Spring 25 - AHA Test 2 Flashcards
1
Q
What items define the thoracic cage?
A
- Sternum
- 12 pairs of ribs
- 12 pairs of thoracic vertebra
2
Q
Thoracic cage divided into?
A
- Anterior thorax
- Posterior thorax
- RIbs are in the anterior and posterior thorax
3
Q
What are the True ribs, and how do they attach?
A
1 - 7
Attach directly to the sternum
4
Q
What are the False ribs, and how do they attach?
A
8 - 10
Attach to the costal cartilage above
5
Q
what are the Free-floating ribs, and how do they attach?
A
11 & 12
Tips can be palpated
6
Q
Which joint can be found between the head of the rib and the transverse costal facet of the corresponding vertebra
A
Posterior Costotransvere joint
7
Q
Which joint can be found Between the head of the rib, the superior costal facet of the corresponding vertebra, and the inferior facet of the vertebra
A
Posterior Costovertebral joint
8
Q
Which Rib is shorter and wider than the other ribs, with only one facet on its head for articulation with its corresponding vertebra?
A
Rib 1
9
Q
Which rib is thinner and longer than rib one and has two articular facets on the head?
A
Rib 2
10
Q
Where does the serratus anterior muscle originate from?
A
The roughened area on the upper surface of Rib 2
11
Q
Which Rib Only has one facet – for articulation with its
numerically corresponding vertebra?
A
Rib 10
12
Q
Which ribs have no neck and only contain one facet, which is for articulation with their corresponding vertebra.
A
Rib 11 & 12
13
Q
What are the Main structures of the Anterior thoracic cage?
A
- Suprasternal notch
- Sternum
- Manubriosternal angle
- Costal angle
14
Q
Describe suprasternal notch
A
U-shaped depression just above sternum between clavicles.
15
Q
Parts of the sternum
A
- Manubrium
- Body
- Xiphoid Process
16
Q
What is the location of the Manubriosternal angle: “Angle of Louis,” “Sternal Angle”?
A
At articulation of manubrium and sternum, and continuous with
second rib
17
Q
How is the Manubriosternal angle identified?
A
Palpate lightly to second rib and slide down to second intercostal space
18
Q
What is the importance of the Manubriosternal angle: “Angle of Louis,” “Sternal Angle”
A
- Marks site of tracheal bifurcation into right and left main bronchi
- Corresponds with upper border of atria of the heart, and it lies above fourth thoracic vertebra on back
19
Q
Where do the right and left costal margins meet?
A
They meet at the xiphoid process.
20
Q
What are the posterior Thoracic Landmarks?
A
- Vertebra prominens
- Spinous processes
- Inferior border of scapula
- Twelfth rib
21
Q
What is the location and function of the Vertebral prominens?
A
Seventh Cervical Vertebra
* Flex your head and feel for most prominent bony spur protruding at base of neck.
* Largest and most inferior vertebra in the neck region.
* “No split at the tip”.
22
Q
What is the location of the Inferior border of the scapula:
A
Lower tip is usually at the 7th or 8th Rib
23
Q
What is the location of the 12th rib
A
Palpate midway between spine and a
person’s side to identify its free tip.
24
Q
What are the reference lines for the Anterior chest:
A
- midsternal
- midclavicular line
25
What are the Reference lines for the Posterior chest?
- Vertebral (midspinal) line
- Scapular line
26
Reference lines for lateral chest
- Anterior axillary line
- Posterior axillary line
- Midaxillary line
27
What structures enclose the Thoracic Cavity?
* ribs
* Sternum
* vertebral column
* top of diaphragm
28
What essential systems are housed/pass through the Thoracic Cavity?
* Respiratory
* Cardiovascular
* Nervous
* Immune
* Digestive
29
What is the Content of the mediastinum?
Ø esophagus
Ø trachea
Ø heart
Ø great vessels
30
How many lobes on R lung?
3
31
How many lobes on L lung
2
32
What is the Name and location of the highest point of lung tissue?
Apex
Sits 3 to 4 cm above inner 1/3 clavicle
33
What is the Name and location of the lower border of the lung?
Base
Sits arounf 6th rib, midclavicular line
34
Which lung has no middle lobe?
Left one
35
What form an envelope between the lungs and the chest wall?
Pleura
36
What type of pressure is found in the pleural cavity?
Vacuum (Negative pressure) that holds the lung tightly against the chest wall
37
The Pleural cavity is also known as?
Potentional Space
Filled with a few ml of lubricating fluid
38
Location and description of oblique fissure
On anterior chest, oblique fissure crosses fifth rib in midaxillary line and terminates at sixth rib in midclavicular line.
39
Where would you look for almost all the lateral lobes of the lung?
Posterior chest
40
Where does the trachea lie compared to the Esophagus, and how long is it?
