates the nasal cavities → turbinates (nasal conchae) runs through nasal cavities; superior, inferior, middle concha → internal nares (choanae) is an opening that separates the posterior nasal cavity from the nasopharynx → pharyngeal tonsil/adenoids → opening that goes to middle ear (auditory tube) which equalizes air pressure when you change altitude → palatine tonsil → lingual tonsil → vestibular fold (false vocal cord) → true vocal cord → larynx → trachea → primary bronchi (lobes) → secondary bronchi (lobules) → tertiary bronchi → bronchiopulmonary segment → terminal bronchioles → respiratory bronchioles → alveolar duct → alveolar sacs → alveoli.
What is the function of nasal conchae?
-prepare air for going deeper
-agitation of airflow to redirect it up & improve sense of smell
-humidify the air
Which nasal concha is considered true individual bone (of our 206 bones)?
inferior concha
The superior and middle conchae belongs to which bone and what plates are involved here?
ethmoid bone
Perpendicular plate and cribriform plate as also a part of ethmoid bone
Olfactory n. (CN I) passes through the ventral surface of the cerebrum to the cribriform plate
What epithelia line the different regions of the respiratory tract (nasopharynx, laryngopharynx, oropharynx, bronchi, bronchioles, alveoli)
Nasopharynx= ciliated pseudostratified columnar epithelium
Largyngeopharynx= nonkeratinized stratified squamous epithelium
Oropharynx= nonkeratinized stratified squamous epithelium
From the nasal cavity to the bronchi, it is lined by pseudostratified columnar ciliated epithelium
Bronchioles are lined by simple columnar to the cuboidal epithelium
Alveoli possess a lining of thin squamous epithelium that allows for gas exchange
What are the cartilages of the larynx?
Nine Cartilages
3 unpaired (6) - Anteriorly located
-Epiglottis
-Thyroid cartilage
-Cricoid cartilage - Landmark for artificial airway placement
3 paired (3) - Posteriorly located
-Cuneiform cartilage
-Corniculate cartilage
-Arytenoid cartilage
Describe the anatomy of the trachea and name its point of bifurcation and relate that bifurcation to bony landmarks
Trachea is the tube that connects the larynx to the chest
Angle of louis is found here and is a palpable bony landmark (sternal angle)
At the Carina the trachea bifurcates at T-4 vertebrae (posteriorly) & 2nd intercostal space (anteriorly).
The bifurcation forms R/L primary bronchus
The R primary bronchus is straighter and has 3 lobes (R upper, middle, and lower)
The left primary bronchus is more angled than right side because the mass of the heart takes up space
-has 2 lobes (left upper and lower)
The hilum of lung contains the primary bronchus and per lung, there are 2 pulmonary veins (superior and inferior), 1 pulmonary artery (blood is blue in artery), and bronchial arteries
Primary bronchus leads to 5 total secondary bronchi
Lung lobules will have tertiary bronchi (gives off 14-16 bronchial divisions)
Describe the 3 divisions of the bronchi and relate them to the anatomical division of the lungs
Primary (first) bronchi are the left and right main bronchi in the upper portion of your lungs
Secondary bronchi near the middle of your lungs, also called lobar bronchi
Tertiary (third) bronchi at the edge of your lungs (also called segmental bronchi), just before the bronchioles
Describe a bronchopulmonary segment
A portion of lung supplied by a specific segmental bronchus and its vessels
These arteries branch from the pulmonary and bronchial arteries, and run together through the center of the segment
There are 10 bronchopulmonary segments in the right lung (3 in superior lobe, 2 in middle lobe, 5 in inferior lobe) and 9 segments on the left (4 in upper lobe, 5 in lower lobe)
Discuss the pleural cavities and serous membranes
2 pleural cavities on right and left side
Mediastinum separates the cavities and they do not communicate
Serous membranes associated with lungs = visceral and parietal pleura
Attached to wall of thoracic cavity= parietal
Attached to surface of lungs= visceral
Space between them= pleural cavity
Describe the gross anatomy of the lungs (apex, base, surfaces, structures entering and leaving at the hilum)
lung general shape = Pyramidal shape
Apex - pointy end
Base - flat end; sitting on the diaphragm
Surfaces
Mediastinal surface → hilum
costal surface → against the ribcage
Diaphragmatic surface (base)
Both left and right hilum contain a pulmonary artery, pulmonary veins (superior and inferior), and bronchial arteries
Outline systemic and pulmonary circulations
Pulmonary circulation moves blood between the heart and the lungs. It transports deoxygenated blood to the lungs to absorb oxygen and release carbon dioxide. The oxygenated blood then flows back to the heart. Systemic circulation moves blood between the heart and the rest of the body.
