OMS 1 Thorax Clinical Supplement
Tension Pneumothorax definition + S/S
anatomy: rupture of visceral pleura, lung tissue forms 1-way valve (w/ each breath more air enters pleural cavity + becomes trapped) mediastinal shift (trachea + mediastinum pushed away from affected lung; reduces size of pulmonary cavity on contralateral side) -> impaired pulmonary function + compressed diaphragm/vena cava -> less blood to atria -> reduced cardiac output (hypotension) S/S: sudden onset chest pain, dyspnea, reduced breath sounds, hypotension, hypoxia, jugulovenous distension, tachycardia, anxiety, fatigue Requires immediate decompression (emergency = no time for radiographs) - thoracostomy @ 2nd intercostal space at midclavicular line, then chest tube
What can compression of the left recurrent laryngeal nerve be caused by?
aneurysm of aortic arch or enlarged L atrium
What artery supplies the IV septum?
anterior-superior 2/3s of IV septum is supplied by the left coronary artery (incl. AV bundle and right/left bundle branches) posterior-inferior 1/3 is right coronary artery (in R dominant heart)
LIMA left internal mammary artery
antiquated term for the internal thoracic artery commonly used for CABG, especially to bypass the LAD
Coartation of the Aorta
aortic narrowing/constriction 2x more common in males, more common in females w/ Turner syndrome 50% of subjects also have a bicuspid aortic valve
What three points is the aorta fixed to and what are these points susceptible to?
aortic valve, ligamentum arteriosum, and aortic hiatus (diaphragm) susceptible to deceleration trauma (eg tearing from MVA)
Where do most non-penetrating aortic injuries occur?
at the aortic isthmus (between left subclavian artery and ligamentum arteriosum)
Where does the majority of breast tissue lymph drain to?
axillary nodes (anterior/pectoral)
Route of lymph drainage from skin of breast
axillary, inferior deep cervical, infraclavicular and parasternal nodes (lymph from nipple/areola is not included)
Where would fractures of ribs 6-9 have to occur to cause laceration
between head and tubercle
complete bundle block
blockage along the AV bundle results in dissociations between atrial and ventricular contraction
Pulmonary embolism definition
blockage of a branch of the pulmonary artery with a blood clot (DVT), fat droplet or air bubble; often from deep veins in the lower extremity
hemopneumothorax
blood + air
What must you avoid in pericardiocentesis?
branches of the internal thoracic artery
signs/symptoms of breast cancer
breast mass/focule nodule axillary lump, skin dimpling (suspensory ligaments of Cooper) impaired lymphatic drainage (Peau d'orange/orange peel skin) nipple inverts, retracts or has bloody discharge skin ulceration (advanced)
exsanguination can be caused by...
can be caused by laceration of the aorta
what can be compressed by thymic tumors?
can compress trachea or recurrent laryngeal nerve (hoarseness), esophagus (dysphagia), great veins (cyanosis) a significant number of patients with myasthenia gravis have thymic tumors (thymoma)
Thoracic Outlet Syndrome
caused by bony issues (cervical rib or hypo plastic first rib); soft tissue changes (hypertrophic/spastic muscles - ant/middle scalene; fibrous CT band); trauma/tumors S/S: compression of C8 + T1, vascular compression (subclavian a - cold fingers, color changes in hands, claudication, pain)
Most common sites of lung metastases through venous channels are...
central nervous system (brainstem + cerebellum), bone (vertebrae), liver, adrenal gland
esophagus Lymphatic Drainage
cervical part - deep cervical and/or paratracheal nodes Thoracic part - posterior mediastinal abdominal part - left gastric, celiac
Angina Pectoris
chest pain from heart resulting from insufficient supply of oxygen to cardiac muscle
What is the cough reflex and what is its innervation?
clears airway of foreign bodies/irritants sensory = CN 10 Motor = CN 10 + phrenic/ intercostal nn
What heart defect is common in females with turner syndrome?
coarctation of the aorta
Atelectasis
collapse of lung or lobe resulting from blockage of the airway opening to the right middle lobe is the smallest/most narrow -> R middle lobe is most commonly affected obstructive atelectasis may cause mediastinal shift towards the affected lung
Chest tubes purpose + location of insertion
commonly inserted to drain large amounts of air, fluid, etc from the pleural space - tube is inserted at 4th or 5th intercostal space near the midaxillary line
cardiac tamponade
compression of the heart from accumulated fluid in the pericardial sac
What are risk factors for aortic dissection?
