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FAB > Thorax > Flashcards

Thorax Flashcards

1
Q

What lies between the pleural cavities

A

The mediastinum

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2
Q

Where is the arch of the aorta

A

Superior mediastinum

It passes slightly left but is direct anteroposteriorly

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3
Q

What forms the superior vena cava

A

The brachiocephalic veins

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4
Q

Where is the thymus gland

A

In the inferior mediastinum (rudimentary in adults)

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5
Q

What is in the inferior mediastinum (6)

A 
Pericardium
Oesophagus
Descending thoracic aorta 
Sympathetic trunks
Thoracic duct
Thymus gland
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6
Q

What does the pericardium fuse onto

A

Pulmonary trunk
Ascending aorta
Pulmonary veins
Venae cavae

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7
Q

What does the SVC drain

A

Head
Neck
Upper limbs
Upper trunk

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8
Q

What separates the right heart chambers

A

Tricuspid valve

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9
Q

Where is the mitral valve

A

Between left heart chambers

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10
Q

True or false

The aorta and pulmonary trunk have the same kind of valve

A

True - tricuspid semi lunar valves to prevent back flow

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11
Q

What disease can damage heart valves

A

Rheumatic fever

Atherosclerosis

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12
Q

What does the left coronary artery supply mostly

A

Most tif the interventricular septum, containing the bundle of His

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13
Q

Where is venous drainage from the heart

A

From the coronary sinus into the right atrium

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14
Q

What can dysfunction of the heart’s conducting system lead to

A

Angina
Arrhythmia
Myocardial infarction
Sudden death

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15
Q

What can rubella lead to if the patient is pregnant

A

Cyanosis at birth

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16
Q

What is the oesophagus continuous of

A

The pharynx

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17
Q

Where does a hiatus hernia occur

A

Gastro oesophageal junction

When part of the stomach slides up into the thorax

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18
Q

What is the thoracic inlet formed by

A

T1, 1st ribs and their costal cartilages, and the manubrium

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19
Q

What limits the superior mediastinum

A

Superiorly: thoracic Inlet
Inferiorly: a transverse plane from manubriosternal joint to T4/5 disc

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20
Q

What is the position of the subclavian vein in relation to the scalenes

A

Anterior to scalenus anterior

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21
Q

Where does the IJV commence

A

In the jugular foramina from the sigmoid sinuses

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22
Q

Where is the SVC formed

What does this mean

A

Behind Lower border of the first right costal cartilage

The left brachiocephalic vein is long to reach over to the right

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23
Q

How many cusps in the aortic valve

A

3

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24
Q

What arises from the aortic sinuses

A

Coronary arteries (also know as anterior and left posterior sinuses)

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25
Q

Where does the arch of the aorta begin and end

A

T4/5

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26
Q

What does the arch of the aorta arch over

What are its 3 branches

A

Left main bronchus

Brachiocephalic artery
Left common carotid
Left subclavian artery

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27
Q

Describe the brachiocephalic artery

A

Lies to right of trachea

Divides into right subclavian and right common carotid arteries

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28
Q

What muscle is the subclavian artery associated with

A

Scalenus anterior

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29
Q

Tell me about the part of the subclavian artery that is behind scalenus anteruor

A

It is related to the apex of the lung but is posterior to structures passing into the thorax

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30
Q

3 branches of the subclavian artery

A

Internal thoracic
Vertebral
Thyrocervical trunk

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31
Q

What are the terminal branches of the internal thoracic artery

A

Musculophrenic

Superiorepigastric

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32
Q

Which transverse foramen does the vertebral artery enter

What happens to it eventually

A

C6

It unites with its partner to form the Basilar artery, supplying the cerebellum and occipital lobe

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33
Q

Which artery sends branches to the vertebrae and spinal cord

A

Vertebral artery

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34
Q

When does the common carotid divide

Which branch supplies the brain

A

Upper thyroid cartilage (C4)

Internal

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35
Q

Where does the thoracic duct enter the left subclavian

A

Behind the Sternoclavicular joint

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36
Q

Describe the thymus gland

A

Lymphoid organ
Large in childhood
Superior to and anterior to mediastinum

After puberty is atrophies and undergoes fibrofatty degeneration

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37
Q

Which muscle do the vagus and phrenic run on

Which is more medial

A

Scalenus anterior

Vagus (lying within the carotid sheath)

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38
Q

Describe the course of the left phrenic

A

Enters thorax above aortic arch and anterior to lung apex

Descends on the fibrous pericardium overlyin the ventricle

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39
Q

Describe the course of the right phrenic

A

Runs behind right brachiocephalic veins and then into right side of SVC and right atrium

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40
Q

What is the sensory innervation of the phrenic

What are the spinal roots

A

Pericardium
Mediastinal pleura
Subdiaphragmatic peritoneum

(C3,4,5)

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41
Q

Describe the course of the left vagus

A

Descends in carotid sheath with common carotid and crosses anteriorly at the aortic arch

It then descends behind left bronchus to form the pulmonary plexus. Before this it gives the left recurrent laryngeal nerves which winds laterally around ligamentum arteriosum and ascends medial to aortic arch

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42
Q

Describe the course of the right vagus

A

Runs with common carotid and brachiocephalic trunk
Runs beside trachea before descending behind right main bronchus

As it passes anteriorly over subclavian artery it gives off the right recurrent laryngeal nerve

