Thorax
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Content
Sternum
•
Manubrium, body, xiphoid process
•
•
Jugular notch at T2
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Sternal angle at T4/5
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Xiphoid process at T9
Vertebral levels
Denver F. Sapo, MD
Ribs
•
TRUE ribs
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Attach to sternum
•
Ribs 1 to 7
Rib fracture (Clinical correlation)
TYPICAL rib
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• Ribs 3-9
ATYPICAL rib
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• Ribs 1, 2
•
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FALSE RIBS
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Attach to costal cartilage above
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Ribs 8 to 10
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Ribs 10, 11, 12
•
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No attachment anteriorly
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Ribs 11 and 12
HPE—Paradoxical chest
movement
MC—ribs 5 to 10
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Cx—?
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Rx—intercostal nerve block
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Rib 1 and 2 fracture means?
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Lower rib fracture
Cervical rib (Clinical correlation)
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From the transverse process of C7
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Cx—thoracic outlet syndrome
Two separate fractures in ≥ 3 ribs
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Costochondral junction
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Angle
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pulmonary contusion—major cause
of respiratory compromise
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Rx—PEEP
Thoracic outlet syndrome (Clinical correlation)
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Just anterior to the angle of the rib
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FLOATING RIBS
Flail chest (Clinical correlation)
•
•
What do you call this maneuver?
Manubriosternal joint
Dermatome vs Vertebral level
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Vertebral level
Xiphoid process at T9
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Nipple at T4
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Umbilicus at L4
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Xiphoid process at T7
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Umbilicus at T10
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Inguinal ligament at L1
EKG electrode placement (Clinical correlation)
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Sternal angle (of Louis)
•
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At the level of…
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V2—left 4th ICS
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V3—?
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V4—5th ICS MCL
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V5—AAL (same level as V4)
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V6—MAL (same level as V4)
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Junction of superior and inferior
mediastina
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Bifurcation of the trachea
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T4/5 IV disk
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Beginning and end of the aortic
arch
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2nd costal cartilage
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Azygous vein drains into the SVC
Dermatomal level
•
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V1—right 4th ICS
Costovertebral and
costotransverse joints
•
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Head↔vertebral body
•
•
•
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Costochondritis (Clinical correlation)
Costovertebral joints
Corresponding
Above
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Aka Teitz syndrome
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Tenderness over the costochondral
joints
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Treatment—?
Costotransverse joints
Tubercle↔transverse process
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Corresponding
Thoracic outlet???
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Superior thoracic aperture
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Inferior thoracic aperture
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Which aperture is affected in
thoracic outlet syndrome?
Intercostal muscles
•
•
•
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Costal groove
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“V-A-N”
Intercostal arteries
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Posterior intercostal arteries
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Superior intercostal artery (1-2)
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Innermost intercostal
Intercostal arteries
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Anterior intercostal arteries
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Internal thoracic artery (1-6)
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One finger breath lateral to
sternal margin
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Divides in its terminal branches at
the 6th intercostal space
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Musculophrenic artery (7-9)
Coarctation of the aorta (Clinical correlation)
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Rib notching
•
PE?
Intercostal artery (3-11)
Subcostal artery
Intercostal space (Clinical correlation)
To enter the pleural cavity...
•
•
Posterior/Internal intercostal
membrane
Thoracic aorta
•
•
Anterior/external intercostal
membrane
Internal intercostal
•
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Intercostal space
External intercostal
superior border of the rib
To perform intercostal nerve
block...
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inferior border of the rib
Intercostal nerve block (Clinical correlation)
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V-A-N
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Cx
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Pneumothorax
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Hemorrhage
Needle thoracostomy (Clinical correlation)
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Management for tension
pneumothorax
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Anterior approach
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•
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Incision
2nd ICS MCL
Lateral approach
•
Tube thoracostomy (Clinical correlation)
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Diaphragm
4th or 5th ICS (Snell)
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5th or 6th ICS (Moore)
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AAL or MAL
Indications
2nd ICS AAL
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•
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Air removal
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Fluid drainage
Structures penetrated?