Portal caval system= type of anastomoses which occurs between the veins of portal circulation and veins of systemic circulation
Systemic is pumped at higher pressure compared to pulmonary circulation
-If not, could cause pulmonary edema
Hilum of the lungs
-Systemic circulation branches: bronchial vessels → feed pleura
Systemic begins: Left ventricle → ascending aorta → Aortic Arch → Brachiocephalic → Common carotid → Subclavian Left → Descending Aorta → Thoracic Aorta → Abdominal Aorta → Lower extremity via caval system → Superior/ Inferior Vena Cava → Right Atrium.
Upper Extremity via the superior caval system
Pulmonary Circulation: Right Ventricle → Pulmonary Artery → Lungs → Pulmonary Veins → Left Atrium
T/F: At the same time there are equal amount of blood flow in pulmonary and systemic circulation
True!
T/F: Pulmonary and Systemic is pumped at the same pressure
Explain why
False!
If you pumped right ventricle into the lungs at the same pressure
-Causes systemic insufficiency
-Causes excessive pulmonary
Results in Pulmonary Edema → Lack of blood flow to extremities and go into shock
What makes the digestive tract a good barrier?
GI mucosa acts as a semipermeable barrier that allows the absorption of nutrients, while limiting the transport of potentially harmful antigens/microorganisms
What are the clinical divisions of the digestive tract?
Upper GI (esophagus, stomach, and duodenum of small intestine) and lower GI (large intestine and anus)
Follow the food or liquid from your lips to your anus identifying the organs a drop of food or liquid passes across
Start at oral cavity, the labia guards the entrance (superior and inferior labia) and vestibules (space between teeth and outer lip) > jaw > pharynx > esophagus > lower esophageal sphincter > stomach > small intestine > large intestine > colon > rectum > anus
What epithelia line the different regions of the GI tract?
Nonkeratinized stratified squamous epithelium from the oral cavity through the upper esophagus, then changes to simple columnar epithelium until the rectum
Intestines are lined with simple columnar epithelium and contain goblet cells that make mucus
Ingestion begins in the oral cavity. Review the structure of the oral cavity related to mastication and deglutition.
The muscles of mastication move the mandible during mastication and speech. They are the masseter, temporalis, lateral pterygoid, and medial pterygoid muscles
TMJ also helps with mastication
Muscles of deglutition= omohyoid, sternohyoid, and sternothyroid muscles (ansa cervicalis), and the thyrohyoid muscle (CN XII).
Structures involved in deglutition = tongue, hard and soft palate, pharyngeal muscles, esophagus, and gastroesophageal junction
The tongue has both intrinsic and extrinsic musculature
Cranial nerves involved in oral cavity:
trigeminal nerve (CN V, both)
facial nerve (CN VII, both)
glossopharyngeal nerve (CN IX, both)
vagus nerve (CN X, both)
hypoglossal nerve (CN XII, motor)
What are the muscles of mastication?
The muscles of mastication move the mandible during mastication and speech. They are the masseter, temporalis, lateral pterygoid, and medial pterygoid muscles
What are the muscles of deglutition?
omohyoid, sternohyoid, and sternothyroid muscles (ansa cervicalis), and the thyrohyoid muscle (CN XII).
What structures are involved in deglutition?
Tongue, hard and soft palate, pharyngeal muscles, esophagus, and gastroesophageal junction
Does the tongue have intrinsic or extrinsic musculature, or both?
both
What cranial nerves are involved in the oral cavity?
