Week 2 Flashcards
Thoracic Skeleton
12 pairs of C shaped ribs
Ribs 1-7
join at sternum with cartilage end points (true ribs)
Ribs 8-10
join sternum with combined cartilage at 7th rib (false ribs)
Ribs 11 + 12
no anterior attachment; attached to T11 + T12 (floating ribs)
Sternum: Manubrium
joins to clavicle and 1st rib; jugular notch
Sternum: Angle of Louis
found T4-T5 & marks bifurcation of atria
Sternum: Body
junction of manubrium with sternal body and attachment to 2nd rib
-sternal angle (Angle of Louis)
Sternum: Xiphoid Process
distal portion of sternum
-most common area of fractures in the sternum (chest compressions)
Fractured ribs 3-8 leads to:
Flail Chest (uneven)
Thorax
formed by 12 pairs of ribs that join posteriorly with the thoracic spine and anteriorly with the sternum (except ribs 11 + 12)
Thoracic Cavity
- lined with thin layer of tissue (pleura)
- one lung in each cavity
- mediastinum is between chest cavity (pleura)
- spinal cord protected by vertebral column
Lung Function
oxygenation
Mediastinum Components
heart, aorta, superior and inferior vena cava, trachea, major bronchi, espohagus
Pneumothorax
collapsed lung
- cavity shrinks, decrease in pressure
- usually seen in traumas
Mediastinal Shift
organs shift to where they do not belong
-caused by Pneumothorax
Reference Lines
points for dictating pain or location (ex. mass) when documenting / diagnosing
Anterior Chest Reference Lines
- mid-sternal line
- mid-clavicular line
Posterior Chest Reference Lines
- vertebral line (midspinal)
- scapular line
Lateral Chest Reference Lines
- anterior axillary line
- posterior axillary line
- mid-axillary line
Anterior Thoracic Landmarks
-suprasternal notch (U shaped depression)
-sternum
-manubrium (angle of Louis)
-body
-xiphoid process
Posterior Thoracic Landmarks
-vertebra prominens (C7 projection at the end of neck, anterior to T1)
-spinous processes (fractured easily)
-scapula (shoulder blade; helps arm with degree of motion)
Superior Vena Cava
brings deoxygenated blood from head, eyes, neck and upper limbs to the R atrium of the heart
Inferior Vena Cava
brings deoxygenated blood from the abdomen and lower extremities to the R atrium
Right Atrium
receives deoxygenated blood from SVC + IVC
RA → tricuspid valve → RV
Right Ventricle
receives deoxygenated blood from R atrium through tricuspid valve
RV → pulmonary valve → pulmonary artery
Pulmonary Artery
carries R side (deoxygenated) blood to lungs for oxygenation
RV → PA → PV → LA
Pulmonary Vein
carries oxygenated blood from the lungs to the L side of the heart (L atrium)
PV → LA
Left Atrium
receives oxygenated blood from pulmonary veins
LA → mitral valve → L ventricle
Left Ventricle
receives oxygenated blood from L atrium through mitral valve
LV → aortic valve → aorta
Aorta
carries O2 rich blood to the rest of the body
LV → aortic valve → aorta
Trabeculae Carne
muscular columns projecting from inner surface of ventricles
-prevents suction of the blood due to pressure
Apex
PMI (point of max impulse)
cardiac output =
stroke volume x HR
Cor Pulmonale
pulmonary/chronic HTN causing R sided heart failure
-R sided heart failure not caused by L
Cardiac Tamponade
compression of the heart caused by fluid collection in the pericardium (sac surrounding heart)
- compression prevents the heart from filling w/ blood properly
- results in dramatic drop in BP (possibly fatal)
Peripheral Edema
fluid in the lungs
-displays as SOB
Jugular Venous Distension (JVD)
pump failure caused by heart failure
Position of the Heart
about half the length of sternal body from T2-T6
-from sternal angle to xiphoid process
Where to auscultate for: Aortic Valve
2nd intercostal space, R sternal border
Where to auscultate for: Tricuspid Valve
5th intercostal space, L sternal border