Diaphragm
Diaphragmatic apertures
•
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Main muscle of respiration
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Esophageal opening
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Nerve supply?
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Esophagus
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Vagus nerve
•
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THINK—”C3, 4, 5 keeps the
diaphragm alive”
Which is higher?
Trauma (Clinical correlation)
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The dome of the diaphragm can
reach the 5th rib!
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Injury below the nipple line may
involve abdominal and/or chest
organs
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Septum transversum
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Esophageal mesentery
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Pleuroperitoneal membrane
•
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Heart—T1-T4
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Referred to intercostal nerves and
intercostobrachial nerve (T2)
Aortic hiatus
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Aorta
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Thoracic duct
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Azygous vein
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“aortic hiatus” (12 letters)
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Caval opening
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IVC
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Right phrenic nerve
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“vena cava” (8 letters)
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Transverse diameter
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AP diameter
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Vertical diameter
Contraction of diaphragm
Intercostal nerve (Clinical correlation)
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Mesoderm of body wall
Cardiac pain (Clinical correlation)
“Oesophagus” (10 letters)
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Mechanics of respiration
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Congenital diaphragmatic hernia
(Clinical correlation)
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Herpes zoster
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Etiology—VZV reactivation
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Vesicular eruptions
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Dermatomal pattern
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Dormant within what structure?
Inferior mediastinum
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Anterior mediastinum
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Contents
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Thymus
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Sternopericardial ligament
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Inferior wall MI
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LN
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Epigastrium
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fat
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Referred to epigastrium—
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T7, 8, 9
Inferior mediastinum
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Middle mediastinum
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Heart
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Thoracic aorta
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Roots of great vessels
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Esophagus
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Primary bronchi
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Azygos and hemiazygos vein
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Phrenic nerve
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Vagus nerve
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Arch of azygous
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Thoracic duct
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Sympathetic trunk
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SVC
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Brachiocephalic veins
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Arch of the aorta
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(L) RLN
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Thoracic duct
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Esophagus
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(R) and (L) vagus n
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(R) and (L) phrenic nerve
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Thymus
SVC syndrome (Clinical correlation)
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Obstruction of SVC
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MCC—malignant tumor (lung
cancer)
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Thoracic aorta
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Ascending aorta
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Aortic arch
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Formed behind the lower border of
the 1st costal cartilage
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What is the other name of the
brachiocephalic vein?
Question
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Descending aorta
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Which part of the mediastinum?
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What is the first branch of the
aorta?
Thoracic duct
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Starts as the?
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Enters what hiatus?
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Identify its course in the
mediastinum?
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Empties where?
What part of the mediastinum?
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Vagus nerve
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Phrenic nerve
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(R) RLN
Aortic dissection (Clinical correlation)
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THINK—”Know your ABC’s”
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Contents
SVC
Pemberton sign
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Posterior mediastinum
Contents
Contents
•
•
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Superior mediastinum
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Inferior mediastinum
Treatment?
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Stanford classification
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DeBakey classification
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“B-A-D”
Azygos system
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Communicates with the internal
(epidural) vertebral venous
(Batson) plexus
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valveless
Azygos lobe (Clinical correlation)
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Anomalous lateral course of the
azygous vein
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Not a true lobe!
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Incidental finding
Mediastinal masses
(Clinical correlation)
Mediastinal shift (Clinical correlation)
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Tracheal shift
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Atelectasis?
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Pleural effusion?
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Pneumothorax?
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Asthma?
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Pneumonia?
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Diagnose?
Pleura
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Parietal pleura
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Visceral pleura
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Sensitive to pain
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Not sensitive to pain
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Pleural fluid 5 to 10 mL (Snell)
•
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Pneumothorax (Clinical correlation)
What is the lining epithelium?
