Thorax Flashcards
Which nerves in Superior MEdaistinum
Vagus
Phrenic
LEFT RCL
Sup Viscera
Trachea
Oesophagus
Thoracic Duct
Thymus and Thymic Remnants
The nerve in the middle mediastinum
Phrenic Nerve
Posterior Mediastinum Border
T5-T12
Nerves in Posterior Mediastinum
Vagus
Splanchnic
Superior MEdiastinum upper and lower boundaries
Jugular notch / Upper border of T1
to
Sternal angle lower border of T4
VEssels and viscera in posterior
Oesophagus
Thoracic duct
Azygous on right
Hemi + Accessory Azy on left
Angle of Louis
- Bifurcation of trachea (Carina of trachea)
- Bifurcation of pulmonary trunk
- Beginning and end of arch of aorta [aortic arch]
- Azygos vein enters the superior vena cava
- Superior vena cava enters the right atrium
- Crossing over of the thoracic duct from the right side to the left
- Left recurrent laryngeal nerve loops around aortic arch
- Level of ligamentum arteriosum
9 2nd anatomical constriction of the oesophagus
10.Thymus or thymic remnants - Placement of central line tip
- Demarcates superior and inferior mediastinum
- Landmark for counting ribs
Oesopgaus levels
Oesopgaus levels
Cervical: C6-T1 3-5cm
Thoracic: T1-T10
Abdominal T11-T12
Oesophagus constriction distances
Oesophagus constriction distances
3 constrictions
• Cricopharyngeal sphincter (15 cm)
• Aortic arch and L main bronchus (23 cm)
• LOS (40 cm)
Oesophagus Blood supply:
Blood supply:
• Cervical — Inferior thyroid A
• Thoracic — Bronchial and oesophageal branches of thoracic aorta
• Abdominal — Ascending branches from left gastric A and inferior phrenic arteries
Oesophagus Microanatomy
Microscopic Anatomy: • Layer 1: Mucosa • Innermost layer • Stratified squamous epithelium 4 squamous epithelium
• Layer 2: Submucosa • Contains larger blood vessels, nerve plexus, oesophageal glands
• Layer 3: Muscle fibres • Inner circular and outer longitudinal fibres
• Layer 4: Fibrous layer • Dense connective tissue
Thorascopic sympathectomy – division of
Thorascopic sympathectomy – division of parietal pleura
Most anterior and Most posterior to lung root
Phrenic nerves most anterior and vagus most posterior to lung root
Phrenic - levels supplies
Phrenic - C3,4,5 - Diaphragm, sensation central diaphragm and pericardium
Phrenics are anterior to…
Phrenic
Lt – ant to 1st of subclavian artery
Rt – anterior to scalenus anterior
Both posterior to subclavian vein
CABG median sternotomy – division of
CABG median sternotomy – division of interclavicular ligament
Safe triangle -
latissimus dorsi, pectoralis major, superior to the nipple and apex at the axilla, 6th IC MAL
Pulmonary arteries = which pharyngeal pouch
Pulmonary arteries = 6th Pharyngeal pouch
Origin of trachea =, Carina bifurcates at
Origin of trachea = C6, Carina bifurcates at T5
Lung met with clear cells =
Lung met with clear cells – renal primary
Increased lung compliance =
Increased lung compliance = Older age, COPD
Widespread mets, big bronchial tumour, paraneoplastic syndrome
Least likely to resect!
Small Cell Lung Ca: Widespread mets, big bronchial tumour, paraneoplastic syndrome
Least likely to resect!