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43
Q

What do the recurrent laryngeal nerves ascend in

A

The tracheo- oesophageal groove

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44
Q

What happens to the vagus after it forms the pulmonary plexus

A

Reforms as the oesophageal plexus

This sends an anterior and posterior Vagal trunk through the diaphragm to the stomach

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45
Q

How do the Vagal trunks relate to the original vagi

A

Anterior trunk is mostly left vagus

Posterior trunk is mostly right

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46
Q

How far does the vagus innervate the intestines

A

As far as 2/3 along the transverse colon

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47
Q

Where does the sympathetic outflow emerge

A

T1-L2

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48
Q

How many sympathetic ganglia one the neck

Name them

A

3

Inferior cervical
Middle cervical
Superior cervical

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49
Q

What can often happen to the inferior cervical ganglion

Where is it found

How are its branches distributed

A

Fuse with the upper thoracic ganglion to become the Stellate ganglion

On the 1st rib neck

Forms a plexus on the subclavian artery to be distributed with its branches

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50
Q

Which artery is the middle cervical ganglion associated with

A

Inferior thyroid artery

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51
Q

Where is the superior cervical ganglion

How does it send branches

A

Opposite the atlas and axis

As plexuses on the internal and external carotid arteries

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52
Q

What forms the cardiac plexus

A

3 cervical ganglia and vagi

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53
Q

What do the cervical ganglia give to other than the cardiac plexus

A

Grey rami communicantes to cervical somatic nerves: 4 from superior and 2 from middle and inferior ganglia

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54
Q

What is sympathetic innervation important for on the skin

What else in the head ?

A

Vasomotor
Pilomotor
Sudomotor

Pupillary dilation and raising eyelid

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55
Q

Which muscle raises the eyelid involuntarily

A

Levator palpebrae superioris

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56
Q

What is thoracic outlet syndrome

What is affected

What are signs and symptoms

What can cause it

A

Compression of neurovascular structures between 1st rib and clavicle

Lower trunk of brachial plexus, subclavian vein and artery

Ischaemia, swelling, pain, paraesthesia of hand wasting of C8-T1 muscles

Cervical rib (at C7)

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57
Q

What must be avoided when inserting a catheter into the subclavian veins

Hence what must be done after such a procedure

A

Puncturing the pleura

A chest radiograph

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58
Q

Why is the left brachiocephalic vein at risk in a tracheostomy in children

A

It may lie above the suprasternal notch in children

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59
Q

When might pain be referred to the tip of the shoulder

A

Inflammation of sub phrenic organs eg gall bladder touching the peritoneum

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60
Q

What is a Pancoast tumour

What can it lead to

Why

A

A bronchogenic carcinoma at the apex of the lung

Horner’s syndrome

It may affect cervical sympathetic chain

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61
Q

What are the signs and symptoms of Horner’s syndrome

A

Ptosis (droopy upper eye lid due to loss of sympathetic supply to levator palpebrae superioris)
Miosis (constricted pupil)
Anhyrodsis (decreases sweating) in affected side of face
Vasodilation leading to flush

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62
Q

What is the inferior mediastinum divided into

A

Anterior
Middle
posterior

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63
Q

Describe the anterior mediastinum

A

Between the sternum and anterior border of the pericardial sac
Contains some lymph nodes and the thymus gland

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64
Q

Describe the posterior mediastinum

A

Contains oesophagus with vagi, descending aorta, azygous vein and thoracic duct

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65
Q

Describe the middle mediastinum

A

contains the pericardium and heart, roots of the great veins and the holum of each lung

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66
Q

When are the 2 pleural layers continuous

A

At the hilum

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67
Q

Wha is the costodiaphragmatic recess

When is it deepest

A

A recess between the parietal pleura lining the superior diaphragmatic surface and the parietal pleura of the thoracic wall

At full expiration

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68
Q

Which pleural cavity is smaller

Why

A

Left

The heart extends into it

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69
Q

Describe the sensory nature of the pleura

A

Visceral pleura is insensitive

Parietal pleura receives segmental innervation from intercostal nerves and phrenic nerves

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70
Q

Which parietal pleura do the phrenic nerves innervate

A

Mediastinal and diaphragmatic

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71
Q

How are the lungs divided

A

Right: into 3 (upper, middle, lower) by 2 fissures (oblique and transverse)

Left: 2 by the oblique fissure

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72
Q

What is the lingula

A

A small tongue of upper lobe on the left between the oblique fissure and the cardiac notch

It corresponds to the middle lobe of the right lung

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73
Q

Describe the surface markings of the pleura

A

Apex: 2.5cm above medial 1/3 of clavicle

2nd costal cartilage: pleurae meet on both sides

4th costal cartilage: left diverges to accommodate heart

6th: right descends
8th: cross mid-clavicular line
10th: crosses mid axillary line

12th rib: reaches just below neck of 12th rib posteriorly

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74
Q

Describe the surface markings of the lungs

A

Correspond with those of the pleurae expect inferiorly where they are 2 spaces higher in full expiration

Thus lungs lie opposite the 6th costal cartilage at the mid clavicular line, the 8th at the mid axillary line and reach the 10th rib posteriorly