The trachea lies anterior to the esophagus and is 10 to 11 cm long in adults.
41
R vs L main bronchus
The right main bronchus is shorter, wider, and more vertical than the left main bronchus
42
What Cells secrete mucus in the airway
Goblet cells
43
What is the second most dx cancer?
Lung cancer
44
What disease affected more than 1/3 of the world population
TB
45
What is the most chronic disease in childhood
Asthma
46
What are the 5 As of smoking counseling
- Ask
- Advise
- Assess
- Assist
- Arrange
47
Pediatric Hx red flags
- Frequent colds
- Hx of allergy
- Cough/congestion
- Noisy breathing or wheezing
- Rule out foreign bodies in airway
- hx of 2nd hand smoke exposure
48
What is the appropriate ratio of AP to Transverse diameter
0.70 - 0.75
49
How is Tactile (or vocal) fremitus assessment performed?
Using hands to assess for palpable vibrations
* Repetition of phrases by patient (“99” or “blue moon”)
* Be aware of factors that can influence normal intensity.
50
What is percussion?
Determine predominant note over lung fields starting at apices and percuss band of normally resonant tissue across tops of both shoulders
51
What is auscultation?
LISTENING to the passage of air through the tracheobronchial tree creates a characteristic set of noises that are audible through the chest wall.
52
What are the three types of breath sounds heard in adults?
- Bronchial, sometimes called tracheal or tubular
- Bronchovesicular
- Vesicular
53
Describe Atelectatic crackles
(Not pathological) Short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths
54
Describe Stridor
Inspiratory crowing sound, loudest in the neck
55
What are the discontinuous sounds
- Crackles (fine/coarse)
- Atelectatic crackles
- Pleural friction rub
56
What are the continuous sounds
- Wheeze (sibilant / Sonorous rhonchi)
- Stridor
57
How is voice perceived through a stethoscope?
Normal voice transmission is soft, muffled, and indistinct; you can hear sound through a stethoscope but cannot distinguish exactly what is being said.
58
Pathology that increases lung density do what to voice?
Enhances transmission of voice sounds.
59
List abnormal findings of Tactile Fremitus
- Increased tactile fremitus
- Decreased tactile fremitus
- Rhonchial fremitus
- Pleural friction fremitus
60
What would the Percussion finding be in the Right hemithorax?
The upper border of liver dullness is located in fifth intercostal space in the right midclavicular line
61
What would the Percussion finding be in the Left hemithorax
Tympany is evident over gastric space.
62
What is force expiration time
Number of seconds it takes to exhale from
total lung capacity to residual volume.
63
Normal SpO2
97 - 98%
64
Every SpO2 result must be evaluated in context of
Hgb level, acid-base balance, and ventilatory status.
65
Describe infant thorax
Rounded thorax with an equal anteroposterior-to-transverse chest diameter.
66
What changes are expected by age 6 in Child's thorax?
By age 6 years, thorax reaches adult ratio of 1:2
67
What is the Newborn’s first respiratory assessment to measure the successful transition to extrauterine life?
Apgar
68
What is the newborn's chest circumference compared to that of their head?
Newborn’s chest circumference is 30 to 36 cm. 2 cm smaller than head circumference until 2 years of age
69
The infant is obligate nose breather until what age
3 months old
70
In infants, are Brief periods of apnea less than 10 or 15 seconds common?
Yes
71
Where would you position the stethoscope on the infant?
Try using smaller pediatric diaphragm endpiece, or place bell over infant’s interspaces and not over ribs
72
What are the main Respiratory changes during pregnancy?
- Thoracic cage may appear wider.
- Deeper respirations and an increase in tidal volume by 40%
73
What are the pulmonary clues to chronic dyspnea?
Alveolar, interstitial, obstruction of airflow, restrictive, or vascular
74
What are cardiac clues of chronic dyspnea?
- Dysrhythmia
- Heart failure
- Restrictive or constrictive pericardial or valvular disease
75
What are GI clues of chronic dyspnea?
Aspiration (Aspiration pneumonitis doesn't require and abx)
76
What are neuromuscular clues of chronic dyspnea?
- Respiratory muscle weakness
- MS
- Muscular distrophy
77
Psychological clues of chronic dyspnea
Anxiety
78
Common Respiratory Conditions
- Atelectasis, lobar pneumonia, or bronchitis
- Emphysema or asthma (reactive airway disease)
- Pleural effusion (fluid) or thickening
- Pneumocystis jiroveci (P. carinii) pneumonia
- Tuberculosis
- Pulmonary embolism
- Acute respiratory distress syndrome (ARDS)
- Lung cancer
79
What are three requirements for the dx of COPD
- Productive cough for greater than 3 months
- 2 successive years
- Not attributed to another cause
80
What are the COPD Gold Classification
81
When would an ABG be helpful for a COPD patient?
