Thorax Clinical Supplement Flashcards
What is pectus excavatum
depression of the sternum, associated with exercise intolerance, dyspnea, chest pain
What is pectus carinatum
pigeon chest, anterior protrusion of the sternum
dyspnea, frequent respiratory tract infections, scoliosis
What is sternal angle (angle of Louis)
union of the manubrium and body of the sternum, associated with sternal end of the 2nd rib
projects posteriorly to TV4
What structures are approximated at the sternal angle
superior border of the middle mediastinum, arch of aorta, bifurcation of trachea
What kind of tissue can the sternum be used for
red bone marrow sample
What happens if the sternum is biopsied
result in sternal fracture
pneumomediastinum
pneumothorax
cardiac tamponade
What are three types of causes of thoracic outlet syndrome
bony issues: cervical rib or hypo plastic first rib
soft tissue changes: hypertrophic/spastic muscles
others: trauma and tumors
What are signs and symptoms of thoracic outlet syndrome
compression of C8-T1 roots of brachial plexus: upper limb sensation and motor
vascular compression of subclavian: cold fingers, color changes in hands, claudication, pain
What are 5 consequences of rib fractures
flail chest pneumo or hemothorax spleen injury or liver injury lacerations of the aorta/great vessels diaphragmatic hernia if diaphragm is pierced
fracture of which ribs may rupture spleen
9-12
Which ribs if fractured may rupture aorta
ribs 1+2
What is the dermatome of the male nipple
T4
What is the dermatome of the xiphoid process
T6
How does herpes zoster present
rash that follow dermatomal patterns
At which levels do we tend to find 66% of all herpes zoster eruptions
T5-T10
What is intercostal nerve block
injection of anesthesia into the intercostal space
Between which layers should the anesthesia for an intercostal nerve block be placed
internal intercostals
innermost intercostals
Which nerves are most at risk of iatrogenic injury in an intercostal nerve block and why
intercostal nerve and collateral branch
neurovascular bundle protects vein and artery while leaving nerve most exposed
In which direction does lymphatic drainage of organs in the body cavities generally follow
which three are exceptions
backwards to lymph nodes around main arterial branches
lungs, parts of liver, oral cavity and tongue
Three mechanisms of cancer cell metastasis
local spread and invasion (seeding of pleura and peritoneum) lymphatic channels blood vessels (vein, arteries, then capillary beds)
Lymph drainage of breast
majority to axillary
medial to parasternal
inferior to inferior phrenic (route to liver metastasis)
Where do 60% of malignant breast tumors arise from
superior lateral quadrant
How can breast cancer metastasize to liver
inferior phrenic nodes
Signs and symptoms of breast cancer
peau de orange-edema breast mass axillary lump skin dimpling impaired lymphatic drainage nipple inversion metastasis
Where does lymph from the skin of the breast drain to
axillary, parasternal
inferior deep cervical
infraclavicular
Metastasis from the breast via what venous channels
azygos
intercostals
What does the pleural space do
maintain a vacuum for breathing, if disrupted cannot function properly
What is pleural effusion
accumulation of fluid in pleural cavity
What is pneumothorax
accumulation of air in the pleural cavity
What is spontaneous pneumothorax
rupture of visceral pleura, air from lung enters pleural cavity
What are predisposes to spontaneous pneumothorax
Marfan or EDS, tall thin stature, young, smoker
What is the signs and symptoms of spontaneous pneumothorax
acute onset, chest and shoulder pain that is worse with inspire, SOB, decreased breath sounds
What is tension pneumothorax
rupture of visceral pleura, lung tissue forms a 1 way valve so with each breath, more air is drawn into pleural cavity
What are signs and symptoms of tension pneumothorax
sudden onset of chest pain, dyspnea, reduced breath sounds, hypotension, hypoxia, JV distention, tachycardia
What is treatment for tension pneumothorax
immediate decompression via thoracotomy at 2nd intercostal space, midclavicular, then chest tube
What is hydropneumothorax
air and fluid in the pleural space
What is hemopneumothorax
blood and air in the pleural space
What is chylothorax
lymphatic fluid in pleural space
What is pyopneumothorax
pus and air in pleural space
What is empyema
pus in pleural cavity from an infection or abscess
What is pleurisy
inflammation of pleura
What are the levels of lung fissures: oblique
scapular, midaxillary, midclavicular
Scapular: 4th rib
Midaxillary: 5th rib
Midcalvicular 6th rib
What are the levels of lung fissure: horizontal
4th rib
Where should the stethoscope be placed to hear the superior lobes
anterior chest wall
R: above 3rd rib
L: above 5th rib
Where should the stethoscope be placed to hear the middle lobe
Anterior chest wall
below 4th rib
Where should stethoscope be placed to hear the inferior lobes
posterior wall
below 5th rib
What is thoracocentesis
used to sample pleura fluid or for removing pleural effusions or empyemas
done at 8th or 9th intercostal space midaxillary line
what are chest tubes placed for
drain large amounts of air or fluid from the pleural space
Where are chest tubes inserted
4th or 5th intercostal space midaxillary line
What is the innervation of parietal pleura
GSA
Intercostal nerves (costal and peripheral diaphragmatic)
Phrenic nerve (mediastinal and central diaphragmatic)
What is the innervation of visceral pleura
GVA–no pain innervation
Venous drainage of the lungs: 4 common sites of metastasis
CNS, cerebellum, brainstem
Bone
Liver
Adrenal Gland
What is the significance of an enlarged inferior tracheobronchial/carinal node seen in bronchoscopy