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75
Q

Where does the oblique fissure start

Where does it end

What about when atm is abducted

A

Posteriorly next to T3

Curves down and forward to end at 6th costal cartilage

Medial border of the scapula is in line with oblique fissure

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76
Q

What are the surface markings of the right lung fissures

A

Transverse fissure: parallel 4th costal cartilage

Oblique: meets transverse at 5th rib in mid axillary line

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77
Q

What are the 6 structures in the lung hilum

A 
Bronchus
Pulmonary artery
Pulmonary vein
Bronchial artery
Lymph node
Nerves of pulmonary plexus
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78
Q

On which side is the main bronchus longer

What is the other difference

A

Left

The left has 1 bronchus

On the right there are 2: the right main bronchus and upper lobe bronchus)

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79
Q

What lie laterally to the lungs on each side

A

Costal cartilages and ribs with intervening intercostal muscle

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80
Q

What is the left lung related to medially

A

Left ventricle
Aortic Arch and descending aorta

The oesophagus may also groove the left lung as it move to the left in front of the aorta

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81
Q

What is related to the left lung inferiorly

A

Diaphragm

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82
Q

What is the right lung related to medially

A

Right atrium with both vena cava vessels and the azygous arch entering the SVC
Brachiocephalic trunk
Trachea

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83
Q

Why is the right lung shorter and wider than the left

A

The liver pushes up into it

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84
Q

What line the bronchi

Which bronchi go to bronchopulmonary segments

How many segments does each lung have

A

Pseudostratified ciliated columnar epithelium

Tertiary bronchi

10

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85
Q

How many segments are the upper lobes of the lungs divided into

Lower lobes?

A

3: apical, anterior, posterior
5: apical and 4 basal (anterior, posterior, medial, lateral)

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86
Q

How many segments in the middle lobe?

Which lung is this?

What about the other lung?

A

2: medial and lateral

The right has a middle lobe

The lingula on the left also has 2 segments (upper and lower)

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87
Q

Where do the lymphatics run in the lungs

Where do the lymphatic plexuses converge

Where do they drain to

A

Along the bronchi and under the pleurae

On lymph nodes at the lung hila

Drain to nodes at the carina which drain up to mediastinal nerves and then to right lymphatic duct or Thoracic duct

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88
Q

What do the hilar nodes look like in smokers

A

Blackened

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89
Q

Where are the tracheobronchial nodes

A

Around the carina

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90
Q

What is the carina

A

Where the trachea divides into the main bronchi

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91
Q

What is the parasympathetic innervation to the lungs

Sympathetic?

A

Via the vagus

From the thoracic sympathetic chain

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92
Q

What is parasympathetic action on the lungs

What about sympathetic

A

Bronchoconstriction to decrease dead space making quiet respiration more efficient

Bronchodilation to increase airflow

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93
Q

How do the phrenic nerves travel around the pericardium

A

Left: descends over left ventricle

Right descends alongside SVC, right atrium and IVC

They both pass anterior to hilum of each lung

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94
Q

What is the shape of the fibrous pericardium

A

Conical

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95
Q

What does the fibrous pericardium fuse with

A

Ascending aorta
Pulmonary trunk
SVC

Central tendon of diaphragm

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96
Q

What are the layers of the pericardium

A

Fibrous, parietal and visceral serous layers

The fibrous pericardium is lined by the parietal layer of serous pericardium
The visceral serous pericardium covers the heart and roots of the great vessels

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97
Q

What is the pericardial Cavity

What does it contain and why?

A

The potential space between the 2 layers of serous pericardium

Contains a thin film of fluid enabling the heart to move and beat in a frictionless environment

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98
Q

What is the transverse sinus

How is it used clinically

A

Lies within pericardial sac between arterial and venous ends of the heart

Used for passing slings through when clamping off major vessels in cardiac surgery

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99
Q

Where is the pericardial transverse sinus

A

Posterior to ascending aorta and pulmonary trunk

Anterior to SVC and pulmonary veins

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100
Q

What is the pericardial oblique sinus

What does it allow

How is it similar to lung hila

A

A recess in the pericardial cavity between pulmonary veins and behind left atrium

Distension of the left atrium

It is where the visceral layer reflects to become parietal

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101
Q

What can cause the lung to collapse

A

Pneumothorax

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102
Q

Where are foreign bodies likely to collect in the lungs of a supine patient

Why

A

Apical lower lobe segment in right lung

It is the first to arise posteriorly

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103
Q

A foreign body is most like to be impacted where in the lungs of a standing/ sitting patient

A

One of the basal bronchi

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104
Q

What is the most common cause of cancer related death in men worldwide

What rating is this in women

A

Bronchogenic carcinoma (primary lung cancer)

2nd most common in women

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105
Q

Where do most bronchogenic carcinomas arise

What symptoms can be seen

A

In mucosa of the large bronchi

Persistent productive cough
Haemoptysis (coughing up blood)

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106
Q

Where do lung tumours metastasise to

Does this happen early?

Where are common sites of haematogenous metastases

A

Bronchopulmonary lymph nodes and thus to thoracic nodes

Early

Brain
Bones
Lung
Liver
Adrenals
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107
Q

the lungs common sites of metastasis from which cancers

A 
Breast
Stomach
Colon
Testes 
Bladder
Kidney
Malignant melanoma
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108
Q

What is pericardiocentesis ?

A

Fluid aspiration from the pericardium

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109
Q

Can a pericardiocentesis be performed without puncturing the lungs?

How is it usually performed?

A

Yes
The needle can be inserted immediately left of the xiphisternum and directed upwards towards the tip of the left scapula

Under ultrasound guidance to minimise complications

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110
Q

When is ultrasound not possible for pericardiocentesis?