Parietal pleura
Parts and innervation
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•
•
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Spontaneous pneumothorax
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HPE
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Pleura?
“Sucking chest wound”
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Pleura?
Cervical/cupula
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Costal
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Diaphragmatic
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Tension pneumothorax
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“Ball-valve effect”
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Clinical dx
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Intercostal nerves
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Central—phrenic nerve
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Peripheral—intercostal nerve
Mediastinal
•
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Medisatinal shift Æ ↓ VR
Sternal lines of reflection
•
•
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Open pneumothorax
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Phrenic nerve
Pleurisy (Clinical correlation)
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Shoulder?
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Anterior abdominal wall?
Costal and vertebral lines of reflection
Right
•
SC joint →midline at MS joint
Bottom of
lung
→XS joint
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SC joint →midline at MS joint
→deviates laterally at the 4th
costal cartilage →6th costal
cartilage
6th rib
8th rib
MAL
8th rib
10th rib
Paravertebral
line
10th rib
12th rib
•
Pericardiocentesis (Clinical correlation)
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Beck’s triad
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Distended neck veins
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Distant heart sounds
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Decreased blood pressure
Intercostal approach
•
•
5th or 6th ICS near the
sternum—”bare area”
Cx—hemorrhage from internal
mammary artery or its branches
Bottom of
parietal pleura
(Costal line)
MCL
Left
•
•
Pleural cavity
Vertebral lines of pleural reflection
parallel the paravertebral lines from
T1 to T12
Water bottle heart
•
Initial management?
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Definitive treatment?
Pericardiocentesis (Clinical correlation)
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Xiphisternal approach
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250 mL →diastolic filling is
Thoracentesis (Clinical correlation)
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Site—9th ICS MAL
compromised
Pleural effusion (Clinical correlation)
•
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Costodiaphragmatic angle
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Posterior—most dependent
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Lateral
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Anterior—least dependent
•
•
Left shoulder pain
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Splenic rupture →Hemorrhage
within the peritoneal cavity
300 mL
Endothoracic fascia
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Kehr sign (Clinical correlation)
Respiratory system (Histology)
Loose connective tissue separating
the parietal pleura from the thoracic
wall
Suprapleural membrane—Sibson
fascia
Respiratory system (Histology)
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Conducting portion
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Respiratory portion
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Upper respiratory tract
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Lower respiratory tract
Clara cells
Trachea
Bronchi
Bronchiole
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Club cell (January 1, 2013)
Pseudostratified
ciliated epithelium
Pseudostratified
ciliated epithelium
Simple cuboidal
epithelium
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Bronchioles
C-shaped
Irregular plates
none
•
Function
Glands
++
+
none
Smooth muscle
yes
yes
yes
Epithelium
Cartilage
•
Differentiate terminal bronchiole
from respiratory bronchiole?
Alveoli
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Type I pneumocyte
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Simple squamous epitheliul
Type II pneumocyte
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Cuboidal
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Regenerate and divide
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Synthesize surfactant
•
•
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Surface tension
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Compliace/Elasticity
Start at 20-24 weeks (Nelson)
Alveolar macrophage
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Differentiate to ciliated cells
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Secrete GAGs
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Metabolize airborne toxins
Blood-gas barrier
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What forms the blood-gas barrier?
Trachea
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Extent?
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What type of cartilage?
EA and TEF (Clinical correlation)
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Type B
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1%
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AXR—gasless abdomen
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Type D
8-10% (2nd MC)
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SSx?
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Dx—failure to pass NGT
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AXR—gasless abdomen
•
EA and TEF (Clinical correlation)
•
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Type C
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EA + distal TEF
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THINK—Common
85%
EA and TEF (Clinical correlation)
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Type E—H-type
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TEF without EA
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THINK—Double connection
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THINK—Eyts
2%
Principal/Primary/Main bronchi
Right
•
•
•
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± excessive secretions
Eparterial bronchus
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Right upper lobe bronchus
Narrower, longer, more horizontal
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Tertiary/Segmental bronchus
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8%
Left
Secondary/Lobar bronchus
•
•
Wider, shorter, more vertical
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How many?
