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ACEM Primary VIVA > VIVA: Anatomy - Thorax > Flashcards

VIVA: Anatomy - Thorax Flashcards

1
Q

Describe the course of the thoracic aorta

A

Ascending aorta*:
- Begins at aortic orifice

Arch of aorta*:
- Begins behind sternocostal junction, passes supero-posteriorly and to the left anterior to the right pulmonary artery and the carina
- The apex of the arch lies to the left of the trachea/oesophagus and descends posterior to the left lung root, ending back to the level of the T4 (2nd sternocostal joint)

Descending aorta:
- Origin is at the left side at the level of the T4 vertebra
- Courses inferiorly to the level of T12
- It approaches the midline as it descends alongside the oesophagus
- At the inferior border of T12 it exits through the aortic hiatus and becomes the abdominal aorta

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2
Q

Outline the structures that make up the right and left cardiomediastinal borders on this XR

A

6/10 to pass:
Right cardiomediastinal border:
- Right brachiocephalic vein
- SVC
- Right pulmonary trunk
- Right atrium
- IVC

Left cardiomediastinal borders:
- Left subclavian artery / left brachiocephalic vein
- Aortic arch
- Left pulmonary trunk
- Left atrial appendage
- Left ventricle

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3
Q

Describe the lobes of the lungs and their fissures

A

Both lungs:
- Oblique fissures* from T2 posteriorly to 6th costal cartilage anteriorly separate upper and lower lobes

Right lung:
- Transverse fissure at level of right lung hilum along line of 4th rib separates upper and middle lobes

Left lung:
- Prominent cardiac notch in lower lobe with lingula below

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4
Q

What part of the lung forms the right heart border?

A

Right middle lobe

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5
Q

Describe the expected positions of the fissures of the lung on a normal CXR

A
  • Right lung has 3 lobes, left 2 lobes
  • Oblique fissures separate the upper from lower lobes, and horizontal fissure separates the right upper and middle lobes
  • Oblique fissures* follow the 5th ribs (run from 4th thoracic vertebrae to 3cm posterior of the junction between the diaphragm and the sternum on the left, and to the sternodiaphragmatic junction on the right)
  • Horizontal fissure on right* at level of 4th costal cartilage or hilum
  • needed to pass (within 1 space either way)
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6
Q

Describe the position of the neurovascular structures in the intercostal space

A
  • Between the middle and innermost layers, protected by the costal groove of the superior rib of each intercostal space*
  • Ordered vein, artery, nerve from superior to inferior*
  • needed to pass
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7
Q

When placing an intercostal catheter (ICC) in the 5th intercostal space laterally,

A
  • Skin
  • Subcutaneous tissues
  • External intercostal muscle*
  • Internal intercostal muscle*
  • Innermost intercostal muscle*
  • Parietal pleura
  • 2 needed to pass
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8
Q

What structures may be at risk from an ICC inserted laterally?

A
  • Neurovascular bundle*
  • Long thoracic nerve* (lies in serratus anterior behind the mid-axillary line)
  • Lung*
  • Diaphragm*
  • Pericardium/heart* and spleen if on left
  • Liver* if on right
  • 2 to pass
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9
Q

Which lobes of the lung lie adjacent to the right and left cardio-mediastinum?

A

Right upper mediastinum:
- Right superior lobe

Right heart border:
- Right middle lobe

Left upper mediastinum:
- Left superior lobe

Left heart border*:
- Left superior lobe (lingula segment)

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10
Q

What are the boundaries of the lung lobes? Demonstrate the lobes on this XR

A

RUL:
- Right superior mediastinum to apex
- Apex to horizontal fissure / upper right mediastinum medially

RML:
- Right heart border and horizontal fissure (superior border 4th rib) to 6th costal cartilage

LUL:
- Left superior mediastinum to apex
- Apex to left 4th intercostal space in parasternal line, 6th intercostal space in midclavicular line and 5th intercostal space in anterior axillary line

Lingula:
- Left heart border

Lower lobes:
- Posteriorly, sit over domes of diaphragms and rise as high as 3rd intercostal space posteriorly
- From oblique fissure (T2 spinous process to 6th costal cartilage anteriorly) to T10 spinous process posteriorly, 10th ribs at scapular line and 8th ribs in mid-axillary line

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11
Q

Describe the surface anatomy of the parietal pleura

A
  • Supraclavicular fossa
  • Medially follow the middle of the sternum to the level of 6th costal cartilage
  • Deviates laterally reaching 8th rib in midclavicular line, 10th rib in midaxillary line, and 12th rib at paravertebral line
  • Notch on left
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12
Q

In a patient who has sustained blunt trauma in a motor vehicle accident, what injuries may be seen on a CXR?