A

In life threatening situations eg cardiac tamponade

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111
Q

What is the base of the heart

A

The posterior surface where it is attached to the great vessels

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112
Q

Where is the right border of the heart

Left border?

A

Right 3rd to 6th costal cartilages

Left 2nd costal cartilage to 5 intercostal space

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113
Q

What are the auscultation points for the heart valves

A

Pulmonary valve: 2nd /3rd left intercostal space
Aortic valve: 2nd right intercostal space radiating up neck
Tricuspid: lower left sternal edge, (maybe also on right)
Mitral: apex, 5th intercostal space, midclavicular line

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114
Q

How to remember auscultation points for heart valves

A 
valves are in verticals line behind sternum:
P
A
M
T
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115
Q

How is the heart divided longitudinally

A

By a vertical septum in coronal plane

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116
Q

How are the atria divided from the ventricles

A

By the coronary (atrioventricular) groove lying in the sagittal plane

117
Q

How is the right heat border formed

What is most of the anterior surface of the heart

A

By the right atrium with the auricle pointing left

Right ventricle

118
Q

How are the left chambers of the heart arranged on the heart surface

A

Left atrium lies as the base of the heart posteriorly

Ventricle is on the diaphragmatic surface

119
Q

What are the portions of the chambers of the heart on its surface

A

2/3 of anterior surface is right ventricle and 1/3 is left ventricle

2/3 of diaphragmatic surface is left ventricle and 1/3 is right ventricle

120
Q

Describe the course of the right coronary artery

What are its 3 branches

A

Arises from right aortic sinus
Passes between pulmonary trunk and right auricle
Runs backwards and down in atrioventricular groove

Right marginal artery
Posterior interventricular artery
Nodal branches

121
Q

Describe the course of the left coronary artery

Give its 3 branches

A

Arises from left aortic sinus
Passes between pulmonary trunk and left auricle

Anterior interventricular
Circumflex
Nodal branches

122
Q

Which artery passes between the left ventricle and atrium

A

Circumflex

123
Q

What are the 5 cardiac veins

A 
Great cardiac vein
Middle cardiac
Small cardiac
Anterior cardiac 
Venae cordis minimae
124
Q

What do cardiac veins do

A

Return blood from the muscular wall of the heart to the coronary sinus which enters the lower right atrium, just below the IVC

125
Q

Which artery does the great cardiac vein follow

A

Circumflex

126
Q

Describe the venae cordis minimae

A

V small veins opening into all Heart chambers (especially RA) and these account for 20-30% of all drainage

127
Q

How do the vagi provide parasympathetic innervation to the heart

A

Via the superficial and deep cardiac plexuses

128
Q

Which thoracic and cervical ganglia provide sympathetic innervation to the heart

A

T1-5

All cervical

129
Q

Where are the 2 cardiac plexuses found

How do they enter the heart

A

Tracheal bifurcation and ligamentum arteriosum

With the coronary arteries

130
Q

Is all the right atrium smooth?

A

No
The smooth part is from the sinus venosus in embryo
The auricle is ridges by musculi pectinati
These are separated by the crista terminalis

131
Q

What is the external counterpart of the crista terminalis

A

Sulcus terminalis

132
Q

Where is the SAN

A

Upper end of the crista terminalis

Left of the SVC

133
Q

What is the AVN near

A

The tricuspid valve

134
Q

What prevents random propagation of conduction to the ventricles

A

A figure of eight fibrous skeleton which supports the atria on one side, the ventricles on the other and the valves in the middle

135
Q

What is the moderator band

What is another name

A

Branches from the right bundle from the bundle of His in the anterior wall of the right ventricle

Septomarginal trabecula

136
Q

What muscles control the tricuspid valve

What is the arrangement

What is the action

A

Papillary muscles connected to the chordae tendineae

Each muscle sends chordae to 2 cusps

Contraction draws the cusps together, preventing them entering the atria

137
Q

What is the right ventricular muscle ridged by

Is any smooth?

A

Trabaculae carnae

The inner surface is smooth towards its outflow at the infundibulum to create laminar flow into pulmonary trunk

138
Q

True or false

the left atrium is thin walled

A

True

139
Q

Are there trabeculae carnae

A

Yes

They are finer and more numerous than on the right

140
Q

How are the ventricles arranged in a cross section

A

Left is circular woth right wrapped around as a crescent

141
Q

How much thicker is the LV wall than the RV wall

A

3x

142
Q

How is de oxygenated blood returned to the placenta from the embryo

How is oxygenated blood returned to the foetus

A

Via 2 umbilical arteries from the superior vesical or internal iliac arteries

Via left umbilical vein which joins the left branch of the portal vein

143
Q

Where does the left umbilical vein join the portal vein

What happens to the blood from here

A

In the region of porta hepatis

Some goes into liver but most takes bypass to IVC and right atrium

144
Q

Where does the newly oxygenated blood from the mother than has just entered the right atrium go?