* suspected hypoxemia
* Suspected hypercapnia
* When post-op ventilator management is likely
82
When would you consider a dx Chest X-ray on a COPD patient?
* changes noted from baseline
* Com-morbid cardiac and respiratory problems
* Major intrathoracic or intrabdominal surgeries
83
What are some Post-op pulmonary complications for the COPD patient?
Ø atelectasis
Ø respiratory infections exacerbation of underlying pulmonary disease
Ø Hypoxemia
84
What chronic inflammatory disease affects the Airways, causing bronchial hyperresponsiveness and airflow obstruction?
Asthma
85
What is the pathology of Asthma?
* chronic airway inflammation
* increased bronchial smooth muscle mass
* mucus hypersecretion
* luminal narrowing
86
What are pre- and post-op concerns for patients with asthma?
- Bronchospasm
- status asthmaticus
87
What is the ARISCAT scoring?
It is a prediction tool used to predict the risk of postoperative pulmonary complications (PPCs) in surgical patients.
88
What is the ARISCAT Scoring range?
Score < 20 = Low risk
Score 20 - 44 = Intermediate
Score > 44 = high risk
89
What are the grounds for canceling elective surgery on Asthmatic patients?
- active wheezing
- poorly controlled asthma
- respiratory infection (in the previous 6 weeks)
90
What is Cystic Fibrosis?
Autosomal disorder is found on the epithelial cells and most exocrine glands
91
What does the Cystic Fibrosis mutation cause?
- Abnormal / thickened secretions
- Abnormalities of other systems
92
What will the Pulmonary Function Tests of a CF patient look like?
- Decreased FEV1
- Decreased FEV1 to FVC ratio
- Increased residual volume
93
What will the Lung of a CF patient sound like?
- Wheezing
- Sounds consistent with upper airway secretions
94
Anesthesia Care Plan patient with Cystic Fibrosis
- Avoid general anesthesia if possible
- Restrict fluids
- Optimize pain control
- Chest Physiology
- Use of I.S.
95
What is the disease presentation and progression for CF?
- Cough, sputum production wheezing, decreasing exercise tolerance should be investigated
(Only treatment is lung transplant)
96
What are CF-related co-morbidities?
- Diabetes
- Liver disease
- GERD
97
What are the PFT findings on restrictive lung diseases?
- decreased total lung capacity (TLC),
- Decreased FEV1 and FVC
- normal or increased FEV1/FVC ratio
98
What is the Intrinsic Cause of Restrictive Lung Disease?
Interstitial Lung Disease
99
What are the Extrinsic causes of Restrictive Lung Disease?
pleural effusions, ankylosing spondylitis,
kyphoscoliosis, obesity
100
OSA Classification
Mild OSA 5 - 14
Moderate OSA 15 - 30
Severe OSA > 30
101
What are the OSA Screening tools
- Stop bang
- P-Sap
- Berlin
- ASA Checklist
102
What is the leading cause of preventable morbidity and mortality
Tobacco smoking
103
What are some post-op respiratory complications for a smoker?
- Atelectasis
- respiratory infections
- exacerbation of underlying pulmonary diseases
- Hypoxemia
- need for noninvasive mechanical ventilation
104
What does the PFT look for?
Look for evidence of respiratory disease when patients present with respiratory symptoms (e.g. dyspnea, cough, cyanosis, wheezing, etc.)
105
What is a pulmonary function test?
Measures how well the lungs work.
106
ERV definition
Expiratory reserve volume: the maximal volume of air that can be exhaled from the end-expiratory position
107
TLC definition
Total lung capacity: the volume in the lungs at maximal inflation, the sum of VC and RV
108
VC definition
Vital capacity: the volume of air breathed out after the deepest inhalation
109
IC definition
Inspiratory capacity: the sum of IRV and TV
110
FVC definition
Forced vital capacity: the determination of the vital capacity from a maximally forced expiratory effort
111
Lung volumes and capacities
112
Normal lung volumes
113
What are PFT results for obstructive vs restrictive lung disease?
- FEV1/FVC <80% = Obstructive lung disease
- Restrictive lung disease has normal or increased FEV1/FVC
114
Normal PFT pattern
115
Acute Asthma pattern
Restrictive = Right shift
116
Obstructive emphysema pattern
117
PFT Obstructive pattern
Decreased FEV1, normal or decreased FVC, and decreased FEV1/FVC
118
PFT Restrictive pattern
Decreased TLC, FEV1, and FVC with a normal FEV1/FVC, and a low DLCO
119
PFT Summary table
120
PFT Practical interpretation
- FEV1 over 70% predicted: MILD
- FEV1 60-70%predicted: MODERATE
- FEV1 50-60% predicted: MOD - SEVERE
- FEV1 35-50% predicted: SEVERE
- FEV1 <35% predicted: VERY SEVERE
121
What leads read the Right Ventricle?