congenital: Marfan Syndrome, Ehlers-Danlos, turner syndrome, osteogenesis imperfecta acquired: syphilis, trauma, cocaine use
Aortic dissection
creation of space within the wall of the aorta; this space can accumulate significant amounts of blood resulting in strokes or infarcts
thymic tumor compression of great veins causes..
cyanosis
How can arrhythmias occur?
damage to components of the conducting system (eg loss of blood supply from RCA)
Infantile Coarctation of the Aorta
defect is on aortic arch proximal to PDA (dumps venous blood into aorta) S/S: cyanosis in Lower extremity requires surgery to occlude PDA
Adult Coarctation of the Aorta
defect located opposite the ligamentum arteriosum, distal to great arteries. S/S: hypertension in upper extremity, weak pulses in lower extremity development of enlarged collateral circulation (int thoracic + intercostal aa), rib notching, left ventricle hypertrophy
dyspnea
difficulty breathing
signs/symptoms of breast cancer metastasis
difficulty breathing, bone/back pain, jaundice, neurological (headache, cognitive, sensory/motor)
What can enlarged tracheobronchial/carinal nodes do?
displace the carina and this can be detected on bronchoscopy
thymic tumor compression of esophagus causes...
dysphagia
Rib Fractures lead to what injuries?
flail chest pneumo/hemothorax spleen injury (ribs 9-11 on left) liver injury (lower ribs on right) lacerations of aorta/great vessels (1st/2nd rib) Diaphragmatic hernia (if diaphragm is pierced)
Signs and symptoms of Pulmonary Embolism
from dvt: edema, leg pain/tenderness chest pain, dyspnea, tachypnea, tachycardia, fever, cyanosis
Lymphatic drainage general pattern
generally follows the arterial supply backwards to lymph nodes around the main arterial trunks
thymic tumor compression of recurrent laryngeal nerve causes...
hoarseness
What does compression of left recurrent laryngeal nerve cause?
hoarseness > dysphagia > dyspnea
What are signs and symptoms of aortic dissection?
hypotension, exsanguination (loss of blood), stroke, ischemia, claudication (sign of atherosclerosis,) compression of surrounding structures
What can happen if ribs 6-9 are fractured (between head/tubercle) or dislocated?
impingement or laceration of the descending aorta (exsanguination)
herpes zoster
infection of the posterior root ganglion; produces pain/burning and blisters along the cutaneous distribution of the affected ganglion
Phrenic nerve irritation
inflammation can "refer" pain to shoulder
pericarditis
inflammation of the pericardium, characterized by pericardial friction rub
pleurisy
inflammation of the pleura
intercostal nerve block procedure + what is at risk
injection of anesthesia into the intercostal space anesthesia should be directed between internal and innermost intercostal muscles (along superior aspect of intercostal space) nerves (intercostal nn + collateral branches) are most at risk of iatrogenic injury
Transverse pericardial sinus
insertion of a finger through this sinus puts the aorta and pulmonary artery anterior to the finger (clamping for CABG surgery)
pericardiocentesis location of needle + what's at risk
insertion of needle inferior to the thoracic cage at L xiphisternal junction needle is directed towards the pericardium to remove fluid (blood/pus) from between the serious layers of parietal pericardium and the serous layer of the visceral pericardium (epicardium) Care must be taken to avoid branches of the internal thoracic artery
esophageal constrictions (where things get stuck)
junction with pharynx aortic arch L main bronchus diaphragm at esophageal hiatus
Borders of the cardiac silhouette
left - aortic arch, pulmonary trunk, L auricle, L ventricle Right - R brachiocephalic vein, SVC, R atrium, IVC
anterior interventricular artery
left anterior descending artery
How can esophageal cancer spread?
local spread (to vagus nerve, recurrent laryngeal nerve, trachea, pleura, pericardium) lymph veins (to liver, lungs, vertebra)
Metastasis of cancerous cells from a primary tumor occurs by three mechanisms:
local spread/invasion (includes seeding of pleura and peritoneum - mesothelioma) lymphatic channels blood vessels
Exceptions to lymph drainage
lungs, parts of the liver, oral cavity and tongue (drain bilaterally)
chylothorax
lymph (milky white fluid); injury to thoracic duct
Most common site of metastasis
lymph nodes, liver, and lung
What do most non-penetrating aortic injuries cause?