Where to auscultate for: Pulmonary Valve
2nd intercostal space, L sternal border
Where to auscultate for: Mitral Valve
5th intercostal space, mid clavicular line
Systemic Circuit
BV transports blood to and from tissues
Pulmonary Circuit
BV carries blood to and from the lungs
Pericardium Characteristics
double walled sac around the heart
- superficial fibrous pericardium
- deep, 2 layer subserous pericardium
Pericardium Function
protects and anchors the heart, prevents overfilling with blood, allows heart to work friction free
-limits expansion to an extent
Pericardium: Parietal Layer
lines internal surface of fibrous pericardium (tissue)
Pericardium: Visceral Layer
separated by fluid filled sac of serous fluid, covers heart muscle layer
-aka epicardium
Pericardial Effusion
build up of fluid within the heart’s pericardium
no expansion = conduction defects
- muffled heart sounds, SOB, edema
- must drain fluid to revert A-fib to normal rhythm
- check for lupus
Heart Wall contains:
- epicardium
- myocardium
- fibrous skeleton
- endocardium
Heart Wall: Epicardium
visceral layer of serous pericardium
Heart Wall: Myocardium
cardiac muscle forming bulk of heart
Heart Wall: Fibrous Skeleton
criss crossing interlacing layer of connective tissue
Heart Wall: Endocardium
endothelial layer of inner surface
Pericardial Sac
encloses the heart
-tough fibrous covering layer
-secretory lining: secretes pericardial fluid to reduce friction between pericardial layers
Pericarditis
inflammation of pericardium
- fluid in lung sac
- increased fluid = pressure and compression of heart
Complications of Pericarditis
-increased fluid = pressure and compression of heart
→ cardiac tamponade → heart cannot fill due to compression = decreased output
→ infection by Tuberculosis (TB): BCG vaccine prevents pulmonary TB in infants (weans over time)
Complications of Ventricular Hypertrophy
Ventricular Hypertrophy (enlarged heart) → less space to pump blood → LV fails
→ back flow (regurgitation) to LA → LA fails (O2 rich blood dumps into LA from pulmonary veins)
→ blood goes backward into lungs → RV fail → Hepatomegaly + JVD
Regurgitation
back flow of blood
ex. valve stops working and one-directional blood flow goes in the backwards direction
Vessels that return blood to the heart
pulmonary veins, IVC, SVC
Vessels that take blood away from the heart:
aorta, L common carotid, brachiocephalic, subclavian, pulmonary arteries
Vessels that supply/drain the heart (anterior view)
Arteries:
- R + L coronary (AV groove)
- marginal
- circumflex
- anterior ventricular arteries
Veins:
- small cardiac
- great cardiac
- anterior cardiac
Vessels that supply/drain the heart (posterior view)
Arteries:
- R coronary artery (AV groove)
- posterior interventricular artery
Veins:
- great cardiac vein
- posterior vein to L ventricle
- coronary sinus
- middle cardiac vein
Heart Valves Function
ensure unidirectional blood flow through the heart
Atrioventricular (AV) Valves
prevent back flow into the atria when vessels contract
-tricuspid + mitral (bicuspid)
Tricuspid Valve
RA to RV
-deoxygenated blood
Mitral Valve
LA to LV
-oxygenated blood
Chordae Tendonae
anchor AV valves to papillary muscles and prevent valves from being inverted
Semilunar Valves
prevent regurgitation of blood into the ventricles (one way flow)
-pulmonary valve + aortic valve
Pulmonary Valve
RV to pulmonary trunk → lungs
-deoxygenated blood
Aortic Valve
LV to aorta → rest of body
-oxygenated blood
Endocarditis
inflammation of heart’s inner linings of chambers/valves
destruction of chordae tendonae
- decreased function in chordae tendonae = valve failure (leaks), ventricle not getting enough blood → hypertrophy
- also caused by M.I., connective tissue disorder, infection
Ventricle not getting enough blood causes a….