trigeminal nerve (CN V, both)
facial nerve (CN VII, both)
glossopharyngeal nerve (CN IX, both)
vagus nerve (CN X, both)
hypoglossal nerve (CN XII, motor)
Review the regions of the pharynx specific to digestion
Oropharynx and laryngopharynx = specific to digestion
Describe the anatomy of the esophagus
Upper esophagus has some skeletal muscles that are related to deglutition/chewing
Mastication is voluntary
Deglutition is both voluntary and involuntary (peristalsis)
Salivation is both controlled and uncontrolled
The esophagus has a dentate line which is embryologically separating the non-keratinized stratified tissues behind the cords from the simple columnar
Describe the anatomy of the diaphragm and name the hiatuses it contains and what passes through them
I Eat Apples at 8, 10 and 12
IVC - T8
Esophagus - T10
Aorta - T12
Describe the anatomy of the stomach, its regions, and layers
Regions:
-Cardia (top portion of stomach)
-Fundus
-Body (corpus) is the largest section of stomach
-Pylorus (bottom portion of stomach)
Curvatures
-Greater and lesser omentum
Layers (from outside to inside)
-Mucosa, submucosa, muscularis externa (smooth muscle bands in this layer) , and the serosa
Contains rugae
Stomach contains 3 directional bands of smooth muscle:
-Circulatory: Inner Band - Does Peristalsis
-Longitudinal Band: Outer Band
-Deep Oblique Band: Responsible for churning
-Esophagus, Small and Large Intestine:
»Only has two directional bands
Histological Feature: Mucosa → Gastric Pits: Gastric cells like chief cells & parietal cells are here.
-Mucosa @ the small intestines have intestinal “crypts” where tissues are folded into finger-like projections called villi.
-Cells of the fingers have microvilli.
-Mucosa of the stomach when empty has folds called → Rugae: Folds that allow the stomach to stretch when we eat.
Describe the anatomy of the small intestine, its regions, and layers
Right and left hypochondriac regions and epigastric region do NOT contain the small intestine
Regions: duodenum, jejunum, and ileum
The pancreas creates natural juices called pancreatic enzymes to break down foods. These juices travel through the pancreas via ducts. They empty into the upper part of the small intestine called the duodenum.
The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct. This runs from the liver to the duodenum (the first section of the small intestine).
Special movement that the small intestine can do is called segmentation, it is where primary absorption occurs (unique movement like windshield wiper)
Duodenum → goes from pH from 1 (stomach) to pH of 8
-Shortest Region
-Bile duct from gallbladder
-Pyloric sphincter from stomach
-Pancreatic Duct
-How do we not suffer from going to such extreme pH?
»Sodium Bicarbonate & Mucus
»Bile = pH 8
»Pancreatic Juice = pH 8
-By the time we reach the ileum the pH goes down to 7.5 pH.
Layers (from outside to inside)
-Mucosa, submucosa, muscularis externa, and the serosa
Has intestinal crypts that involve villi and microvilli
-The crypts are pleated like circular folds
Valves involved with the small intestine
-Upper esophageal sphincter, lower esophageal sphincter (cardiac) and ileocecal valve
Pyloric Sphincter → Small Intestines → Duodenum → Jejunum → Ileum → Ileocecal Valve
Describe the anatomy of the large intestine, its regions, and layers
Regions
-cecum, colon, rectum, and anal canal
Layers (from outside to inside)
-Mucosa, submucosa, muscularis externa, and the serosa
The cecum and colon have 3 longitudinal muscular bands
-Outer bands: longitudinal
-Deeper bands: circular
-Stomach has deeper oblique bands to do churning, the stomach also has gastric pits
Haustra are saccules in the colon that give it its segmented appearance
Teniae coli are three longitudinal smooth muscle bands in the colon wall
Vermiform appendix is found near the cecum and ilium
The appendix position is normally retrocecal
Ileocecal Valve → Cecum → Ascending Colon → Transverse Colon → Descending Colon → Sigmoid Colon → Rectum → Anal Canal.
Describe the anatomy of the abdominal accessory organ, the spleen
Found in left hypochondriac region
Contains a splenic vein that forms into the hepatic portal vein
Describe the anatomy of the abdominal accessory organ, the liver
Found in the right upper quadrant
Has 4 lobes
Describe the anatomy of the abdominal accessory organ, the gallbladder
Found in the right upper quadrant of the abdomen, or right hypochondriac region
3 regions from lateral to medial= fundus, body and neck (infundibulum)
Attached to the ventral surface of the liver
Describe the anatomy of the abdominal accessory organ, the pancreas
Found in the upper left quadrant
Retroperitoneal & behind greater omentum
Contains the Islets of langerhans cells
-Alpha = glucagon (storage of glucose)
-Beta = insulin (breaks down glucose, also allows glucose to enter the cells)
Discuss the vascularity of the foregut, midgut, and hindgut structures
foregut = celiac trunk (gives off the left gastric & hepatic proper artery)
midgut= superior mesenteric artery
hindgut= inferior mesenteric artery
Describe the membrane, proper or “true” mesentery
-Largest mesnetary
-Connects small intestine to abdominal wall
-Binds the loops of the small intestine together
-Allows for the small intestines to fold and not get tangled
What is the largest mesentery?
