Thorax I,II,III

Innermost intercostal muscles.

This muscle group is just on the lateral portion of front and back ribs. Fibers angled outward.

Subcostal msucles

This muscle group is only located on back ribs and extends across multiple levels.

Transversus thoracis

This muscle group is only on the back of the front ribs and it extends to costal cartilages.

External intercostal muscle

This type of intercostal muscle: - most external/outermost - doesn't extend all the way to sternum, stops laterally - its membrane extends to sternum - fibers angled inward

Located in brain stem and fibers sent through vagus nerve

Where are preganglionic parasympathetic cell bodies located and where are those fibers sent through which will synapse at the target organ?

Along costal margin and L1-L3 verterbrae.

Where does the diaphragm attach?

Head of rib

Which part of the ribs articulates posteriorly with the costal facet (located in front of pedicle) of each vertebrae?

In the upper extremities because that's where they're going to.

If things that come out of the Superior thoracic aperature, such as the T1 spinal nerve, lungs, thymus, subclavian artery and vein are compressed, where will the symptoms show?

Sympathetics above T1 and below L2: - fibers would still enter sympathetic chain at white rami communicans but only at T1-L2 levels, then those preganglionic fibers would travel up to the specific level in chain and synapse with postganglionic sympathetic cell bodies, then at that level those postganglionic sympathetic fibers would travel out through grey rami communicans --> dorsal and ventral rami.

Main difference between sympathetics within T1-L2 and sympathetics above T1 and below L2?

Thoracic splachnic nerves

Main type of nerve the postganglionic sympathetic fibers travel through to get to the lungs?

Inferior posterior intercostal veins drain into hemiazygos vein --> azygos vein --> superior vena cava

Posteriorly, on the left side where do inferior posterior intercostal veins drain?

Superior posterior intercostal veins drain into accessory hemiazygos vein, then crosses to right side to drain into azygos vein --> superior vena cava.

Posteriorly, on the left side where do superior posterior intercostal veins drain?

Posterior intercostal veins --> azygos vein --> superior vena cava

Posteriorly, on the right side how do posterior intercostal veins drain?

True!!

T/F: Phrenic nerve adheres to the outer part of the fibrous pericardium and heads down toward diaphragm.

True!!!..&

T/F: The anterior and posterior vagal trunks enter the abdomen with the esophagus to continue providing parasympathetic innervation.

Yep!

T/F: The phrenic nerve carries GSA, GSE, GVE sympathetics.

Coronary artery bypass graft

2nd way to treat heart attack that includes creating alternate means for blood to get to vessel. When occlusion is more severe.

Left anterior descending (LAD)/ anterior interventricular artery Left circumflex artery Left marginal artery

3 branches that come off the left coronary artery?

tiny branch to SA node Right posterior descending artery / Posterior interventricular artery (on posterior side of heart) Right marginal artery

3 branches that come off the right coronary artery?

posterior intercostal arteries on both sides bronchial artery esophageal artery

3 branches that the descending/thoracic aorta give rise to?

Top portion: manubrium Bottom portion: Body Bottom tip: Xiphoid process Sternal angle: in between manubrium and body

3 main components of the sternum?

1. Keep intercostal spaces rigid 2 and 3. Maintain spacing and coordination.

3 main purposes of intercostal muscles?

General Somatic Afferent (sensory) General Somatic Efferent (motor) General Visceral Efferent (sympathetics)

3 main types of information that the Phrenic Nerve supply?

i8 10 eggs at 12. T8 = inferior vena cava passes through (caval opening) T10 = esophageal hiatus (esophagus passing through) T12 = aortic hiatus (aorta passing through)

3 major openings within diaphragm?

Serratus Posterior Superior Serratus Posterior Inferior Pec minor Scalenes

4 accessory muscles of Respiration?

1. divides superior and inferior mediastinum 2. located at T4 intervertebral disc 3. where trachea bifurcates 4. distinguishes arch of aorta from ascending and descending aorta

4 characteristics associated with sternal angle?

Cervica pleura, costal part, diaphragmatic part, mediastinal part

4 parts of the parietal pleura?

Internal thoracic vessels Thymus (in children) Fat Lymphatics (LIFT)

4 structures withi the Anterior mediastinum?

Superior, middle and inferior cervical cardiac nerves and thoracic splachnic nerves

4 types of nerves that postganglionic sympathetic fibers travel through to get to the heart?