Murmur
Incidental Murmur
in children - may go away with age
- must listen for sounds between “lub-dub” (S1 and S2)
ex. rumbling between 1st + 2nd, or between 2nd and 1st
Increased pressure from contraction closes ______
valve
Pressure gradient problems leads to _______
valve complications
Mitral Valve Prolapse
mitral valve is no longer one way flow to the ventricle
-instead, opens towards atria → regurgitation
-diagnose by echocardiogram
-concerning for pregnancy: more pressure in the heart = high risk pregnancy
Interatrial Septum
divides LA and RA
Interventricular Septum
divides RV and LV
L side has _____ pressure than R side
higher
Septal Defect Complications
hole in heart → less blood to LV = hypoxia
→ cyanosis (peripheral - toes, fingers)
increased pressure RA → heart failure
Foramen Ovale
hole in interatrial septum that shunts oxygenated blood from R to L atria
-in utero
Fossa Ovalis
remnant of foramen ovale; depression in the RA of the heart
-post natal
Patent Foramen Ovale (PFO)
foramen ovale does not close after birth
-causes murmur due to septal defect
Ductus Arteriosus
bypasses non-functional lungs in fetus, pumping blood away from the lungs
- right ventricle
- in utero
Patent Ductus Arteriosus (PDA)
oxygenated blood from aorta enters pulmonary artery & mixes with deoxygenated blood
-both systolic and diastolic murmurs
Ligamentum Arteriosum
attaches aorta to pulmonary artery
remnant of ductus arteriosus; serves no function in adults
-post natal
Ventricular Septal Defect (VSD)
superior part of interventricular septum fails to form; blood mixes between RV + LV
Transposition of the Great Vessels
aorta comes from RV, pulmonary trunk comes from L
- result of bulbus cordis not dividing properly
- deoxygenated blood passes through systemic circuit
- oxygenated blood passes through pulmonary circuit
- pulmonary artery is not pulmonary artery
Coarcitation of Aorta
part of aorta is narrowed → increase work on LV
1/1500 births
Tetralogy of Fallot
multiple defects
- pulmonary trunk is too narrow and PV stenosed
- ventricular septal defect
- aorta opens from both ventricles
- RV wall thickened from overwork
Pulmonary Stenosis
pulmonary semilunar valve is narrowed (stenosis) → decreased blood flow to lungs
High Frequency Sounds
related to opening
-closure sounds = S1 + S2
Low Frequency Sounds
related to closing
-early and late diastolic filling events of LV
-S3 + S4
S1 + S1 Sounds
Lub-Dub
- audible with stethoscope
- contraction
S3 + S4
usually not audible under normal conditions
Ventricular Systole
when mitral valve and tricuspid valve close
contraction
S1 + S2
Ventricular Diastole
occurs w/ closure of aortic and pulmonary valves
relaxation
S2 + S1
Most heart sounds are associated with closing. Hearing the valve opening means it is ________
stenotic
Factors affecting S1
-structural integrity of valve → inadequate joining of mitral valve (SOFT S1) or loss of leaflet tissue (SOFT S1)
-velocity of valve closure → position of mitral valve can be altered by atrial and ventricular systole
-status of ventricular contraction → increased myocardial contractility = increased LV pressure [exercise, high output state] (LOUD S1) or decreased contractility due to M.I. or myocarditis (SOFT S1)
-heart rate → tachycardia (LOUD S1) [shorter PR interval, wide valves due to short diastole increase myocardial contractility
-transmission characteristics → obesity, emphysema, pericardial effusion decreases intensity of auscultory events, thin chest wall increases intensity
Conditions causing LOUD S1
- mitral stenosis
- mitral valve prolapse
- exercise
- tricuspid stenosis
- atrial septal defect
- anomalous pulmonary venous connection with increased tricuspid flow
Mitral Stenosis
LOUD S1
increased L arterial pressure, mitral valve trying to close, flaps are thicker, turbulent blood flow due to narrow space
Mitral Valve Prolapse
LOUD S1
floppy leaflet snaps into prolapsed position and makes a loud click
increases regurgitation
Exercise
LOUD S1
increased HR, increased ventricular pressure
Tricuspid Stenosis
LOUD S1
thickened tricuspid leaflets, increased turbulence (narrow)
Atrial Septal Defect
LOUD S1
exists in foramen ovale during fetal development
normal conditions: shunt blood to RA → LA
hole doesn’t close: increased volume to RA → increased flow across pulmonic valve
Anomalous Pulmonary Venous Connection w/ Increased Tricuspid Flow