A

Passes through foramen ovale to left atrium and then to coronary arteries, head, and upper limbs

This blood returns via the SVC into right ventricle and onto the pulmonary trunk. It then flows into aortic arch via the ductus arteriosus

145
Q

What does clamping the umbilical cord do

A

Close off left umbilical vein

146
Q

What causes closure of the ductus arteriosus

A

Decreasing prostaglandin levels from mother and release of bradykinin from lungs

147
Q

What can palpitation of the apex heart beat assist in

A

Diagnosis of cardiomegaly

148
Q

Where do areas for heart auscultation tend to be

Why

A

Superficial to the chamber/ vessel into which the blood has passed and in line with valve orifice

Blood carries sound In the direction of flow

149
Q

What can stenosis/ occlusion of coronary artery result from

A

Atherosclerosis due to lipid deposition in the intima

150
Q

Are there anastomoses between coronary arteries

A

Yes but not v effective ones

151
Q

How can you treat coronary artery disease

A

Angioplasty (radiologically controlled balloon dilation) or coronary bypass

152
Q

What vessels are used in coronary bypass

A

Great saphenous vein
Internal thoracic artery
Radial artery

153
Q

What can cause damage to the conduction system in the heart

A

Ischaemia

Eg by occlusion of nodal branches

154
Q

Does cyanosis occur in left to right shunting due to different pressures

A

No

155
Q

Does a persistent ductus arteriosus cause cyanosis

What can happen

How is it treated

A

Not initially

It only caused blood to pump round the heart repeatedly but right side is strained so increases right pressure might reverse shunting leading to cyanosis

Ligation if prostaglandin synthetase inhibitors are ineffective

156
Q

What is indomethacin?

A

A prostaglandin synthase inhibitor

157
Q

What % of times is the posterior interventricular artery supplies by the right coronary? What are these people called?

What about to the SAN and AVN

A

90%. Right cardiac dominant
And 10% from left coronary artery

SAN: 60% from right coronary artery
AVN: 90% from right coronary artery

158
Q

Where does the descending thoracic aorta lie

Which branches does it give

A

On the vertebral column between T4 and T12

giving posterior intercostal, bronchial and oesophageal branches

159
Q

How does the oesophagus relate to the thoracic aorta

A

The oesophagus crosses anterior to the aorta

160
Q

When does the oesophagus cross the crus of the diaphragm

A

T10

161
Q

What happens to the venous drainage from the lower third of the oesophageal

A

Forms a portosystematic anastomoses

162
Q

What forms the oesophageal plexus

How does it pass through the diaphragm

A

Formed by 2 vagi

The plexus reforms into posterior and anterior Vagal trunks to pass through the diaphragm

163
Q

What is the course of the azygous vein

A

Starts at abdomen (L1/2) as a union of right sub costal vein and ascending lumbar veins

Ascends to the right of the aorta through aortic opening in diaphragm

Arches over the right lung hilum to drain into SVC

164
Q

How does the thoracic duct commence

Where does it enter the thorax

When does it cross to the left

A

As the cisterna chyli in the abdomen

To the right of the aorta

T4/5

165
Q

Which sympathetic nerves innervate abdominal viscera

Where do they come from

A

Greater, lesser, and least splanchnic nerves

The thoracic sympathetic chain

166
Q

Describe the structure of the diaphragm

A

Muscular peripheral portion and a central tendon which is fused with the fibrous pericardium

167
Q

Where does the intercostal neurovascular bundle lie

A

In the costal groove of the rib at the inferior border

168
Q

When does the aorta cross the diaphragm

A

T12

169
Q

Where does the oesophagus begin

A

C6

Just below the cricoid cartilage

170
Q

True or false
The oesophagus crosses the diaphragm at the mid line

Which structures accompany it

A

False
It is to the left of the midline

The posterior and anterior Vagal trunks

171
Q

What are the diaphragmatic crura

Give an example of their action

A

Tendons that extend below the diaphragm to the vertebral Column

The right crus forms a sling around the oesophagus, providing sphincter action

172
Q

What is the epithelium of the oesophagus

A

Stratified squamous

173
Q

What is “wear and tear” epithelium

A

Stratified squamous epithelium

174
Q

Which arteries is the upper oesophagus supplied by

Middle?

Lower?

A

Inferior thyroid artery

Directly by aortic branches

Branch of the left gastric artery

175
Q

How does upper oesophageal venous drainage enter the main circulation

What about lower 1/3?

A

Via the azygous

Via left gastric vein to hepatic portal vein forming a site of portosystemic anastomoses in the submucosal layer

176
Q

What innervates upper 1/3 of oesophagus

Lower 2/3?

A

Recurrent laryngeal and sympathetic nerves from middle cervical ganglia

Vagi and sympathetic nerves in oesophageal plexus

177
Q

How many hemiazygous veins are there

A

2 on the left

178
Q

Where do posterior intercostal veins drain into on the left

A

Into hemiazygous veins and then into azygous

179
Q

What does the superior intercostal vein drain

How do they empty on the left and right

A

2nd and 3rd intercostal spaces

Right: into azygous

Left: drains anteriorly across the ascending aorta in between the vagus and phrenic nerves into left brachiocephalic vein

180
Q

What drains the first intercostal space

What do these drain into on each side

A

Supreme intercostal vein

The respective brachiocephalic vein

181
Q

Describe the course of the thoracic duct

A

Commences as a continuation oh cisterna chyli
Passes up on right, behind median arcuate ligament, ascending on the vertebral column behind the oesophagus, between aorta and azygous vein

At T4/5 it crosses behind oesophagus to the left
It arches forward at the level of the apex of the lung and over the subclavian artery to enter the junction of the left subclavian and internal jugular veins

182
Q

Describe a key valve in the thoracic duct

A

A bicuspid valve is present at its termination To avoid blood reflux

183
Q

Why may the proximal thoracic duct look like a vein after death

A

Backflow of blood into the duct

184
Q

Sympathetic outflow comes from where

Preganglionic neurons emerge from which root

How do sympathetic fibres leave the spinal cord ? How do they leave the spinal cord?

