Thorax Flashcards
Where metallic valves are located on X ray
Aortic
Usually located medial to the 3rd interspace on the right.
Mitral
Usually located medial to the 4th interspace on the left.
Tricuspid
Usually located medial to the 5th interspace on the right.
Root of lung - ant to posterior
Ant- phrenic
Pul vein
Pul artery sup post
Bronchus posterior to artery and superior to vein
Post- vagus
Which muscles/nerves are closely related to the carotid sheath at
Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid
Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.
Opposite the cricoid cartilage - crossed by the superior belly of omohyoid.
At its lower end -sternohyoid and sternothyroid.
Aortic arches origins
1- disappears -maxillary
3- common carotid and prog internal carotid
4- aortic arch left, right subclavian prox
6- left and right pulmonary
What is divided routinely in midline sternotomy
Interclavicular ligament
If pleural reflections are divided in stenotomy what should be done
Chest drain inserted
Chest drain inserted and blood apparent at site- which structure damaged
Intercostal artery
Most inferior
V
A
N
Which nerve is often damaged in axillary surgery and what is the result
Intercostalbrachial
Parasthesia in armpit
Each heart valve, number of cusps, number of anterior cusps, muscle attachments
Mitral- 2, 1 anterior
Attached to chord tenindae
Aortic-3, 2 anterior
No chordae
Pulmonary- 3,2 anterior
No chordae
Tricuspid- 3, 2 anterior
Attached to chordae
Which fascia overlies apices of lungs
Sibsons
C7 to the first rib -It lies between the parietal pleura and the thoracic cage.
How persistent SVC drains into heart
Via coronary sinus
Foramen of Morgani contents
Superior epigastric artery and vein
Ligaments of diaphragm
Central tendon
Left and right crus-Median Arcuate around aorta
Then medial arcuate - around psoas
then lateral arcuate
Contents of Middle Mediastinum
- P ericardium
- H eart
- A ortic root
- A rch of azygos vein
- Bronchi
BAAPH
Contents Posterior Mediastinum
D escending aorta
A zygous and hemiazygos vein
T horacic duct
E sophagus
S ympathetic trunk/ganglia; splanchnic nerves
Vagus nerve
DATES V
Where does the Great Cardiac Vein begin, run and drain
Begins at the cardiac apex
Runs in the anterior interventricular sulcus with LAD
Drains both ventricles and left atrium – to Left extremity of coronary sinus
Where does the middle Cardiac Vein begin, run and drain
Begins at the cardiac apex
Runs in the posterior interventricular sulcus with PDA
Drains the areas supplied by PDA of right – to Right extremity of coronary sinus
Where does the small Cardiac Vein begin, run and drain
Runs in the right posterior atrioventricular (AV) groove
Drains the posterior part of right atrium & ventricle – to Right extremity of coronary sinus near its atrial end.
Receptors in heart and location
The ventricles: beta-1 adrenoceptors The atria: cholinergic receptors.
The aortic arch: contains baroreceptors. The carotid body: contains baroreceptors
Unique feature of right atrium
Musculi pectinati
CI to lung cancer surgery
SVC obstruction
FEV <1.5
Malignant pleural effusion
Vocal cord paralysis
What do thebsian veins drain into
Atrium
With SVC obstruction how many collaterals are there
Azygos venous system
Internal mammary venous pathway
Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)
Which artery is likely encountered in axillary surgery
Thoracodorsal
If damaged lat flap can’t be used
What prolapses in disc prolapse
Nucleus pulposus
Where does thyroid ima arise from
Brachiocephalic
At which level does the trachea bifurcate?
T5
From which structure is the central tendon of the diaphragm derived?
Septum transversus
Which nerves are commonly damaged in axillary node biopsies
Thoracodorsal - problems painting etc
intercostobrachial nerve
What is the outer layer of the intrathoracic oesophagus?
Loose connective tissue
Adventita
What level is the apex of the middle lobe
6th interspace in MAL
Where oblique runs up and meets horizontal
Horizontal runs from 4thCC to 6th MAL
Where are the greatest proportion of musculi pectinati found?