Small Cell Carcinoma
15% of lung cancers
60% already have mets on presentation
poor prognosis
PROXIMAL hilar mass - neuroendocrine cells - paraneoplastic
STRONG LINK TO SMOKING
(Both SCC acronyms are proximal)
Non Small-Cell
Majority - 85%
Adenocarcinoma 38%
- PERIPHERAL lung tissue
- glandular tissue
SCC (20%)
- close to main bronchi
- airway epithelial change from COLUMNAR CUBOIDAL to SQUAMOUS
Large CC (55) RAPID GROWTH - proximal or peripheral (Big boy does whatever he wants - peripheral or central)
Lung
Heart Brain Liver Adrenal Glands Bone
Paraneoplastic
Small Cell and Squamous
- Ectopic Cushing’s - stimualte adrenals
- Increase ADH - stimulate kidneys to retain hormone
- PTH like substance - hypercalcaemia
- Hyperpulmonary osteoarthropahty - clubbing
- Inflammatory myopathy - muscle weakness
Stabbed to the right of the Manubriosternal joint –
Stabbed to the right of the Manubriosternal joint – right recurrent nerve damage
Normal FEV1/FVC =
Normal FEV1/FVC = 70%
Burns – electrolyte and CO drop…
Burns – hypokalaemia and lose CO 50% in 30 minutes
Central tendon of diaphragm – derived form
Central tendon of diaphragm – derived form septum transversum
suture for chest drains
2/0 silk for chest drains
Mesothelioma
Asbestos – Mesothelioma – NOT smoking
Mesothelial cells of lung pleura
Investigation: pleural biopsy, CT Scanning, (PET Scanning if surgery considered)
Lung cancer: non-small cell management
Surgery contraindications
Surgery contraindications
Assess general health
Stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
Malignant pleural effusion
Tumour near hilum
Vocal cord paralysis
SVC obstruction
- However if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
Left main bronchus is at
Left main bronchus is at T6
ARDS = Pulmonary wedge / Swan Ganz
ARDS = Pulmonary wedge / Swan Ganz <18mmHg
Stab in parasternal left L4
Stab in parasternal left L4 – RV
Stab L4 MCL -
Stab L4 MCL - LV
National Abdominal Aortic Aneurysm Screening Programme
Started 2013 65 yr invited for USS > 3cm enter surveillance 3.0-4.5cm invited for annual USS >4.5cm for 3 monthly USS
Men - referred for treatment at 5.5cm
Women referred for treatment at 5.2cm
False aneurysm – not
False aneurysm – not expansile – not all muscular layers
ABPI of 0.3, ulcer without venous insufficiency -
ABPI of 0.3, ulcer without venous insufficiency - Chronic obliterative arterial disease
Median sacral artery –
L4
IVC formed
at L5
Occlude common iliac bleeding point with
Occlude common iliac bleeding point with digital pressure and consider direct sutured repair with 5/0 polypropylene
dressing for Ray diabetic foot amputation
VAC dressing for Ray diabetic foot amputation
Asian females - Large vessel granulomatous arteritis
Takayasu – Asian females - Large vessel granulomatous arteritis
Pathophysiology of AAA
Loss of intima, elastin from media
proteolytic activity, lymphocyte infiltration
> 50yo infra-renal AA size in males and females
What size considered aneurysmal?
F 1.5cm and M 1.7cm.
> 3cm = aneurysmal
Incisura
Incisura – elastic recoil of aorta on arterial line trace
Femoropopliteal bypass graft:
3,000 units of unfractionated heparin, 3 minutes prior to cross-clamping
for cardiopulmonary bypass
30,000 units of unfractionated heparin for cardiopulmonary bypass
Klippel-Trenaunay-Weber Syndrome
Varicose Veins + Port wine stains!
+Bone/soft tissue hypertrophy
Aortic rupture distal to left subclavian…
Aortic rupture distal to left subclavian more likely, ones prior would not survive
Temporal artery biopsy – not diagnostic in
Temporal artery biopsy – not diagnostic in 50%
PTFE graft - to minimise neointimal hyperplasia
PTFE graft – neointimal hyperplasia – use a Millar Cuff
Marfann’s aorta –
Marfann’s aorta – medial cystic necrosis
During a SFJ dissection - you at high risk of
Damage to the deep Deep internal pudendal artery
Post-transplant infections…
<6months CMV
> 6months lymphoproliferative EBV
AAA rupture rates
F 1.5cm and M 1.7cm.
>3cm = aneurysmal
5-6cm 25%,
6-7cm 35%,
>7cm 75%
Thyroid ima –
Thyroid ima – brachiocephalic artery.
Brachial artery embolectomy – nerve at risk
Brachial artery embolectomy – Median Nerve Risk
has the most musculi pectinate
RA has the most musculi pectinate
Persistent Left SVC – drains via
Persistent Left SVC – drains via coronary sinus
Conus arteriosus –
Conus arteriosus – infundibulum – LVOT
Normal Stroke Volume
50-110ml, 70ml for 70kg
Inferior MI + Systolic Murmur = think..!
Inferior MI + Murmur = Proximal Aortic Dissection! Creation of false lumen between intima + media
Apple green birefringence with polarised light =
Apple green birefringence with polarised light = amyloidosis
Bainbridge reflex =
Bainbridge reflex is the increase in heart rate mediated via atrial stretch receptors that occurs following a rapid infusion of blood
Stop unfractionated heparin how long before surgery
Stop unfractionated heparin 6 hours before surgery
Great cardiac vein runs in
Great cardiac vein runs in the anterior IV groove - largest tributary of the coronary sinus.
Thebesian veins drain into
chambers directly
J waves are pathognomonic of
J waves are pathognomonic of hypothermia.
1st heart sound =
Mitral and Tricuspid Valve closure =
Proximal LAD occlusion – good conduit for bypass
Proximal LAD occlusion – internal mammery artery - good conduit for bypass!
Endocarditis – typical organism is..
strep viridians!
Middle cardiac vein - accompanies the
Middle cardiac vein - accompanies the posterior I-V artery within the posterior IV groove
Verapamil – contraindicated in
tachycardias
Sodium thiopentone – can cause
Sodium thiopentone – myocardial depression