Thoracic descending aorta Esophagus Thoracic duct Azygos & hemiazygos veins Vagus N (CN X) V-DATE

5 structures within Posterior Medastinum?

Thymus Great vessels (aorta and pulmonary trunk) Trachea Esophagus Thoracic duct Vagus (CN X) Phrenic nerve (PVT GET T)

7 structures within the Superior mediastinum?

Pericardium Phrenic nerves Heart Ascending aorta* Pulmonary trunk Superior vena cava Arch of azygos vein Primary bronchi (peter parker has a PP)

8 strucutres within Middle mediastinum?

Left vagus nerve gives off left recurrent laryngeal nerve which loops under arch of aorta and ligamentum arteriosum. Right vagus nerves gives off right recurrent laryngeal nerve which loops under the subclavian artery.

Branches that the left and right vagus give off and where they loop under?

Yes it can

Can intercostal nerves carry GSA, GSE, GVE fibers?

1. right pulmonary plexus 2. left pulmonary plexus 3. Cardiac plexus 4. esophageal plexus

Cervical and thoracic splachnic nerves form which 4 plexuses?

1 neuron pathway and yes.

For the GVA pathway, is it a 1 or 2 neuron pathway, and does one fiber coming in with cell body in dorsal root ganglion and enter in the dorsal root to the spinal cord (no synapsing in chain)?

Treat heart attack by removing clot, and placing this to open up blood vessel and allow blood supply in vessel.

Function of stents?

Aorta + pulmonary trunk

Great vessels = ?

Pre-ganglionic sympathetic cell bodies located in lateral grey horn. Those fibers travel to ventral root --> spinal nerve --> ventral ramus --> entering sympathetic chain via white rami communicans --> synapse on postganglionic sympathetic cell bodies located in chain --> postganglionic sympathetic fibers travel out of the chain via grey rami communicans ---> ventral + dorsal ramus

How do sympathetics travel from lateral gray horn in the body wall?

Inserting needle with anesthesia below the rib, angled superiorly, not penetrating intercostal nerve but bathing the nerve with anesthesia. (may not produce complete anesthesia due to overlapping dermatones)

How do you do intercostal nerve block?

Each rib articulates with the inferior costal facet of the Thoracic vertebra above. Each rib articulates with the superior costal facet and transverse costal facet of the vertebra on the same level.

How does each rib articulate with: 1. superior costal facet 2. inferior costal facet 3. transverse costal facet

Depending on if posterior interventricular artery comes off left or right coronary artery

How does one determine if they are right or left heart dominant?

3 lobes - Superior, middle, inferior 3 fissures - Oblique and horizontal tissue

How many lobes does the right lung have? How many fissures and what are they called?

12

How many ribs are there total?

You know. look at slides.

Identify all parts of this radiograph.

Thoracic outlet syndrome

If any boundaries surrounding the superior thoracic aperature become injured (more than likely at the root of neck), clinical manifestations will show in the upper extremities. What is this syndrome called?

Anterior ribs = angled inferiorly Posterior ribs = horizontal

In an x-ray, how does the anterior ribs look? What about posterior ribs?

C3-C5 dermatonal levels (shoulder area)

In referred pain, pain from the diaphragmatic pleura and peritoneum is referred which dermatonal levels?

Greater, lesser and least splachnic nerves

In which type of splachnic nerves do they NOT synapse in the sympathetic chain and most fibers descend into abdomen and synapse in abdominal preverterbal ganglia?

Cervical and thoracic splachnic nerves (cardiopulmonary splachnic nerves)

In which type of splachnic nerves does the preganglionic fiber synapse in the sympathetic chain and these nerves innervate thoracic viscera?

Central tendon and muscular portion

2 components of diaphragm?

Cardiac impression anteriorly and aortic impression posteriorly

2 impressions in left lung?

Cardiac impression anteriorly and esophageal impression posteriorly

2 impressions in right lung?

between the internal intercostal muscle and innermost intercostal muscles.

the intercostal nerve dives in between which 2 intercostal muscles?

Right side

Is the azygos vein located on the right or left side posteriorly?

Pleural cavity

Lungs sit within which cavity?

Heart, left and right lung

Main 3 components of the thorax?

Internal intercostal muscles + innermost intercostal muscles

Neurovascular bundles (intercostal vein, intercostal artery, intercostal vein) run between which 2 muscles in thoracic wall?