PV drains blood to RA instead of LA → mixes with deoxygenated blood → increased volume and increased pressure on tricuspid
Conditions causing SOFT S1
- mitral regurgitation
- calcific mitral stenosis (immobile mitral valve)
- severe atrial regurgitation
- left bundle branch block (LBBB) (decreased LV contractility)
S2 Split
normally during inspiration
AV closes before PV
-usually seen in RBBB (conduction issue)
Wide Split S2
deeper inhalation
AV closes a while before PV
-usually seen in Pulmonary Stenosis
Paradoxical Split S2
seen during expiration but disappears on inspiration
PV closes before AV
- think pediatric cardiomyopathy
- Aortic Stenosis, LBBB, HCM (hypertrophic cardiomyopathy)
Fixed Split S2
no change in S2 w/ deeper inspirations
-Atrial Septal Defect (ASD), R Ventricular failure
S3 Sounds
rare extra heart sound that occurs soon after normal “lub-dub” (heard between S2 and S1)
-associated with LV heart failure
-normal in children and young people w/o abnormalities
S4 Sounds
very difficult to hear
caused by vibration of ventricular wall during atrial contraction
-associated with stiffened ventricle (low ventricular compliance)
-heard in patterns w/ Ventricular Hypertrophy + Myocardial Ischemia (tissue dies + no function)
Heart Murmurs
abnormal sounds produced due to abnormal flow of turbulent blood through abnormal heart valves
ex. stenosis or incompetence
- increased velocity = murmur sounds
When blood is forced through a stenotic valve, produces an abnormal ______ sound
whistling
When blood forced backward through an incompetent valve (regurgitation), it produces a ________ sound
swishing or gurgling murmur
Rheumatic Fever
autoimmune disease triggered by streptococcus bacterial infection
- antigen-antibody complexes damage the valve
- stenotic valve dysfunction often caused by a missed strep infection
- most common strep = Impetigo
Systolic Murmur
produced during systole of ventricle (contraction) between S1 and S2
- innocent murmurs
- common in children and young adults
- ex. Aortic Stenosis + Mitral Incompetence
Diastolic Murmur
produced during diastole of ventricle (relaxation) between S2 and S1
-ex. Aortic Incompetence + Mitral Stenosis
ASS - BACKWARDS
A = P
T = M
Aortic Stenosis is Systole
Aortic Stenosis = systole
Pulmonary Stenosis = systole
Tricuspid Stenosis = diastole
Mitral Stenosis = diastole
Aortic Regurgitation = diastole
Pulmonary Regurgitation = diastole
Tricuspid Regurgitation = systole
Mitral Regurgitation = systole
Ventricular Septal Defect (VSD)
commonly caused by congenital defect; hole in the heart between LV + RV that may never be identified
- undiagnosed → gets louder w/ age
- LV shunts blood to RV, increasing RV pressure
- may be associated w/ other defects: Tetralogy of Fallot
VSD Complications
LV shunts blood to RV, increasing RV pressure
RV hypertrophy → R side failure
regurgitation in R side causes blood to pool in venous system
L side oxygen poor → cyanosis
Electrical Conduction System
AV Node
SA Node
Bundle of HIS
Bundle Branch
Purkinje Fibers
AV Node blocked → _______ will start its own electrical impulse (supraventricular rhythm)
Bundle of HIS
Supraventricular rhythm becomes so irregular / not in sync, causing __________
Ventricular Tachycardia
Cardiac cells produce their own __________
electrical impulse
_________ will shock the heart until the optimal rhythm is achieved
Pacemaker
RBBB
affects electrical conductivity of the heart
Contraction begins at ______
apex
Autonomic Innvervation
sympathetic - increase rate/force of contractions
parasympathetic - slow HR by Vagus nerve stimulation
Flow of Fetal Blood Circulation:
- Oxygenated / nutrient rich blood from PLACENTA travel through UMBILICAL VEIN
- UMBILICAL VEIN passes through the LIVER (still oxygenated) and combines with IVC (deoxygenated)
- Mixed blood enters the heart through RA
- SVC brings deoxygenated blood to RA, pumping from RA to RV to PULMONARY TRUNK to DUCTUS ARTERIOSUS then DESCENDING AORTA
- Some mixed blood enters RV but most enters LA through FORAMEN OVALE
- LA pumps to LV
- LV pumps to AORTA
- Any blood that entered the PULMONARY TRUNK instead of FORAMEN OVALE or RV can re-enter the AORTA through the DUCTUS ARTERIOSUS
- ILLIAC ARTERIES are mostly now deoxygenated after blood moves through tissues and returns to UMBILICAL VEIN for oxygenation