A

T1-L2

Ventral

As white rami communicantes
As grey rami communicantes

185
Q

Where do the greater, lesser and least splanchnic nerves emerge from

Are they preganglionic

A

T5-T12

Yes

186
Q

Which 3 ribs are atypical

A

1
11
12

187
Q

Describe the 1st rib

A

Relatively immobile

Its shaft is flat and its head articulates with its own vertebral body only

188
Q

Describe the 11th and 12th ribs

A

Articulate with their own vertebral bodies only

They are tethered to their own transverse processes by fibrous tissue without forming synovial joints

189
Q

Describe the cartilage associated with the true ribs

A

True ribs= 1-7

Each ribs forms a primary cartilaginous joint with its own hyaline costal cartilage

The first costal cartilage forms a primary cartilaginous joint with the manubrium but all other other form synovial joints with the sternum b

190
Q

What is found on the joint surfaces of the ribs instead of hyaline cartilage

A

Fibrocartilage

191
Q

What is the costal margin

A

The costal cartilages of ribs 8-10 join the cartilage of the ribs above

192
Q

Discuss the intercostal neurovascular bundle

A

Found in the costal groove
The nerve is the appropriate spinal nerve
The artery is formed from the posterior intercostal artery which anastomoses with an anterior intercostal branch of the internal thoracic artery
The vein drains posteriorly to the azygous or hemiazygous veins or anteriorly to the internal thoracic veins

193
Q

Describe the external intercostal muscle

A

Anteriorly it is a membranous sheet between costal cartilages

It becomes muscular between the ribs and fibres run downwards from one rib anteriorly to the upper edge of the rib below

194
Q

Describe the internal intercostal muscle

A

Lies between costal cartilages and the shafts of the ribs

Fibres run downwards and backwards at right angles to the external intercostal

Replaced posteriorly by the posterior intercostal muscle

195
Q

What is the 3rd layer of intercostal muscles

How are they divided

A

The innermost intercostals

Anteriorly: transversus thoracis arises in slips from the sternum, running up and lateral, often spanning >2 ribs

Posteriorly: subcostalis runs across several ribs

196
Q

What is the pump handle movement

What is the effect

A

Elevating the upper ribs that slope down to push the sternum up and forward for inspiration

This increases the anteroposterior diameter of the thorax with minimal lateral expansion

197
Q

Which ribs expand laterally when inspiring

What do ribs 5-9 do

A

Lower ribs that don’t attach to the sternum

A mixture of lateral expansion and the pump handle movement

198
Q

How does rib 1 move during inspiration

A

It doesn’t: it acts as a fixed platform during respiration

199
Q

What does the diaphragm do during inspiration

What is the effect

A

Contracts and its domes flatten

Increases vertical dimensions of the thorax

200
Q

What does the abdominal wall do during inspiration

A

Relaxes to allow downward pressure on the abdominal contents

201
Q

What happens to the diaphragm if there is an increase in respiratory rate and force

What limits this

A

The diaphragm itself and not just its dimes are drawn inferiorly

Its connection to the pericardium

202
Q

What does the central tendon of the diaphragm do in deep inspiration

What is the effect

What is this called

A

Acts as a fixed point to allow it to pull on the 7th to 10th ribs

Causes these ribs to evert and increase transverse diameter

The bucket hand movement

203
Q

What does quiet expiration rely on

A

Elastic recoil and passive muscular relaxation as well as accessory muscles of respiration which aid both forces inspiration and expiration eg during stress after trauma

204
Q

What are the accessory muscles of respiration that aid forced inspiration

A

Muscles with elevate thorax

Sternocleidomastoid
Pec Major and minor
Scalenes

205
Q

What are the accessory muscles of respiration that aid forced expiration

A

Muscles that compress the thorax

Latissimus dorsi
And anterior abdominal wall muscles which force the diaphragm upwards

206
Q

What are the roles of the intercostals

A

External intercostals raise ribs during inspiration

Internal and innermost and under discussion

207
Q

Why are the sites of “natural” constructions in the oesophagus dangerous

A

They are potential areas for a carcinoma to develop or for inflammation due to ingestion of corrosive substances

208
Q

How can portal hypertension affect the oesophagus

A

Can lead to dilation of the lower oesophageal submucosal veins to give oesophageal varices

209
Q

Why are oesophageal varices dangerous

How can it be treated

A

They can rupture and cause severe haemorrhaging which is life threatening and difficult to control surgically

Endoscopic band ligation is the treatment of choice to stop bleeding during acute episodes and to prevent recurrent bleeding

210
Q

What is a chylothorax

A

The presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct

211
Q

What can cause a chylothorax

A

Malignancy eg lymphoma
Or
Traumatic eg penetrating trauma or after thoracic surgery in oesophagectomy

212
Q

Where is foregut pain referred to

Why

A

Epigastric region

General visceral afferents run with the greater splanchnic nerve from T5-9

213
Q

Where is midgut pain referred to

Why

A

Umbilical region

Lesser splanchnic comes from T10-11

214
Q

Where is hind gut pain referred to

Why

A

Suprapubic region

Via least splanchnic nerve from T12

215
Q

Where should the trochar be placed when a chest drain is inserted

Why

A

Immediately above the rib (ie low in the intercostal space)

to avoid injury to the neurovascular bundle

216
Q

Where would you inject an intercostal nerve bloc

Why

A

Local anaesthetic is directed towards the costal groove in the upper part of the intercostal space

