Thorax/breast ppt Flashcards
superior thoracic aperture
-inlet refers to region just above first rib and opening between clavicle and first rib
-posteriorly, by vertebra T1, body of which protrudes anteriorly into the opening
-laterally, by the 1st pair of ribs and their costal cartilages
-anteriorly, by the superior border of manubrium/sternum
inferior thoracic aperture
-outlet occurs through right and left subclavian arteries and veins pass through superior thoracic aperture
-posteriorly, by the 12th thoracic vertebra, body of which protrudes anteriorly into the opening
-posterolaterally, by the 11th and 12th pairs of ribs
-anterolaterally by the joined costal cartilages of ribs 7-10, forming the costal margins
-anteriorly, by xiphisternal joint
subclavian artery/brachial plexus
-Subclavian artery/Brachial Plexus can be compressed by anterior or middle scalene muscles
-can also be compressed by apex of lung
thoracic outlet syndrome
-misnomer
-occurs at the area of thoracic inlet NOT OUTLET
ribs
-true- vertebrocostal ribs (ribs 1-7)
-false- vertebrochondral ribs (ribs 8-10, joint cartilage of ribs 6 & 7)
-floating- vertebrofree ribs (ribs 11-12)
-typical ribs have common features (3-9 while atypical ribs differ from one another (1, 2, 10, 11, 12)
-ribs vary, inferior border of upper rib varies!
-costal margins- 7-10
veins of thoracic wall
-right superior intercostal vein is the final tributary of the azygos vein, before it enters SVC
-left superior intercostal vein usually empties into left brachiocephalic vein
-passes across the arch of aorta or the root of the great vessel arising from it, between the vagus and phrenic nerves
-receives the left bronchial veins and may receive the left pericardiacophrenic vein as well
-communicates inferiorly with accessory hemi-azygos vein
-internal thoracic veins are the companion veins of the internal thoracic arteries
-paravertebral veins on the posterior
right lung
-right oblique and horizontal fissues
-right lobes- superior, middle, inferior
-larger and heavier than left, but shorter and wider
left lung
-oblique fissure dividing it into 2 left lobes
-superior and inferior lobe
-cardiac notch primarily indents the antero-inferior aspect of superior lobe
-indentation often shapes the most inferior and anterior part of the superior lobe into a thin, tongue like process -> the lingula
-lingula can develop into a pneumonia
lung surfaces
-costal
-mediastinal
-diaphragmatic
-anterior, posterior, inferior borders
-roots of the lung*
lung roots
-in the right lung, pulmonary artery anterior to the bronchus -> instead in left lung the pulmonary artery is superior to bronchus
-RALS- in the right lung, the pulmonary artery is Anterior to the bronchus, while in the Left lung, the pulmonary artery is Superior to the bronchus
breast tissue
-modified sweat gland
-axillary process of the breast- Spence’s tail
-most breast cancer is found in upper outer quadrant -> superolateral -> importance of axillary process of breast
-pathologies:
-skin dimpling (spiculated lesions)
-peau d’orange- orange tinted skin and edema
-abnormal contours
-retracted nipple
-could be hypercystic fibroabnormas malignancy
-disseminated -> inflammatory -> lymphatic spread of tumor
breast borders
-superior- clavicle
-lateral- latissimus dorsi
-medial- lateral border of sternum
-inferior- rectus abdominus
-important to know for mastectomy
-too lateral of a incision -> impaired innervation to serratus anterior muscle-> long thoracic nerve damaged -> winged scapula
manubriosternal joint
-angle of louis, sternal angle
-landmark for auscultation of heart
-right side 2nd intercostal space is where you hear the aortic valve -> listen to murmurs here
-T4-T5 angle
-articulation of 2nd rib
-azygous vein
-ligamentum arteriosum
-left recurrent laryngeal nerve
-bifurcation of pulmonary trunk
-bifurcation of trachea
osseocartilaginous cage
-sternum
-manubrium
-xyphoid process
-costal cartilages
-ribs
-vertebrae
-intervertebral discs
-these all function to protect structures with cavity (lung, mediastinum, heart)
-lower rib cage also protects abdominal cavity -> spleen and liver
-floating ribs protect the kidneys posteriorly
ground level mechanical fall
-in an older pt
-can fracture multiples
-osteopenia/porosis
-transmit forces to underlying structure
-ex. pulmonary contusion of lung, pneumothorax, hemothorax, splenic laceration
-osseocartilaginous cage functions to protect but when injured can injury underlying structures as well
inlet and outlet
-superior thoracic aperture/inlet- neck and upper limb exit/entrance
-inferior thoracic aperture/outlet- covered by diaphragm muscle -> Separate thorax from abdomen
superior thoracic aperture
-inlet
-p
xiphoid process
-right above left lobe of liver
-avoid liver laceration with improper technique cpr
main diaphragm apertures
-T8- inferior vena cava penetrates into thoracic cavity
-T10- esophagus penetrates to stomach
-T12- abdominal aorta penetrates (formed by cruras)
-I 8 10 EGGS AT 12
lesser diaphragmatic apertures
-2 in right crus of diaphragm- transmit greater and lesser right splanchnic nerves
-3 in the left crus of diaphragm- transmit greater and lesser left splanchnic nerves as well as hemiazygos vein
-under the medial arcuate ligament- usually transmit sympathetic trunks
-under lateral arcuate ligament- subcostal nerve and vessels