A

Chest wall*:
- Rib fracture
- Clavicular fracture
- Sternum fracture

Lung*:
- Pneumothorax
- Haemothorax
- Pulmonary contusion

Cardiovascular:
- Damage to aorta or other great vessels (widened mediastinum)

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13
Q

Identify this bone and demonstrate its features

A
  • First rib*
  • Left* (determined by identifying superior surface)
  • Broadest, flattest, shortest rib
  • Lies nearly horizontal, with wide body
  • Groove for subclavian artery*
  • Features include head, neck, tubercle, shaft, single facet on head for articulation with T1 vertebra only
  • On superior surface, from neck to tip: groove for subclavian artery and lower trunk of brachial plexus (posterior to artery), scalene tubercle and ridge for attachment of scalenus anterior, groove for subclavian vein, flat out surface for attachment of first digitation of serratus anterior, attachments to costoclavicular ligament (inner) and subclavius (outer)
  • Tip articulates with costal cartilage
  • needed to pass + 2 other features
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14
Q

Describe the neurovascular relations of the first rib

A

Nerves:
- C8 nerve root above and T1 nerve root below unite to form the lower trunk of the brachial plexus, which sits above rib surface behind subclavian artery
- Sympathetic trunk (cervicothoracic ganglion) in contact with anterior border of neck

Vessels:
- Subclavian artery* runs in groove behind scale tubercle, touching outer border of rib
- Subclavian vein runs anterior to scalene tubercle, in its own groove
- First intercostal neurovascular bundle beneath the undersurface, covered by parietal pleura

  • needed to pass + 1 nerve
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15
Q

What are the important relations of the first rib?

A
  • Apex of lung*
  • Subclavian vessels*
  • Intercostal vessels and nerves
  • Sympathetic trunk
  • Lower trunk of brachial plexus (superior to rib)
  • Scalenus anterior/medius
  • Intercostal muscles
  • Serratus anterior
  • Subclavius
  • needed to pass
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16
Q

Identify the great vessels and branches which enter and exit the heart on this model

A
  • SVC* with right and left brachiocephalic veins
  • IVC*
  • Ascending aorta* with brachiocephalic trunk, L common carotid artery and L subclavian artery
  • Pulmonary trunk* and pulmonary arteries
  • Pulmonary veins
17
Q

Identify the chambers and valves of the heart on this model

A

To pass:
- Right atrium
- Left atrium
- Right ventricle
- Left ventricle
- Tricuspid valve
- Mitral valve
- Aortic valve
- Pulmonary valve

18
Q

Describe the structures of the conducting system of the heart

A
  • SA node*: anterolateral near the junction of SVC and RA
  • AV node*: posteroinferior region of interatrial septum, near the opening of the coronary sinus
  • AV bundle of His: through fibrous skeletal of the heart, along the membranous part of the interventricular septum -> divides into left and right bundles which pass on each side of the muscular interventricular septum
  • needed to pass + rough location
19
Q

Describe the arterial supply to the cardiac conduction system

A

SA node: RCA 60%, circumflex 40%
AV node and bundle: RCA, AV nodal artery
Right and left bundles, Purkinje fibres: LAD

  • needed to pass
20
Q

Demonstrate on this model the arterial supply of the heart

A

Coronary arteries arise from the aortic sinuses:
- Right coronary artery: gives off SA nodal branch (in 60%), right marginal branch, AV nodal branch, posterior interventricular (in 66%), and interventricular septal
- Left coronary artery: gives off circumflex artery* which branches to give the SA nodal artery in 40%, left marginal artery, posterior interventricular (in 15%), and LAD
- Left anterior descending: from left coronary artery (supplies anterior 2/3 of septum), gives off lateral diagonal branches

  • needed to pass
21
Q

Occlusion of which vessel would result in an anterolateral STEMI

A

Proximal LAD (before first diagonal branch)

22
Q

Describe the venous drainage of the heart

A
  • Coronary sinus*
  • Great cardiac veins (accompanies LAD then LCx)
  • Middle cardiac veins (accompanies PIV)
  • Small cardiac veins (accompanies R marginal)
  • Left posterior ventricular
  • Left marginal
  • Anterior cardiac (starts on anterior surface of RV and drains straight into RA)
  • Oblique veins on left atrium
  • Venae cordis minimae (drains directly into chambers)
  • needed to pass + 1 other
23
Q

Which areas of the heart are supplied by the left coronary artery and its branches?

A

Most of LA
Most of LV*
Part of RV (anterior wall)
Interventricular septum*
Ventricular apex
AV bundle (His)*
SA node in 40% (from LCx)

  • needed to pass
24
Q

Describe the position of the heart in the left hemithorax

A

Inferior border lies on the diaphragm
Apex is in the 5th intercostal space
Base is against the thoracic vertebrae T6-9

25
Q

What does the right coronary artery supply?