How many?
Foreign bodies tend to lodge in which
bronchi?
Endotracheal tube placement
(Clinical correlation)
•
Placement?
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Complications?
Fissures
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Fissures
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Oblique/Major fissure
•
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THINK—Atresia Alone
EA + proximal and distal TEF
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•
•
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Bronchi
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Type A—Pure esophageal atresia
THINK—Blank
EA and TEF (Clinical correlation)
•
•
EA + proximal TEF
•
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EA and TEF (Clinical correlation)
Preferred site for trachesotomy
tube insertion?
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Root of the spine of the
scapula→6th rib →6th
costochondral junction
Horizontal/Minor fissure
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4th costal cartilage →meets
the oblique fissure horizontally
at the MAL
•
THINK—RALeS
Lobes
Right lung
•
•
•
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2 lobes
•
Right lung
Standing/sitting—posterobasal of
RLL
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Supine—superior segment of
RLL
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Right side-lying—middle lobe or
posterior segment of RUL
Segmental vein lies in the
connective tissue between adjacent
segments
Blood vessels of the lungs
•
Pulmonary artery
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Pulmonary vein
•
Bronchial artery
•
Bronchial vein
•
Oxygen content?
Left side-lying—inferior lingular
Hampton’s hump
Wedge-shaped
Pancoast tumor (Clinical correlation)
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Surgically resectable
•
Left lung
•
•
•
Lingula
Foreign body aspiration (Clinical correlation)
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Independent functional and surgical
units
Cardiac notch
•
•
•
3 lobes
Left lung
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Bronchopulmonary segments
Tumor of the apex of the lung
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Horner syndrome
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Ptosis
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Anhidrosis
•
Mio
Westermark sign
•
Oligemia
Lymphatic drainage
Superficial plexus
Deep plexus
(pulmonary nodes)
Bronchopulmonary
nodes
Tracheobronchial
nodes
sis
Bronchomediastinal trunk
Right lymphatic duct or
thoracic duct
Pericardium
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Fibrous pericardium
•
•
Indistensible!
Serous pericardium
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Parietal pericardium
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Visceral pericardium
•
Pericardial fluid—50 mL (Snell)
•
What is the difference between
visceral pericardium and
epicardium?
•
Lining epithelium?
Pericardial sinuses (Clinical correlation)
•
Oblique sinus
•
Transverse sinus
•
Allows clamping of great vessels
during cardiac surgery
Pericarditis (Clinical correlation)
•
Primitive heart tube
HPE
•
Pain?
•
Pericardial friction rub
•
EKG?
•
Rx?
Truncus arteriosus
•
Adult structure
•
Aorta
•
Pulmonary trunk
Persistent truncus arteriosus (Clinical correlation)
•
Neural crest cell Æ
AP septum
Transposition of great arteries
•
Nonspiral development of AP
septum
•
Most common cause of cardiac
cause of cyanosis in the neonatal
period
Tetralogy of Fallot (Clinical correlation)
•
Skewed development of AP septum
•
THINK—”PROVe”
•
PS
•
RVH
•
Overriding of the aorta
•
Ventricular septal defect
•
Trilogy?
•
Pentalogy?
Primitive ventricle and atrium
•
Adult structure
•
•
•
Partial development of AP septum
Egg-on-a-string sign
Bulbus cordis
•
Adult structure
•
Infundibulum/conus arteriosus
•
Aortic vestibule
Sinus venosus
•
Adult structure
Primitive ventricle →Trabeculated
•
Sinus venarum
part of the ventricles
•
Coronary sinus
Primitive atrium →Trabeculated
•
Oblique vein of LA*
part of the atrium
Fetal circulation
•
Ductus arteriosus
•
•
•
Remnant in adults
•
Functional closure--immedeately
(mediated by bradykinin)
•
•
Fetal circulation
•
Umbilical arteries?