proper/true mesentery
Describe the membrane, mesocolon of large intestine
-Unlike the small intestine that is completely enclosed, the mesocolon of large intestine only segments or a small portion is bound
-Usually non movable parts get a mesencolon - regionalized
-Mesocolon attaches the colon to the abdominal wall
Describe the membrane, greater omentum - “Greasy Apron” (curvature of stomach)- where does it hang?
Hangs from the stomach and closes over the transverse colon
Describe the membrane, lesser omentum (curvature of stomach)- what region does it lie in and what does it connect?
-In the epigastric region
-Connects parts of the lower esophagus, gallbladder, and liver to the cardia region of the stomach.
Which digestive or accessory digestive organs are intraperitoneal?
-stomach
-spleen
-liver
-gallbladder
-1st and 4th part of the duodenum
-jejunum
-ileum
-transverse colon
-sigmoid colon
Which digestive or accessory digestive organs are retroperitoneal?
-adrenal glands
-aorta
-kidneys
-esophagus
-ureters
-pancreas
-rectum
-parts of the stomach and colon
Which digestive or accessory digestive organs are secondary peritoneal?
-pancreas
-ascending and descending colon
-distal part of the duodenum
Compare the hepatic portal venous system to the caval venous system
Caval Venous System
-Restores most of the blood from the lower limbs and from kidneys and organs that do not need to be processed
Hepatic Portal Venous System
-Everything in the GI tract needs to go to the liver first
-Liver is unique in that it has two named veins.
»The Hepatic Portal is entering like an artery
»The Hepatic Vein is leaving to join the inferior vena cava just below the diaphragm
What are the 9 abdominal regions?
What are the sphincters and valves related to the GI tract?
Upper Esophageal Sphincter - Throat region
Lower Esophageal Sphincter aka cardiac notch
-Separates lower esophageal from cardiac region of stomach
Pyloric Valve
Ileocecal Valve
Internal anal sphincter → smooth muscle
External anal sphincter → skeletal muscle (gets myelinated last)
-Explains why babies are incontinence
A 48 y/o man comes to the ED complaining of trouble seeing, and he has difficulty swallowing. Symptoms began 3 hours ago and are increasing in severity. He is visiting friends and indicates that approximately 24 hours ago he ate green beans that were canned at home. Physical examination reveals double vision, drooping eyelids, slurred speech, and difficulty swallowing. There is also muscle weakness. What abnormality would be present at the NMJ?
docking and fusion of the ACh vesicles would be impaired
The surface of the lung that contains the hilum is the….
medial surface
The mainstay of treatment for lead toxicity is….
chelation therapy
The left gastric, splenic, and common hepatic arteries are branches of the….
celiac trunk
A 58 y/o man comes to the ED complaining of bleeding in his mouth. He has multiple small bleeding sites on the mucosal membranes of the nose and mouth. He has suffered from an MI 18 months ago and has been on low dose warfarin. One month ago, he started taking herbal supplements containing ginkgo biloba. HCt= 35% and PT and PTT levels are high. Plasma analysis should dhow decrease in….
thrombin
This is not one of the muscles of mastication that moves the mandible:
A) tongue
B) medial pterygoid
C) temporalis
D) masseter
E) lateral pterygoid
A) tongue
Lead toxicity can result in anemia because….
A) it can cross the BBB
B) hemolysis occurs
C) it inhibits a number of enzymes necessary for heme synthesis
D) both B and C are correct
D) both B and C are correct
The layer of the epidermis deep to the papillary dermis is the?
A) stratum basale
B) reticular layer
C) stratum corneum
D) stratum spinosum
E) none of the above
E) none of the above
An edrophonium test shows an improvement in muscle strength. There is a high probability that the diagnosis is….
myasthenia gravis
The region of the pharynx used for both respiration and digestion is the….
oropharynx and laryngopharynx