A

3/6 to pass:
- RA
- Most of RV
- Diaphragmatic (inferior) part of LV
- Posterior 1/3 of interventricular septum
- SA node in 60%
- AV node in 80%

26
Q

Using the CXR, name and indicate the position of the lobes of the lung

A
  • Right and left upper lobe fill apices/upper zones*
  • Lingular lobe abuts left heart border
  • Left lower lobe abuts left hemidiaphragm*
  • Right lower lobe abuts right hemidiaphragm*
  • Right middle lobe abuts right heart border*
  • needed to pass
27
Q

Describe the surface anatomy of the parietal pleural reflections

A

The right and left sternal parietal pleural reflections are asymmetrical, but the costal and diaphragmatic reflections are symmetrical:
- The right and left sternal pleural reflection start at the apices of the right and left lung*
- They descend inferomedially in parallel to the sternoclavicular joint and pass to the posterior aspect of the sternum in the anterior median line
- At the level of the 2nd-4th costal cartilages, they lie parallel to each other: inferior to this level, they become asymmetrical
- On the left side, at the level of the 4th costal cartilage, the pleura deviates to the left side* of the sternum and reaches the 6th costal cartilage just lateral to the left lateral sternal edge
- The right side passes inferiorly until it reaches the 6th costal cartilage in the anterior median line
- From then on, both sides pass lateral and posteriorly with the following markers: level of 8th costal cartilage in mid-clavicular line, level of 10th costal cartilage in mid-axillary line, level of 12th costal cartilage at neck of 12th rib*

The diaphragmatic pleural reflection is in close contact with the diaphragm

  • needed to pass
28
Q

Which muscles are responsible for respiration?

A
  1. Diaphragm*:
    - Primary muscle of respiration
    - Responsible for most of inspiration (expiration passive)
  2. Costal muscles*:
    - Move ribs during forced respiration
    - Function primarily to support intercostal spaces, resisting negative and positive intrathoracic pressures
    - Externals aid in inspiration, internals aid in forced expiration
  3. Accessory muscles:
    - Scalenes, sternocleidomastoids, pectoralis major and minor, serratus anterior
  4. Abdominal wall muscles:
    - Aid in forced expiration
  • 2/3 needed to pass , with diaphragm as primary muscle
29
Q

What are the anatomical structures to consider when inserting a lateral intercostal catheter?

A
  • Above the rib below* to avoid neurovascular bundle
  • Above 5th-6th intercostal space* to avoid diaphragm
  • Anterior to mid-axillary line or latissimus dorsi
  • Posterior to pectoralis major
  • needed to pass + 1 other
30
Q

Identify the main features of the thoracic inlet and mediastinum on this photograph

A
  • Cricoid cartilage (2)
  • Ascending cervical artery (3)
  • Brachiocephalic trunk (4)
  • Inferior thyroid veins (7)
  • Internal jugular vein (8)*
  • Thyroid gland* (isthmus 11, lateral lobe 12)
  • Left brachiocephalic vein (13)
  • Left common carotid artery (14)*
  • Phrenic nerve (17)
  • Right brachiocephalic vein (18)
  • Right common carotid artery (19)*
  • Recurrent laryngeal nerve (20)
  • Right subclavian artery (21)
  • Right vagus nerve (22)*
  • Scalenus anterior (23)
  • Subclavian vein (24)
  • Superior vena cava (26)
  • Thymus (31)
  • Thyrocervical trunk (32)
  • Trachea (33)*
  • Upper trunk of brachial plexus (35)
  • needed to pass + 3 others
31
Q

What structures do you need to avoid when placing an internal jugular central line?

A
  • Common carotid artery*
  • Apex of lung
  • Thoracic duct
  • Subclavian vessels
  • Vagus nerve
  • Phrenic nerve
  • Brachial plexus
  • Oesophagus
  • Trachea
  • needed to pass
32
Q

Identify the venous structures in this image

A
  • Left internal jugular vein (8)*
  • Right and left subclavian veins (24)*
  • Left brachiocephalic vein (13)*
  • Right brachiocephalic vein (18)*
  • SVC (26)*
  • Inferior thyroid veins (7)
  • needed to pass
33
Q

Identify the major arterial structures in this image

A
  • Brachiocephalic trunk (4)*
  • Right common carotid artery (19)*
  • Left common carotid artery (14)*
  • Right subclavian artery (21)*
  • Internal thoracic artery (9)
  • needed to pass
34
Q

What non-vascular structures can be identified on this image?

A

3 to pass:
- Cricoid
- Thyroid gland
- Trachea
- Lung
- Pleura
- Phrenic nerve
- Scalenus anterior
- Thyrocervical trunk

35
Q

What are some complications of an internal jugular line insertion?

A

3 to pass:
- Pneumothorax/haemothorax
- Arterial puncture or misplacement
- Haemorrhage (including airway obstruction due to haematoma)
- Pericardial tamponade
- Thrombosis/PE
- Air embolism
- Injury to thoracic duct (on L) -> chylothorax
- Arrhythmias
- Catheter loss / embolus
- Wire knotting
- Infection

ACEM Primary VIVA (43 decks)

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