Right atrium
What directly innervated the heart
Superior and inferior cardiac plexuses
What is found at sternal angle
T4-5
2nd CC
Start/end of aortic arch
SVC
Bifurcation of trachea
Bifurcation of pulmonary trunk
Azygous arching to SVC
Thoracic duct crosses midline
Lung projection in relation to first rib
Projects up and beyond constrained by SIbson fascia
Passage of sympathetic trunk into abdomen
Posterior to medial arcuate
Over psoas major
Name of foramen IVC goes through in diaphragm
Caval foramen
What lies anterior and posterior to transverse pericardial sinus
Aorta and pulmonary trunk anterior
SVC posterior
What does the oblique sinus go between
Blind ended sinus between pulmonary veins
Dermatome nipple sits in
T4
Main arterial supply of breast
Internal thoracic
Surface location of lungs vs pleura at base
Lungs 6th MCL, 8th MAL, 10 posterior
Pleural- 8th MCL, 10 MAL, 12 post
Anterior to posterior of heart valves
Pulmonary
Aortic
Mitral and tricuspid
Source of aortic valves
Left- left CA
Right- right CA
Posterior - nothing
Where is AV located
Koch triangle
Pleural location relative to clavicle and name
Cupola
2.5cm above clavicle in middle 1/3
What does the posterior descending coronary supply
Post 1/3 of IV septum
Right and left ventricles
What does the left circumflex supply
Left atrium and ventricle
Which muscles retract scapula
Trap
Rhomboids
Lat
Which muscle protract scapula
Serratus anterior
Serratus anterior attachements
Upper 8 ribs
Insert into medial border of scapula
Which part of the lung does azygous lobe effects
Right upper zone
Super to hilum
Reverse comma sign
What part of diaphragm foes IVC, oesophagus and aorta pass through
IVC- central tendon
Oesophagus- Right crus
Aorta- median arcuate
External intercostal action and attachment
Fibres run inferomedially
Raises ribs and expands in forced inspiration
What path does the oblique fissure follow
Medial border of scapula when abducted
Right- T4 to 6th rib
Left- between T3/4- 6th rib
Horizontal fissure path
6th ICS MAL
to 4th CC anterior border
Phrenic nerve relative to subclavian and scalene
Ant to subclavian artery
Post to subclavian vein
Anterior and Medial to lower border of scalene anterior
Where is the right coronary sulcus and what runs through it
Atrioventricular groove
RCA
Which nodes are difficult to sample in cervical mediastinosocpy
Aortopulmonary
Accessed via VAT instead
What is most likely to be affected in right bronchus lymphadenopathy in superior aspect
Azygous
As loops over
Root of lung vertebral level
T5/6
Vertebral level of xiphoid
T7
Liver biopsy, now pain on tip of right shoulder
Phrenic nerve- supplies here
Location of crest terminals and what is contained here
Posterolateral wall of RA
SA node
Stenosis of what artery is most sever
Anterior inter ventricular - widow maker - widespread ST
Which artery supplies upper 1/3 oesophagus
Inferior thyroidR
Risk of pericardectomy
Phrenic nerve damage
What level does the aortic arch become descending
T4
What covers arch of aorta anteriorly
Left pleura
Aorta relation to brachiocephalic veins
Apex of arch poster inferior to left brachiocepahlic
How many segments does right and left lung have
10 -R
8-9- L
What contains lingual lobe
Left upper lobe
Anteroinfeiror projection
Level hemiazygous crosses over to join azygous
T8
What is located in anterior wall of right atrium
Musclini pectin in auricle
Where coronary sinus sits
Postero inferior
Posterior part of RA next to IVC
Smooth posterior part of RA
Sinus venarum
Joins rough anterior at crest terminals
Level SVC joins RA
3rd CC
Types of joint that steno manubrium is
Secondary cartilaginous
Where is the coronary sinus opening located
located between the inferior vena cava and tricuspid valve
What organs foes subclavian supply
Thyroid gland- via thyrocervical
Breast, RA, diaphgram- internal thoracic
Brainstem, cerebellum- vertebral
Upper limb
Vessel damaged in sternotomy
Brachiocephalic artery vein
Left carotid and subclavian
% of AV branch supplied by RCA
70-80
Central venous cannulation landmark
1-2cm below and lateral to junction between medial 1/3 and lateral 2/3 of clavicle
Subclavian vein location
What does the left marginal branch branch off of
Left circumflex
Level of carina
T4/5
What does the LCA pass between
Left atrial appendage
and pulmonary trunk
Level thoracic duct passes posterior and to left of oesophagus
T5
Right, co and left dominance stats
right 80
co- 10-20
5-10 left
Diagnosis of mesothelioma
Pleural biopsy
Defect in connective tissue disorder causing dissection
Fibrillin 1
Most common lung neoplasms
Mets
Heart transplant rejection types
Acute- T cell, cell death
AB mediated- month to years
Allograft vasculopathy- CA disease- months to years
Diffuse proliferation of intima
Marantic endocarditis
Non bacterial thrombotic endocarditis
Advanced malignancy
Vegetations on mitral and aortic
Major + Minor criteria for IE
Echo findings
2 + blood futures , 1 if coxiella
Fever
Skin
Vascular
IVDU
What would suggest a small cell lung cancer is unresectable
SIADH
Mutation in primary small cell cancers
p53
Paraneoplastic of small cells
PTHrP
ACTH
SIADH
Differentiating TB and sarcoid
TB- caseated calcified lesion
Sarcoid- non caseating
What cells does bronchoalveolar carcinoma rise from
Pneumocytes type 2
What way empyema cause
Frozen chest - pleural stick together
Cortisol after cardiopulmonary bypass
Fall
Tracheostomy effect on V/Q, dead space and secretions
Decrease mismatch and dead space
Used for bronchial toiler- clearing of secretions those unable to cough
End management for IE with pan systolic murmur
Mechanical mitral valve
Type 1 vs 2 resp failure
1- V/Q mismatch
2- hyperventilated alveoli
Strep bovis IE, what next Ix
Colonsocpy as linked to colon cancer
CURB65
Confusion
Urea >7
Resp >30
Bp <90 or 60
>65
2- admission
Most common complication of FNA lung
Pneumothorax
Acquired RF for atherosclerosis
HTN, hyperlipid, smoking, high fibrinogen, obesity, hypothyroid
Normal PAWP
6-12 mmHg
Artery for AV node
Posterior IV artery
Tension pneumothorax CVP and Bp
High CVP and low BP
Caveatting lesion lung
Staph aureus
BP and temp in bypass
Controlled hypotension and hypothermia
To reduce dissection risk and metabolic rate
What is used for bypass
Left internal mammary
If unavailable or not suitable - RIMA
Better than. veins as withstand high pressure and flow during systole and diastole
Use of hyperbaric oxygen therapy
CO poisoning
Small peripheral lesion in healthy non smoker
Pulmonary harmatoma
Bypass coagulopathy
THrombocytosis
Tx of lung abcess
Prolonged Abx 4-6w
Surgical if do not respond or complications
Where bypass machine works
Cannula in right atrium where it is then oxygenated and return in the ascending aorta
Lungs are deflated to allow access
Mx of inhaled FB
Bronchoscopy if visualised
Fibre optic bronchoscopy if not visualised
Mx of empyema
Simple-chest drain
Disabling resp symptoms, fibrous peel, pleural peel for 4-6w -thoracotomy