mediastinal hematoma
how does cancer metastasize to Liver and Lung?
metastasis can move via the blood vessels (most commonly veins) and seed the organ at next major capillary bed which is often these 2 most sarcomas spread predominantly by blood vessels
Horizontal Fissure rib levels (R lung only)
midaxillary line (4th rib), midclavicular line (4th rib)
What determines the dominant coronary artery?
origin of the posterior inter ventricular artery (not how much "heart" is supplied by the right of left coronary arteries - typically left supplies more cardiac muscle)
What is a secondary site of lymph drainage in the breast, especially medial quadrants?
parasternal nodes
How to listen to breath sounds from superior lobes
place stethoscope along anterior chest wall at the costochondral junction Right (above 3rd rib), Left (above 5th rib)
Risk Factors for Pulmonary Embolism
poor venous flow/stasis, recent travel of four hours or more, immobility hyper coagulable states, recent surgery, COPD pregnancy, oral contraceptives, estrogen therapy, smoking
posterior interventricular artery
posterior descending artery
Costochondral Articulation
primary cartilaginous
xiphisternal articulation
primary cartilaginous
parasternal lymph nodes
provide a route for breast cancer to the liver
how can lung cancer spread through venous channels?
pulmonary veins
pyopneumothorax
pus and air
empyema
pus without air, from infection (commonly bacterial pneumonia, abscess)
What is associated with cardiac tamponade/Beck's triad?
rapid heartbeat and muffled heart sounds, distended neck veins, hypotension or weak pulses
Sternocostal articulation
rib 1 - primary cartilaginous (very little movement; when rib 1 moves the rest of the cage goes with it) ribs 2-7 - synovial, plane/gliding
Types of coronary circulation
right dominant (70-75%), left dominant (15-20%) or co-dominant (5-10%)
Where are aspirated foreign objects most likely to go?
right main bronchus (then to middle or inferior lobar branch) because it is shorter, wider and more vertical than the left bronchus
Oblique Fissures rib levels (both lungs)
scapular line (4th rib), midaxillary line (5th rib), midclavicular line (6th rib)
manubriosternal articulation
secondary cartilaginous
Why does the spinal cord misinterpret signals from the body organs about pain?
sensory input converges on relay neurons that also receive innervation from body wall structures, and mistake the organ information for body wall information
what are the three types of pneumothorax?
spontaneous, traumatic, tension
iatrogenic injury from Sternal Biopsy for bone marrow
sternal fracture, pneumomediastinum, pneumothorax or cardiac tamponade
how to listen to breath sounds from inferior lobes
stethoscope along posterior chest wall (scapular line) below the 5th rib
how to listen to Breath sounds from middle lobe
stethoscope along the anterior chest wall, under the 4th rib Right lung only
intercostal nerve block location
superior aspect of the intercostal space
cure for raynaud syndrome
surgical destruction of the sympathetic chain at root of the neck, results in vasodilation of arterioles in the ipsilateral upper extremity
What type of joint is costovertebral?
synovial, plane/gliding
interchondral articulation
synovial, plane/gliding found between costal cartilages of ribs 6/7, 7/8 and 8/9; contact between ribs 9 and 10 is never synovial.
Sternoclavicular articulation
synovial, saddle
What happens in an aortic dissection?
tearing of the tunica intima and subsequent accumulation of blood volume in the wall of the vessel
Where does the left superior lobe rarely drain to?
the carinal nodes
Sternal Angle of Louis
the union of the manubrium and the body of the sternum; associated with the sternal end of the 2nd ribs, landmark for T4, approximates the superior border of the middle mediastinum, arch of the aorta and bifurcation of the trachea
what are important collateral channels that can return blood to the heart via the IVC (caval-caval anastomoses) if SVC is obstructed?