-left phrenic nerve pierces dome of the left hemidiaphragm
-internal mammary artery thorough sternal costal gaps
ribs
-water pump
-increase/decrease anterior posterior diameter of lungs according to diaphragm
-percuss it posteriorly to measure -> diaphragmatic migration
-phrenic nerve pace maker for diaphragm paralysis
-C 3, 4, 5 keep the diaphragm alive
inserting needle into intercostal space
-neurovascular bundle is under the inferior border of the upper rib
-put needle through the upper border of the lower rib to prevent puncture of neurovascular bundle
numbing of spinal nerves
-numb posterior region around spine when pt has significant nerve pain
-prevents pneumonia, atelectasis (subsegmental collapse of lung due to mucus plugging -> parts of lung that get perfusion but no ventilation)
-catheter two fingers away from midline that infuses fluid with LONG acting anesthetic ancupump (grenade)
cardiac contusion
-if sternum is hit it affects underlying structure -> heart
-behave like an MI but no structural damage to heart
-can cause arrythmias
-can cause rupture of the heart when sternum is hit very hard -> fatal
forced inspiration and expiration
-inspiration- external intercostal muscles
-expiration- internal intercostal muscle and rectus abdominus sheath
-normal expiration is governed by elastic recoil pulmonary
VQ
-interface between alveoli and capillary
-VQ ventilation perfusion
-areas of lung that are ventilating need to be perfused -> gas exchange
-dead space- area of lung ventilating but not perfused -> no gas exchange
-shunting- area of perfusion but no ventilating -> blood is passing by with no gas exchange
-gas exchange does NOT occur until respiratory bronchial level
vessels traveling up and down
-muscles and vessels traveling up and down
-innermost aspect of chest wall (inner)
-intercostal vessels and longitudinal vessels extend up and down
-internal thoracic vein and artery extending up and down
-do not want to hit when doing procedures
-internal thoracic artery (internal mammary artery)- used for bypass conoid
deltopectoral triangle
-reliably to locate cephalic vein -> catheters
-placement for wires for pacemakers or defibrillator
-clavicle, deltoid, pectoral sheath
inferior vena cava
-comes up through the diaphragm at T8 and into thoracic cavity
lung infarct
-rarely ever happens!
-there are two blood supplies to the lung
-bronchial and pulmonary blood
suspensory ligaments
-hold architecture of breasts
-retraction -> cancer
-masses shorten the suspensory ligaments -> dimple
-ligaments attach to posterior capsule of breast
-retraction of nipple is normal if its been there your whole life
thoracic imaging
-midline trachea -determine there is pt rotation
-look at clavicular heads to see if distance is equal
-carina- bifurcation of main stem
-right side main stem is much more oblique
-left side is more horizontal
-aspiration -> into right lung rather than left
-right and left hilum- pulmonary artery
-clavicle/1st rib- subclavian artery
D’s method
-locating the carina
-circle around the aortic knob
-line straight down and line 45 angle
costocardiac angle
-diaphragm comes into contact with the heart
-triangular projection- landmark of inferior vena cava comes up and joins inferior portions of right atrium
-may find benign cysts here
costophrenic angle
-sharp
-means there is no fluid
-it is blunt -> fluid accumulation -> pleural effusion -> blood, fluid?
-left hemidiaphragm is lower
-heart pushing down the left hemidiaphragm
-phrenic nerves come down out of the heart and innervates the diaphragm and phrenic arteries
kehrs sign
-pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated
-classic symptom of a ruptured spleen
-this is bc diaphragm is innervated by superior nerves
lobe pneumonia
-heart loses silhouette due to obscured by left UPPER lobe pneumonia involving the lingula lobe
-left low lobe pneumonia -> density in back of heart -> Still can see cardiac border
-lower lobe lesion is located retrocardiac
tension pneumothorax
-tear in parenchyma -> pleura leaks
-air collects -> pneumothorax
-pressure increases so high -> shifts to contralateral side -> displaces mediastinum -> kink off vena cava -> decrease return -> no blood to heart -> tension pneumothorax
-heart shifts to unaffected side
-no breath sounds on that side
-clinical diagnosis
-bleb pops can cause
pneumothorax + pleural effusion
-would show has a flat line of fluid collection on imaging
-meniscus line suggests just pleural effusion
dermatomes
-t4- nipple line
-t6
-t10- abdomen- umbilical
-right lower lobe pneumonia -> mimics appendicitis due to t10 dermatome
-colon on the left side diverticulitis
pneumothorax vs atelectasis
-pneumothorax pushes away
-atelectasis- pushes towards
costophrenic recess
-most dependent part of lung sitting up
-fluid pools here
atelectasis
-perfusion no ventilation
-segmental collapse
-more common on right side
-not taking deep breathes
-alveoli fill with junk
pancoast tumor
- cancers that start in the top part of the lung (the apex)
Paradoxical Embolism (PDE)
-occurs when a thrombus crosses an intracardiac defect into the systemic circulation.
superior mediastinum
thyroid tissue
-thoyroidglossal
-thyomas
-teratomas
-lymphomas
anterior mediastinum
-cardiac tumors
-marantic lesions
-metastatic tumors
-neuroblastomas
winged scapula
-long thoracic nerve