Azygos system

Posteriorly, the posterior intercostal veins use which system to get to superior vena cava?

Anteriorly: sternum Posteriorly: vertebrae

Structure anterior to thorax? Structure posterior to thorax?

Sternal angle

Structure where the manubrium and body of the sternum come together?

Yep.. that's why its innervated still by Phrenic nerve from C3 C4 C5 spinal levels.

T/F: Diaphragm is originally higher up, but it descends down and pulls its innervation with it.

True!!!

T/F: In lab, can see through external intercostal membrane to see internal intercostal muscles, which extend all the way to the sternum and its fiber extend outward.

Yeee

T/F: The right primary bronchus is wider, shorter and more vertical than left primary bronchus. Meaning if you inhale something, object more likely to go to right bronchus.

Very true.

T/F: There's only 1 intercostal nerve extending from posterior to anterior.

Yes..

T/F: as we inhale: increase in distance in transverse plane, increase in distance across anterior to posterior plane, and increase in distance across superior to inferior plane as diaphragm contracts and depresses.

True!!!..

T/F: intercostal nerves matching a dermatone pattern = segmental innervation.

Truee

T/F: the fibers of the internal intercostal muscles and innermost intercostal muscles run outward diagonally.

True..

T/F: the thoracic wall receives blood from anterior and posterior intercostal arteries.

T4 = nipple T10 = umbilicus L1 = groin

T4 dermatone where ? = T10 = ? L1 = ?

C5, C6, C7

The axillary nerve innvervating the deltoid carries which 3 spinal levels?

T1 ventral ramus

This contributes to the bracial plexus and gives rise to intercostal nerves.

Visceral pleura

This part of the pleura adheres to the lungs.

Parietal pleura

This part of the pleura surrounds the lungs and is stuck to walls of pleural cavity.

Coronary bypass surgery

This procedure involves clamping the aorta and pulmonary trunk at the transverse sinus to stop blood from going through the heart during surgery.

transverse pericardial sinus

This sinus is found posterior to aorta and pulmonary trunk.

Oblique pericardial sinus

This sinus is found when you put your hand at the back of the heart all the way up until you feel the reflection of the visceral and parietal pericardium.

Diaphragm

This structure separates the thoracic and abdominal cavities.

Anterior, middle (pericardial sac), posterior mediastinum

What is the inferior mediastinum further divided into?

Intercostal nerves. If pain here, it's referred to costal margin of anterolateral abdominal wall.

What is the peripheral diaphragm innvervated by and if there's pain here, where is the pain referred to?

Area of reflection of where visceral pleura is reflecting onto parietal pleura.

What is the pulmonary ligament?

Costal groove

What part of the rib is in the inferior edge of each rib and is important for neurovasculature?

Thoracocentesis - insert needle in 9th intercostal space to drain fluid, superior to rib

When a patient who has a collapsed lung and fluid filling in the pleural cavity, if they're sitting upright the fluid will accumulate in the diaphragmatic recess (lowest part of pleural cavity), so what can be used to drain that fluid?

Left dominant

When posterior interventricular artery arises from the circumflex branch of LCA.

Right dominant (majority of people)

When posterior interventricular artery arises from the right coronary artery. Blood supply to heart is balanced between L and R coronary arteries.

In sympathetic chain

Where are postganglionic sympathetic cell bodies located?

Lateral gray horn at levels T1-L2 only.

Where are the only places where preganglionic sympathetic cell bodies can be located?

Somewhere along lateral thoracic wall

Where do anterior and posterior intercostal arteries anastomose?

Anterior intercostal veins --> internal thoracic vein --> right subclavian vein --> brachiocephalic vein --> superior vena cava

Where do anterior intercostal veins drain into?

Sympathetics come from lateral grey horn in upper thoracic levels and those preganglionic fibers synapse in sympathetic chain, and postganglion sympathetic fibers go to the heart and lung.

Where do sympathetic fibers come from and where do they synapse to get to the heart and lungs?

Internal thoracic artery (which is branch off right subclavian artery)

Where does the anterior intercostal arteries arise from?

Lateral cutaneous branch of ventral T2 ramus

Where does the intercostobrachial nerve arise from?

Thoracic/descending aorta

Where does the posterior intercostal arteries arise from?