thoracoepigastric vein, internal thoracic vein, vertebral plexus, azygos system
Lymphatic drainage of the right lung
tracheobronchial nodes -> R paratracheal -> R jugulo-venous angle
mesothelioma
tumor of mesothelium, a tissue that lines lungs and other organs (pleura and peritoneum)
Pancoast tumor and its effects
tumor of the lung apex can affect lower trunk of the brachial plexus (Klumpke Palsy) or Cervical sympathetic chain (Horner Syndrome = flushing, ptosis, anhydrosis, miosis)
Esophagus Muscle types
upper 5% - skeletal muscle middle 35% - mix of smooth and skeletal lower 60% - smooth muscle skeletal muscle only found in upper 1/3 of esophagus
Subclavian venipuncture definition + what's at risk
used to gain access to the venous system (central line placement); the vein is punctured inferior to the clavicle - care must be taken to avoid the: a. first rib b. phrenic nerve = hemiparalysis of the diaphragm c. subclavian artery d. cupula of the lung = pneumothorax, hemothorax
thoracocentesis/thoracentesis + where needle is inserted
used to sample pleural fluid or removal of pleural effusions/empyemas most commonly done at the 8th or 9th intercostal space near the midaxillary line and the needle is inserted along the inferior aspect of the intercostal space
Esophagus muscle innervation
vagus nerve
pericardium innervation
vagus nerve, phrenic nerve (inflammation = shoulder pain), sympathetics
path of breast metastasis to vertebrae/brain via venous channels
venous channels -> intercostal veins -> azygos system -> batson's intervertebral plexus -> vertebrae or brain
Path of breast metastasis to lungs/pleura via venous channels
venous channels -> intercostal veins -> azygos system -> lungs or pleura
Where do sympathetic GVE axons distribute?
viscera in the skin (sweat glands, arrector pili, vascular smooth muscle) and deep organs
How often are left circumflex vessels the site of occlusion of coronary arteries?
~20%
how often are anterior inter ventricular vessels the site of occlusion of coronary arteries?
~50%, the "widow maker"
Where do most malignant breast tumors arise from?
~60% from superior lateral quadrant
Why does referred pain occur?
-organs in the body cavity generally yield low levels of pain information to the spinal cord -pain from body cavity organs is poorly mapped -pain from body cavity organs and body wall both synapse on same relay neurons in spinal cord -spinal cord relay neurons are entrained to/prioritize pain from body wall -spinal cord misinterprets pain origin
what are the most common sites of occlusion in coronary arteries?
1. anterior inter ventricular (LAD) - 50% 2. right coronary artery - 30% 3. left circumflex - 20%
Pulmonary valve auscultation
2nd intercostal space just lateral to the sternum, on the L
Aortic Valve Auscultation
2nd intercostal space just lateral to the sternum, on the R
How often is the right coronary artery vessels the site of occlusion of the coronary arteries?
30%
Mitral Valve Auscultation
5th intercostal space at midclavicular line, on the left
Tricuspid valve Auscultation
5th intercostal space just lateral to the sternum, on the L
SA Node arterial supply
60% of people right coronary artery; 40% left; location in cristae terminalis
AV Node arterial supply
85% of people right coronary artery; 15% left
lymphadenopathy
=enlarged lymph nodes cancer can spread through the lymphatic channels -> lymph nodes -> lungs (via jugulo-venous angle) causing this condition most carcinomas spread by lymph
What can surgical repair of a VSD damage?
AV bundle courses in the margin of a VSD; surgical repair can damage the bundle and result in bundle branch block
Open/Traumatic Pneumothorax define + S/S
Anatomy: results from traumatic injury to parietal pleura (rib fx, stabbing), permitting air to enter the pleural cavity from outside (during inspiration) S/S = chest trauma, shortness of breath, decreased breath sounds Chest x-ray = chest wall defect (e.g. broken ribs), line of visceral pleura
spontaneous pneumothorax definition, risk factors, S/S
Anatomy: rupture of visceral pleura (intrapleural or subpleural "bleb"), air from the lung enters the pleural cavity Risk factors: Marfan or Ehlers-Danlos syndrome, tall, thin stature, young (20-30's), smoking S/S = acute onset chest/shoulder pain (worse with inspiration), shortness of breath, decreased breath sounds Chest x-ray = line of visceral pleura (collapsed lung)
upper esophagus sympathetic
CNS = T1-4 pregang = IML postgang = sympathetic chain
heart autonomics - sympathetic
CNS = T1-T4 pregang = IML postgang = sympathetic chain cardiac (splanchnic) nn
upper extremity sympathetic
CNS = T2-7 pregang = IML postgang = sympathetic chain
Lung autonomics - sympathetic
CNS = T2-7 pregang = IML postgang = sympathetic chain
heart autonomics - parasympathetic
CNS = medulla pregang = dorsal vagal nucleus postgang = intramural vagus n
upper esophagus parasympathetic
CNS = medulla pregang = dorsal vagal nucleus postgang = intramural vagus n
Lung Autonomics - parasympathetic
CNS = medulla, pregang = dorsal vagal nucleus postgang = intramural vagus n
Ortner Syndrome
Compression of the left recurrent laryngeal n from a cardiovascular etiology: enlarged L atrium (from mitral valve stenosis), aneurysm of the aortic arch hoarseness > dysphagia > dyspnea
Lymph from lower quadrants of breast drains to...