To produce effective anaesthesia of the intercostal nerve eg in a rib fracture

217
Q

What can phrenic nerve damage lead to

What happens if the damage is bilateral

A

Diaphragmatic paralysis

Rapid ventilatory failure

218
Q

What congenital abnormality can occur in the trachea and oesophagus

A

A tracheo-oesophageal fistula

Also blind ending oesophagus or atresia

219
Q

How are most of the ribs curved

A

Latterly with the longest in the middle region

220
Q

The ribs have a protective function however what else do they need to be capable of

A

Movement to facilitate respiration

221
Q

How are the upper 6/7 ribs attached

A

Attached to the sternum via costal cartilages

222
Q

How are ribs 6/7 - 10 ribs attached

A

To the rib above via costal cartilages

223
Q

Are rib fractures common in children

A

No

They are rare due to the elasticity of the ribs

224
Q

Crush injuries lead to fractures at what point in the rip

Are the fractures anterior or posterior

A

The angle as it is the weakest point

Both anterior and posterior leading to a Flail chest when a segment of the thoracic cage is sucked in during inspiration

225
Q

How do the external intercostals run

What about internal intercostals

A

Downwards and forwards

Downwards and backwards

226
Q

Describe the innermost intercostal space

A

It is incomplete and is separated from the internal intercostals by the neurovascular bundle

227
Q

Describe the arrangement of the intercostal veins, arteries and nerves

A

The veins are superior, the arteries lie below the veins, nerves like most inferiorly

228
Q

What do the intercostal veins drain into

A

Into the internal thoracic and azygous veins

229
Q

Where do the intercostal arteries arise from

A

Posteriorly from the subclavian artery or descending thoracic aorta

anteriorly from the internal thoracic artery anastomosing in the space

230
Q

What is thoracocentsis?

A

The removal of fluid from the plural cavity by insertion of a needle through the intercostal space

231
Q

During thoracocentsis Where is it best to insert the needle

A

In the middle part of the intercostal space to avoid damage to the main vessels or nerve

232
Q

Give the other name for shingles

A

Herpes zoster

233
Q

Which nerves are commonly affected by shingles

What does this cause

A

The intercostal nerves

A vesicular eruption and severe pain

234
Q

What is the pleura

A

A serous membrane that secretes fluid

235
Q

What is the highest part of the parietal pleura

A

The cervical pleura or cupola

This extends into the root of the neck to about 2.5 cm above the middle of the medial part of the clavicle

236
Q

Where do the coastal and Diaphragmatic parietal pleurae join

A

To form the costodiaphragmatic recess

237
Q

When is the costodiaphragmatic recess filled?

A

Only during full inspiration of the lungs

238
Q

Other than a stab and when me a pneumothorax occur

A

From a ruptured lung bulla e.g. in emphysema

239
Q

How can a haemothorax or plural effusion be seen

A

When a fluid level is seen in the plural cavity on a chest radiograph in the upright position

240
Q

When does the trachea divides into the two main bronchi

A

At the level of the sternal angle (vertebral level T4/5)

241
Q

What does the right main bronchus give off before entering the lung

A

The upper lobar bronchus

242
Q

How does the right main bronchus compare to the left

A

It is wider and shorter and more vertical

243
Q

How does the left main bunkers relate to the oesophagus

A

Crosses anterior to the oesophagus

244
Q

There is a greater tendency for foreign bodies to enter into which lung?

Which lobe does it usually pass into

A

The right because the right main bronchus is wider and more vertical than the left

The middle or lower

245
Q

How can the inside of the trachea be visualised

What else can be visualised by this technique

A

Bronchoscopy

Main, lobar and segmental bronchi

246
Q

What do you call the bifurcation of the trachea

A

The carina

247
Q

Why might the carina be distorted?

A

By enlarged lymph nodes in a bronchial carcinoma

248
Q

What are the smallest independent units of lung tissue

What is each supplied by

A

Bronchopulmonary segments

A segmental bronchus, artery and vein

249
Q

How is each bronchopulmonary segment shaped

A

In a cone shape with the base on the lung surface and its apex pointing towards the Hilum

250
Q

How do the segmental bronchus and artery distribute and each bronchopulmonary segment

What about the veins

A

They divide and radiate out from the centre

They drain peripherally i.e. between the bronchopulmonary segment through intersegmental veins

251
Q

What is the smallest unit of lung tissue that can be removed without collapse of surrounding tissue in a lung resection

A

A bronchopulmonary segment

252
Q

Well larger thrombi may block the main and lobar arteries what can smaller thrombi do in the lungs

A

Block a segmental artery which will result in necrosis/infarction of the relevant bronchopulmonary segment

253
Q

How can an infection of the lungs such as pneumonia or tuberculosis be restricted

A

It may be restricted to a bronchopulmonary segment

254
Q

What are the three functions of the fibroserous sack known as the pericardium

Describe each

A

Protective - Reducing friction and restricting the spread of infection from surrounding tissues

supportive - By being anchored to the central tendon of the diaphragm, it restricts swinging of the heart

restrictive - Prevents over distension of the heart diastole

255
Q

What are the two compartments of the pericardium

A

Fibrous - A tough external layer of the sac bound to central tendon of the diaphragm

Serous - Lines the internal aspect of the fibrous pericardium (parietal) and the outer surface of the heart (visceral)

256
Q

Inflammation of the pericardium can lead to what

A

And increase in fluid that can prevent the heart from distending in diastole

If excessive fluid is present e.g. due to the leakage of blood it can be lethal due to the inelasticity of the fibrous pericardium

This is cardiac tamponade

257
Q

Perfusion from the right and left coronary arteries takes place when

Why is this unique?