On left lung, anteriorly at bottom of cardiac impression

Where is the lingula located?

Pleural cavity located in between visceral and parietal pleura. Contains serous fluid that allows 2 layers to easily slide past eachother as we breathe.

Where is the pleural cavity located and what's within it, for what reason?

wall of target organs

Where is the postganglionic cell body located in parasympathetics?

Superior mediastinum = located above sternal angle Inferior mediastinum = located below sternal angle (At T4)

Where is the superior mediastinum located? inferior mediastinum?

anterior intercostal arteries = bottom of front ribs posterior intercostal arteries = bottom of back ribs

Where on the ribs are anterior intercostal arteries located? Posterior intercostal arteries?

At 7th or 8th intercostal space

Where would you insert a chest tube in a person with a collapsed lung/pneumothorax?

From right to left: - Brachiocephalic trunk/artery which gives rise to right subclavian artery and right common carotid artery - Next branch: left common carotid artery - Next branch: left subclavian artery

Which 3 large vessels arise from arch of aorta in order?

1, 11, 12

Which 3 ribs are the only exceptions to how they usually articulate because they only articulate with the vertebral body of the same level?

1. great cardiac vein (anterior side) - runs with anterior interventricular artery 2. middle cardiac vein (on posterior side) - runs with posterior interventricular artery 3. small cardiac vein - runs with right coronary artery

Which 3 veins drain into the coronary sinus of the heart and which arteries do they run with?

Parietal pericardium mediastinal pleura central diaphragmatic pleura central diaphragmatic peritoneum come cook me pasta

Which 4 structures does the phrenic nerve carry sensory information (General Somatic Afferent) from?

1. irritation 2. ischemia 3. severe stretch 4. not true pain

Which 4 types of nociceptive fibers follow sympathetics?

1. cough 2. stretch 3. blood pressure 4. blood gases

Which 4 types of reflexive fibers follow the parasympathetics (vagus)?

index = C6 middle = C7 ring = C8

Which dermatones are associated with the index, middle and ring finger?

Internal intercostal muscles

Which intercostal muscles cause depression of ribs when we exhale?

External intercostal muscles

Which intercostal musles cause elevation of ribs when we inhale?

Phrenic nerve. Made up of C3, C4, C5.

Which nerve innervates the diaphragm and which spinal levels is made up of?

Costal tubercle

Which part of the rib articulates with the transverse costal facet of each vertebrae on the same level?

Body of rib

Which part of the rib comes forward?

Costal angle

Which part of the rib is where the rib turns anteriorly?

Ventral primary rami of T1-T11 become intercostal nerves and travel at every rib space between T1-T11.

Which primary rami become intercostal nerves and where do they travel?

Ventral primary rami of T12 become subcostal nerve and travels below the 12th rib.

Which primary rami becomes the subcostal nerve and where does it travel?

False ribs (8-10)

Which ribs articulate with the costal cartilages from ribs above them?

True ribs (1-7)

Which ribs articulate with the sternum through costal cartilages?

Floating ribs (11-12)

Which ribs have no anterior articulation, and only attach posteriorly?

Between T1 and L2.

Which spinal levels can white rami communicans only be found?

1 major segment 2 minor overlapping segments

Which spinal segments are contributing to each dermatone?

7th rib articulates with: - Inferior costal facet of T6 vertebrae. - Superior costal facet of T7 vertebrae. - Transverse costal facet of T7 vertebrae.

Which superior costal facet, inferior costal facet and transverse costal facet does the 7th rib articulate with?

T4

Which thoraic vertebrae is the sternal angle at?

left vagus nerve*

Which vagus nerve shifts anteriorly to form the anterior vagal trunk?

right vagus nerve*

Which vagus nerve shifts posteriorly to form the posterior vagal trunk?

T1-T12

Which vertebrae articulate with the ribs?

Liver right underneath right hemidiaphragm and the heart is sitting on left hemidiaphragm

Why does the right hemidiaphragm sit up a little higher than the left hemidiaphragm?

Heart attack

Occurs when plaque builds up in coronary arteries blocking the flow of blood to heart. That area of heart the blood vessel is supplying will die.

Esophageal plexus

What do the right and left vagus nerves contribute to?

1. subclavian artery and vein 2. lungs 3. thymus 4. T1 spinal nerve

What 5 things emerge out of the Superior thoracic aperature?