•
Umbilical vein?
100% functional closure at 96
hours (Moore)
Anatomic closure--1 to 3 months
•
Foramen ovale
•
Functional closure--immedeately
•
Anatomic closure--1 year
•
Ductus venosus?
•
Foramen ovale?
Ductus arteriosus?
•
IVC →FO →LA
•
SVC →LV
*Langman
Borders
Surface projections
•
Right—RA
•
3rd right costal cartilage
•
Left—LV + LA
•
6th right costal cartilage
•
Inferior—RV
•
2nd left costal cartilage
•
Apex—LV
•
5th left ICS MCL
Surfaces
•
Base/Posterior—LA
•
Anterior—RV
•
Diaphragmatic—LV
Auscultation areas (Clinical correlation)
•
bicuspid valve
•
tricuspid valve
•
pulmonary valve
•
aortic valve
•
Triangle of auscultation?
•
•
•
•
Arterial supply of the heart
•
(L) 5th ICS
4th ICS to the (L) of the sternum
2nd ICS to the (L) of the sternum
2nd ICS to the (R) of the sternum
Internal features
LCA
RA
•
Circumflex artery
•
Anterior IV artery
•
Supplies
•
AV valves
•
S1—closure of AV valves
• vestibule
Rough
• Pectinate
muscles
(Auricle)
• Trabeculae
carnae
• papillar
y
muscle
• chordae
tendina
• Moderator
e
band
• Trabeculae
carnae
• papillary
muscle
• chordae
tendinae
•
Tricuspid--Anterior, septal, posterior
•
•
Semilunar valves—THINK—”LARP”
•
S2—closure of semilunar valves
•
Aortic—right, left, posterior
•
•
Mitral—Anterior, posterior
Pulmonary—anterior, right, left
Where do the coronary arteries
originate?
• Fossa ovalis
• Crista
terminali
s
• Sulcus
terminalis
• Pectinate
muscles
(Auricle)
• Supraventricular
crest
Arterial supply of the heart
•
LV
• Infundibulum
conus arteriosus
Unique features
•
RV
• Sinus venarum • Entrance of
PVs
IV septum?
Heart valves
LA
Smooth
RCA
•
Origin?
•
Marginal artery
•
Posterior IV artery
•
Supplies?
•
SAN, AVN
•
IV septum?
• Wall is 3x
thicker
Arterial supply of the heart
•
LCA
•
Circumflex artery
•
Anterior IV artery
•
Supplies
•
Myocardial infarction (Clinical correlation)
•
Occlusion
•
CABG
•
•
LAD > RCA > LCx
10-year patency
•
IV septum?
•
•
•
•
Diabetic
•
Elderly
•
Heart transplant patients
Infract localization
(Clinical correlation)
Septal wall MI
•
Lateral wall MI
•
Artery occluded?
•
Artery occluded?
•
Seen in what leads?
•
Seen in what leads?
Infract localization
(Clinical correlation)
•
Variations in arterial supply
Inferior wall MI
•
Artery occluded?
•
Seen in what leads?
•
Right dominant (80%)
•
Left dominant
•
Codominant
•
PDA arises from RCA
•
Venous drainage of the heart
•
Radial artery
Silent MI
•
Infract localization
(Clinical correlation)
IMA—95%
Long saphenous vein—50%
Coronary sinus
PDA arises from LCx
Septa
•
Interatrial septum
•
Interventricular septum
•
Great cardiac vein
•
Middle cardiac vein
•
Membranous—MC site of defect
•
Small cardiac vein
•
Muscular
•
Smallest cardiac vein (thebesian)
•
Anterior cardiac vein
Conduction system
•
Slowest velocity?
•
Fastest conduction?
•
Only connection
•
between atria and ventricles?
SAN
AVN
AV bundle
Bundle branches
Purkinje fibers
Triangle of Koch
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