A

During diastole

All other arteries of the body are perfused during systole

258
Q

Is there some anastomosis of the right and left coronary arteries

A

There is some but they are essentially functional end arteries

259
Q

What is a functional end artery

A

It means a blockage in one cannot be compensated by others including their branches

260
Q

What is restrictive pericarditis

A

When the fibrous pericardium thickens so that it severely affects the filling of the heart.

261
Q

Which coronary artery is the larger of the two

A

Left

262
Q

Describe the course of the right coronary artery (3)

What does it give off

A

1) Passes between the right auriclarappendage and the pulmonary trunk
2) Descends almost vertically in the atrioventricular groove
3) curves posteriorly where are limited and anastomosis occurs between it and the circumflex branch of the left coronary artery

it gives off right marginal artery and posterior interventricular artery

263
Q

And what percentage of cases does the right coronary artery supply the SA node and the AV node

A

SAN: 60%

AVN: 90%

264
Q

Describe the course of the left coronary artery (3)

A

Initially lies between the pulmonary trunk and the left auricle

Enters the atrioventricular group and divides into the interior interventricular artery and the circumflex artery

The anterior interventricular artery gives off 2–9 left anterior ventricular rami over the left ventricle

265
Q

In which percentage of cases does the left coronary artery supply the AVN and SAN

A

SAN: 40%

AVN: 10%

266
Q

What is right cardiac dominance

A

Where the posterior interventricular artery comes from the right coronary artery

267
Q

What is left cardiac dominance

A

Where the posterior interventricular artery comes from the left coronary artery

268
Q

What does it mean if a patient has a cardiac balanced pattern

What is another name

A

Branches of both left and right coronary artery supply the posterior part of the interventricular septum

Co-dominance

269
Q

How do the large extramural coronary arteries give branches

How deep do the penetrate the myocardium

A

At right angled

Almost the full thickness of the myocardium with some anastomosis at the arteriolar level

270
Q

How does the innermost part of the myocardium received its blood

A

From small vessels coming off the chambers directly

271
Q

What is angina pectoris

A

When there is gradual blockage of the coronary arteries due to atheroma, Exertion may induce pain due to ischaemia of the cardiac muscle which is felt substernally but may also be referred to the left arm and neck

272
Q

How is pain carried in angina pectoris

A

The visceral afferents are carriedback to the T1–4 segments of the spinal-cord by a sympathetic nerves mainly on the left side

273
Q

Why can a blockage of the coronary arteries cause arrhythmia

How can this be fixed

A

It may affect the conducting tissue

The blocked artery may be bypassed by a graft or a stent inserted after dilating the artery (angioplasty)

274
Q

How are the AV cusps of the heart attached

A

They are attached to the fibre skeleton of the heart and the free edges have chordae tendinae which are attached to the papillary muscles arising of myocardium within the ventricles

275
Q

How many cusps does each papillary muscle attached to?

A

2

276
Q

How do the papillary muscles contract

A

Isometrically

277
Q

Describe the tricuspid valve

A

On the right between atrium and ventricle

Has three cusps, the largest of which is the anterior one

The anterior papillary muscle is the largest and has a bundle of conducting tissue fibres going to it from the Inter ventricular wall - this is the moderator band or septomarginal trabecula

278
Q

Describe the mitral valve

A

Between the left atrium and left ventricle

Has it to cusps, the larger of which is the anterior one

The anterior cusp is smooth on both surfaces of the inflow of blood from the left atrium and outflow through the aortic vestibule

279
Q

Which atrioventricular valve is more commonly affected by stenosis

What does this lead to

A

The mitral valve, following a bacterial infection e.g. rheumatic fever

Reduced blood flow from the left atrium causes Pulmonary hypertension

280
Q

Which atrioventricular valve is most commonly affected by incompetence

What often comes with it

What happens

A

Left mitral

It is often accompanied by coronary artery disease

Chordae tendinae rupture following regurgitation of blood into the left atrium during ventricular systole

281
Q

How many intercostal spaces are there

A

11

282
Q

What does tension pneumothorax lead to

A

Rapid buildup of pressure due to being sucked in

Collapse of the long

Shift of the mediastinum to the opposite side

Needs emergency chest drain

283
Q

Does a pneumothorax lead to difficulty in lung expansion

A

Yes

284
Q

What is important to remember about the chest drain for pneumothorax

A

The water trap needs to be lower than the patient to prevent regurgitation of the water into the plural cavity

285
Q

What can plural effusion be related to

A

Lung carcinoma

286
Q

What does the fibrous pericardium do

Serous pericardium?

A

Prevent overfilling of ventricles

Secrete small amount of fluid for lubrication

287
Q

What is the origin of the left and right coronary arteries

A

Just above that the sinus of the respective cusp of the aortic valve

288
Q

What is pectoralis quartus

A

A variant of pec major with an additional head

FAB (10 decks)

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