1. transversus thoracis 2. innermost intercostal muscles 3. subcostal muscles

What are the 3 muscle groups making up the innermost layer?

Inferior portion of the body of the sternum, costal margin, and 12th thoracic vertebrae.

What are the boundaries of the Inferior Thoracic Aperature?

Manubrium of sternum, 1st rib, 1st thoracic vertebrae

What are the boundaries of the Superior Thoracic Aperature?

Greater (T5-T9), Lesser (T10-T11), least (T12) Innervate viscera in abdomen

What are the levels for the greater, lesser and least splachnic nerves and what do they innervate?

Mediastinum

What area sits between the 2 lungs?

Trachea

What bifurcates to form the primary bronchi (1 going to each lung)?

pharyngeal cartilages

What do the pharyngeal arches give rise to?

smooth muscle and connective tissue

What does the splanchnic mesoderm give rise to?

Things that are coming out of the Superior Thoracic Aperature.

What is meant by clinical thoracic outlet?

They carry a single spinal nerve and follow a single dermatonal pattern.

What is meant by segmental innervation by ventral rami/intercostal nerves?

Segmental

AKA tertitary bronchi?

Apex

_____ of the heart is located in the 5th rib space on the left side.

Yes!!!

Are grey rami communicans located at every level throughout the vertebral column?

Yeppp...

Are pulmonary arteries located more superiorly to pulmonary veins?

No...

Are there any parasympathetics to the body wall?

Nooooo

Are you supposed to have air/blood in the pleural cavity?

Between T1 and L2

Between which spinal levels can there only be preganglionic sympathetic cell bodies and white rami communicans?

Yepp!

Do intercostal nerves carry information from 1 spinal level?

Just anterior intercostal veins.

Does anterior or posterior intercostal veins follow arterial pattern?

Yeeeep

Does each primary/main bronchi divide into secondary/lobar bronchi?

Yupppppppp

Does the left lung just have an oblique fissure with 2 lobes - superior and inferior?

Yeppp

Does the pattern of intercostal nerve innervation follow that of the dermatones?

Yes, to viscera (sympathetic vasomotor)

Does the phrenic nerve supply General Visceral Effferent information?

Exhalation (less space in thoracic cavity)

Does this image show inhalation or expiration?

Inhalation (more air filling lungs)

Does this image show inhalation or expiration?

Inhalation: diaphragm moves inferiorly Exhalation: diaphragm moves superiorly

During inhalation, does the diaphragm move superiorly or inferiorly? What about during expiration?

Right and left coronary arteries

First 2 branches off the ascending aorta?

anterior interventricular artery

Most common area of blockage within coronary arteries?

Right and left hemidiaphragm

The Phrenic nerve supplies motor information (General Somatic Efferent) to what?

primordial pharynx (gut tube)

The respiratory diverticulum (lung bud) develops from what at approx 4 weeks?

lung

There is one secondary/lobar bronchi for each lobe of each ____?

GVE (general visceral efferent) sympathetics

These fibers come from sweat glands and in blood vessels.

GSE (general somatic efferent)

These fibers come from ventral grey horn and innervate muscles (ie intercostal).

GSA (general somatic afferent)

These fibers come into body wall with cell bodies in dorsal root ganglion/

Cervical and thoracic splachnic nerves

These type of splachnic nerves: - Carry pre-ganglionc sympathetic fibers - Synapse in sympathetic chain - Innervates thorax

Greater (T5-T9), lesser (T10-T11), least (T12) splachnic nerves

These type of splachnic nerves: - Carry pre-ganglionic sympathetic fibers - Don't synapse in sympathetic chain, but synapse in abdominal prevertebral ganglia - Innervates abdominal viscera

Hypoplastic first rib (may compress brachial plexus underneath clavicle)

Very small first rib that didn't develop normally. May form psuedoarthrosis with 2nd rib.

Shingles (Herpes Zoster Infection)

Viral disease of spinal ganglia. Often due to reactivation of chickenpox virus. Pain and skin lesions along a dermatone.

epithelium and glands of respiratory system

What 2 things does the endoderm of the gut tube give rise to?

1. floor of axilla 2. medial and posterior arm

What 2 things does the intercostobrachial nerve supply cutaneous innervation to?

Lateral and anterior cutaneous branches

What 2 types of cutaneous branches does intercostal nerves give off?