can displace carina
Where can aspirated foreign objects most likely end up stuck and why
right main bronchus
shorter, wider, and more vertical than the left with opening
What is sensory of cough reflex
vagus nerve
What is motor of cough reflex
vagus nerve, phrenic, intercostals
What is atelectasis
collapse of lung or lobe due to blockage of the airway
What lobe of lung is most susceptible to atelectasis and why
right middle lobe, smallest and most narrow
What is pan coast tumor
tumor of lung apex
What are 2 effects of pan coast tumor
Klumpke palsy= lower trunk of brachial plexus
Horner syndrome=cervical sympathetic chain
What is pulmonary embolism
blockage of a branch of the pulmonary artery with a blood clot, fat droplet or an air bubble
Signs and symptoms of pulmonary embolism
edema, leg pain, tenderness, chest pain, dyspnea, tachypnea, tachycardia, fever, cyanosis
Risk factors for pulmonary embolism
poor venous flow long travel immobility hyper coagulable states recent surgery COPD pregnancy oral contraceptives estrogen therapy smoking
What is hemoptysis
coughing up blood, bleeding form the airway from bronchial artery/pulmonary arteries
Signs and symptoms caused by presence of thymic tumors
compression of trachea or recurrent laryngeal nerve: hoarsness
esophagus compression: dysphagia
compression of great veins: cyanosis
Thymomas seen in myasthenia gravis
Transverse sinus used for what procedure
CABG
What is pericarditis
inflammation of pericardium
What is pericardial effusion
accumulation of fluid in the pericardial space
What is innervation of the pericardium
vagus
phrenic
sympathetics
Where is needle placed for pericardiocentesis. Where else can we place it. Which vessel and branched do we want to avoid
left xiphisternal junction
5th intercostal space
must avoid internal thoracic artery
What is cardiac tamponade
compression of the heart from accumulated fluid in the pericardial sac
What is Beck’s triad of cardiac tamponade
rapid heartbeat/muffled sounds
distended neck veins
hypotension/weak pulses
Which artery is dominant in 7-75% of hearts. which specific artery determines dominance
right coronary
PDA
Which artery provides the majority of arterial supply to SA and AV nodes
right coronary artery
What artery supplies anterior 2/3 of IV septum, including the AV bundle and L/R bundle branches
LAD
Which coronary artery supplies the posterior-inferior third
RCA
3 sites of occlusion in heart
LAD-50%
RCA- 30%
Left circumflex-20%
Significance of the internal thoracic artery in surgery
can be used for CABG
What is angina pectoris
chest pain from the heart resulting from insufficient supply of oxygen to cardiac muscle
What condition occurs when heart conduction system damage occurs
arrhythmias
Consequences of complete bundle block
dissociation between atrial and ventricular contractions
Where is AV bundle and what are consequences of surgical repair
courses in the margin of a VSD
repair can cause damage and result in bundle branch block
What is Ortner syndrome
compression of left recurrent laryngeal nerve from a cardiovascular etiology
enlarged left atrium, aneurysm of the arch
S/S: hoarseness, dysphagia,, dyspnea
3 points where aorta is fixed and susceptible to deceleration trauma
aortic valve
ligamentum arteriosum
aortic hiatus
where do a majority of non-penetrating aortic injuries occur
aortic isthmus between the left subclavian artery and ligaments arteriosum
In which patient population is coarctation of the aorta most common
females with Turner syndrome 50% of patients have a bicuspid aortic valve
What does coarctation of the aorta in infants cause
cyanosis in lower extremity
requires surgery
What does coarctation of the aorta in adults cause
HTN in upper extremity, weak pulses in lower
develop enlarged collateral circulation with the internal thoracic and intercostal arteries causing rib notching and LVH
What is aortic dissection
creation of space within the wall of the aorta: accumulates a lot of blood resulting in strokes or infarcts
S/S of aortic dissection
hypotension, exsanguination severe blood loss, stroke, ischemia, claudication, compression
Risk factors for aortic dissection
marfan syndrome EDS Turner syndrome osteogenesis imperfecta syphilis trauma cocaine use
Between the head and tubercle of which ribs can impinge or lacerate the descending aorta and cause massive blood loss
ribs6-9
Obstruction of the SVC (SVC syndrome)
most times caused by malignancy of the mediastinum, like lung cancer and lymphoma
cyanosis, dyspnea, facial and arm swelling, distention of neck, thoracic wall veins, cough, hoarseness, chest pain, dysphagia
4 caval to caval anastomoses important in SVC syndrome
thoracoepigastric
internal thoracic
vertebral plexus
azygos system
What 4 structures must be avoided in subclavian venipuncture done inferior to clavicle
first rib
phrenic nerve
subclavian artery
cupola of the lung
Where do GVE distribute
viscera in the skin and deep organs
What is raynaud syndrome and how to treat it
Idiopathic sympathetic dysregulation of UL vasculature characterized by pain and numbness and ischemia of digits
relieved by surgical destruction of the sympathetic chain at the root of the neck
Effect of spinal anesthesia on sympathetic innervation
impart sympathetic relay and produce temporary vasodialtion
What nerve innervates esophagus
vagus nerve
4 places esophagus can be constricted
junction with pharynx
aortic arch
left main bronchus
diaphragm at esophageal hiatus
3 ways esophageal cancer can spread and what structures involved
local: vagus nerve, recurrent laryngeal, trachea, pleura, pericardium
lymph
veins: lungs, liver, vertebra
Sympathetic innervation of the lungs and UE
T2-T7