V1, V2
122
What leads read the Left side of the heart?
V5, V6, Lead I and aVL
123
What leads read the inferior territory?
Leads II, III and aVF (Feet)
124
What lead reads the Right side of the heart?
aVR
125
What leads read the septum of the heart?
V3 and V4
126
P wave meaning
Atrial contration
127
PR interval meaning
Time taken for excitation to spread from the Sinoatrial (SA) node across the atrium and down to the ventricular muscle via the bundle of His
128
QRS meaning
Ventricular contraction
129
ST Segment meaning
Ventricular relaxation
130
T-Wave meaning
Ventricular repolarization
131
What are Two ways to measure the rate on ECG?
* Count the number of QRSs on one line of the ECG and multiply by six.
* Count the number of large squares between R waves and divide 300
by this number (if the patient is in atrial fibrillation it is more accurate
to report a rate range rather than a single value)
132
What are Causes of Left Axis deviation?
* Can be normal if the diaphragms are
raised e.g. Ascites, pregnancy
* Left ventricular hypertrophy (LVH)
* Left anterior hemiblock
* Inferior myocardial infarction
* Hyperkalaemia
* Ventricular tachycardia (VT)
* Paced rhythm
133
What are Causes of Right Axis Deviation
* Normal in children or young, thin adults.
* Right ventricular hypertrophy (RVH)
* Often due to respiratory disease
* Pulmonary embolism (PE)
* Anterolateral myocardial infarction
* Left posterior hemiblock (rare)
* Septal defect
134
P wave abnormalities
In some cases, there can be a notched (or bifid) p-wave known as “p mitral”, indicative of left atrial hypertrophy, which may be caused by mitral stenosis. There may be tall peaked p-waves. This is called “p-pulmonale” and is indicative of right atrial hypertrophy, often secondary to tricuspid stenosis or pulmonary
hypertension.
135
PR interval abnormalitites
* The PR interval may be prolonged in first-degree heart block (described in more detail later).
* The PR interval may be shortened when there is rapid conduction via an accessory pathway, for example, in Wolff Parkinson White syndrome.
136
Normal Q wave description
A q-wave is an initial downward deflection in the QRS complex. These are normal in left-sided chest leads (V5, 6, lead I, aVL) as they
represent septal depolarization from left to right. This is as long as they are <0.04secs long (1 small square) and <2mm deep.
137
What can be the Causes of QRS > 0.12 secs?
* Bundle branch blocks (LBBB or RBBB)
* Hyperkalemia
* Paced rhythm
* Ventricular pre-excitation (e.g. Wolf Parkinson White)
* Ventricular rhythm
* Tricyclic antidepressant (TCA) poisoning
138
What is the criteria suggestive of LVH on the ECG?
The height of the R wave in V6 + the depth of the S wave in V1. If this value is >35mm this
is suggestive of LVH.
139
What makes a ST segment significant?
To be significant, the S-T segment must be depressed or elevated by one or more millimeters in 2 consecutive limb leads or two or more millimeters in 2 consecutive chest leads
140
What can mimic ST Elevation?
High-takeoff, AKA benign early repolarization, is where there is widespread concave ST elevation, often with a slurring of the j-point most prominent in leads V2-5.
141
Best leads to read ST segment?
V2-5
142
What Drugs can prolong QT?
*Tricyclic antidepressants (TCAs)
*Terfenadine
*Erythromycin
*Amiodarone
*Phenothiazines
*Quinidine
143
What Metabolic processes can that prolong QT
*Hypothermia
*Hypokalaemia
*Hypocalcaemia
*Hypothyroidism
144
What are some Familial predispositions to prolonged QT?
*Long QT syndrome
*Brugada syndrome
*Arrhythmogenic RV dysplasia
145
What are some Reasons for inverted T wave?
* Normal variant
* Normal in aVR and V1 and often in V2 and V3 in people of Afro-Caribbean descent.
* Ischemia
* Ventricular hypertrophy
* LBBB (inversion in the anterolateral leads)
* Digoxin
* Hypokalemia (can cause flattened t-waves)
146
What are some Classic changes in Hyperkalemia?
* Small p-wave
* Tall, tented (peaked) t-wave
* Wide QRS
* Widening of the QRS indicates severe cardiac toxicity
147
What is this rhythm?
NSR
148
What is this rhythm?
ST Elevation in leads II, III, aVF
149
What is this rhythm?
Sinus Tach
150
What is this rhythm?
Sinus Brady
151
What is this rhythm?
V-paced
152
What is this rhythm?
Complete Heart block
153
What is this rhythm?
NSR with hyperK
154
What is this rhythm?
Anterior wall MI V3, V4
155
What is this rhythm?
Posterior MI (Depression in V1 - V4