Drains to inferior phrenic nodes (route for mets to liver)
parietal pleura innervation
GSA costal + peripheral diaphragmatic - intercostal nerves mediastinal and central diaphragmatic - phrenic nerve (referred pain to shoulder)
Referred pain from the heart
GVA innervation to the heart arises from spinal cord levels T1-4 (pseudounipolar neuronal cell bodies in DRG at these levels); pain from myocardial infarction is perceived along these dermatomes on the left
Visceral pleura innervation
GVA- no pain innervation
Lymphatic drainage of the left lung
L superior lobe: superior tracheobronchial -> L paratracheal -> L jugulo-venous angle L inferior lobe: inferior tracheobronchial/carinal nodes -> R paratracheal -> R jugulo-venous angle
What coronary artery generally supplies more cardiac muscle?
Left
Structures at risk during mastectomy or radical dissection of diseased axillary lymph nodes
Long thoracic nerve (winged scapula) Intercostobrachial nerve (sensory loss in medial arm/ axilla) Pectoral nerves (weakness in medial rotation; adduction of humerus) (also thoracodorsal n)
What are the anastomoses of the coronary arteries?
RCA to circumflex artery LAD (Anterior IV) to PD (Posterior IV) and within IV septum
What can be produced by the sternum?
Red bone marrow
What coronary artery is most often dominant
Right coronary (70-75%)
Which artery most commonly supplies the SA and AV nodes?
Right coronary artery
SVC syndrome definition, causes, S/S
SVC obstruction 70-90% are caused by mediastinal malignancy (lung cancer, lymphoma) S/S: cyanosis, dyspnea, facial/arm swelling, distention of neck and thoracic wall veins, cough, hoarseness, chest pain, dysphagia caval to caval anastomoses can maintain some degree of collateral venous return to the heart via the inferior vena cava.
Hemoptysis
Spitting blood from lungs bleeding from airway is from bronchial a >> pulmonary arteries; compare to hematemesis (blood from GI)
Key thoracic wall Dermatomes
T4-nipple T6-xiphoid
most common ganglion levels affected by herpes zoster?
T5-T10 - ~66% of cases of herpes zoster eruptions
inferior limit of visceral and parietal pleura during quiet respiration (costodiaphragmatic recesses)
Visceral: scapular line 10th rib, midaxillary line 8th, midclavicular line 6th. Parietal: scapular line 12th, Midaxillary Line 10th, Midclavicular line 8th
Costovertebral articulation information
With vertebral body or with transverse processes Ribs 2-10 articulate with the superior facet of the same number vertebra and the inferior facet of the superior vertebra and the intervening intervertebral disc Ribs 1, 11 and 12 articulate only with the thoracic vertebra of the same number Ribs 11 and 12 do not articulate with transverse processes
pectus excavatum
a depression of the sternum, associated with exercise intolerance, dyspnea, chest pain; funnel chest
spinal anesthesia effect on sympathetics
a high spinal anesthetic may impair sympathetic relay and produce temporary vasodilation
Pleural space
a potential space between the visceral and parietal layers of pleura
What type of heart is more likely to have better collateral circulation?
a right dominant
what is maintained in the pleural space?
a vacuum (negative pressure) that is needed for breathing If this space is disrupted (air, blood) the lung cannot function properly
pericardial effusion
accumulation of fluid in the pericardial space
pleural effusion
accumulation of fluid in the pleural cavity
hydropneumothorax
air and fluid
pneumothorax
air in the pleural cavity
Pectus Carinatum
an anterior protrusion of the sternum, associated with dyspnea, frequent respiratory tract infections, common in scoliosis; pigeon chest
