Test 1 (Part 2) Flashcards
(179 cards)
1
Q
Divisions of Mediastinum Helpful Note
A
- Superior and Inferior are separated by the Sternal Angle.
- The Inferior Mediastinum is further divided into Anterior, Middle, and Posterior Mediastinum.
- The Anterior Mediastinum is Anterior to the Heart
- The Middle Mediastinum is the Heart
- The Posterior Mediastinum is Posterior to the Heart
2
Q
Heart
A
- The heart is two sided, four chambered, self-Initializing, Self-Adjusting pump that propels blood to all parts of the body
- Right side of the heart receives blood from the Superior and Inferior Vena Cava and pumps it out to the lungs for Oxygenation.
- Left side of the Heart receives Oxygen Righ blood from the Lungs and pumps it out to the entire body via the Aorta
3
Q
Circulation Helpful Note
A
1) SYSTEMIC CIRCULATION:
- From the Left Atrium past the Bicuspid Valve into the Left Ventricle out of the Heart past the Aortic Valve into he Aorta, through the Arterial System, through the Capillaries, through the Venous System and back into the Heart though the Inferior and Superior Vena Cavae
2) PULMONARY CIRCULATION:
- From the Superior and Inferior Vena Cavae into the Right Atrium past the Tricuspid Valve into the Right Ventricle out of the Heart past the Pulmonary Valve into he Pulmonary Trunk, through the Right and Left lungs, Back into the Heart through the Pulmonary Veins
4
Q
Layers of the Heart
A
1) Epicardium:
- Outermost layer; made up of Visceral Serous Pericardium
2) Myocardium:
- Thick muscular layer made up of Spiraling, Overlapping layers of Cardiac Muscle
3) Endocardium:
- Thin internal endothelial and sub endothelial layer lining the inside of the chambers of the Heart and Valves
4) Fibrous Skeleton of the Heart
- Dense collagenous fibers
A) Produces Attachment point for the Myocardium
B) Produces attachment points for the valves of the Cuspid Valves
C) Supports and Strengthens ATRIOVENTRICULAR and SEMILINAR ORIFICES
D) Provides an Electrically insulated barrier between the Atria and Ventricles
5
Q
Myocardial Infarction (Clinical Note)
A
- Lack of blood flow to a specific area of the Myocardium, usually the result of a blockage in a Coronary Artery.
- CORONARY ARTHEROSCLEROSIS, or build up of lipids on the Internal walls of the Coronary arteries DECREASES the size of lumen of that vessel, increasing the likelihood of an Embolus, or plug blocking a vessel off entirely
6
Q
Angina Pectoris (Clinical Note)
A
- Pain that originates in the Heart and Produces a Strangling pain of the Chest.
- Angina Pectorals literally means strangling pain of the Chest.
- The main is usually the result of a narrow or obstructed Coronary Arteries that produces ISCHEMIA of the Myocardium
7
Q
External Features of the Heart
A
1) Apex:
- Inferolateral part of the Left Ventricle, projects predominantly to the Left
2) Base:
- Posterior portion, near the Left Atrium
3) Surfaces (3):
A) Sternocostal (Right Ventricle)
B) Diaphragmatic (Right and Left Ventricles)
C) Pulmonary (Paired; Right Atrium and Left Ventricle, Occupying the Cardiac Impression on both Lungs)
4) Borders (4): A) Right (Right Atrium) B) Inferior (Right Ventricle) C) Left (Left Ventricle) D) Superior (Right and Left Atria and the exit point for the Aorta and Pulmonary Trunk)
5) Right Atrioventricular Groove:
- Between the Right Atrium and Right Ventricle, Transmits the Right Coronary Artery
6) Left Atrioventricular Groove:
- Between the Left Atrium and Left Ventricle, Houses the Coronary Sinus
7) Anterior Interventricular Groove:
- Between Right and Left Ventricles on the Anterior aspect of the Heart, transmits the Anterior Interventricular Artery and Great Cardiac Vein
8) Posterior Interventricular Groove:
- Between Right and Left Ventricles on the Posterior aspect of the Heart, transmits the Posterior Interventriculr Artery and middle Cardiac Vein
9) Sulcus Terminalis:
- External vertical groove corresponding to the Internal Cista Terminals
10) Ligamentym Arteriosum:
- Embryological remnant of the DUCTUS ARTERIOSUS, communication between the Pulmonary Trunk and the Arch of the Aorta
8
Q
Ligamentum Artriosum Helpful Note
A
- It travels from the Superior aspect of the Pulmonary Trunk to the Inferior Concave border of the Aortic Arch.
- The Ligamentum Arteriosum is the adult remnant of the embryological Ductus Arteriosus which shunted blood from the Pulmonary Trunk to the Aorta to bypass the nonfunctional lungs.
- The left recurrent Laryngeal Nerve of the Vagus Nerve (CN X) loops around the Aortic Arch and Ligamentum Arteriosum then sends to the Larynx!
9
Q
Internal Features of the Heart (Right Atrium)
A
1) Sinus Venarum:
- Posterior, Smooth, Thin walled region where the Venae Cavae and Coronary Sinus empty
2) Pectinate Muscle:
- Anterior, rough muscular wall
A) Right Auricle
3) Crista Terminalis:
- Internal ridge separating smooth and rough regions
4) Intertribal Septum:
- Wall between the two Atria
A) Fossa Ovalis (Embyronic remnant of the Foramen Ovalis
5) Opening for the Coronary Sinus
10
Q
Atrial Septal Defects Clinical Note
A
- Typically involves an incomplete closure of the Foramen Ovale.
- It is estimated that 15-20% of adults have a small potency of their Foramen Ovale which is considered Clinically Insignificant.
- Larger openings in the Intertribal Septum can be clinically significant as they allow mixture of Oxygen Rich and Oxygen Depleted Blood
11
Q
Internal Features of Heart (Right Atrioventricular Orifice)
A
- Passage from Right Atrium to Right Ventricle, Variably occluded by the Tricuspid Valve
12
Q
Internal Features of Heart (Right Ventricle)
A
1) Tricuspid Valve:
- Separates Right Atrium and Right Ventricle
A) Anterior Cusp
B) Posterior Cusp
C) Septal Cusp
D) Chordae Tendonae
- Attach Free edges of the three Cusps to three corresponding Papillary Muscles
E) Anterior Papillary Muscle:
- Joined to the Anterior Cusp of the Tricuspid valve via Chordae Tendon
F) Posterior Papillary Muscle:
- Cusp of the Tricuspidd valve via Chorda Tendon
G) Septal Papillary Muscle:
- Cusp of the Tricuspid valve via Chordae Tendon
2) Trabecular Carnae:
A) Septomarginal Trabeculum:
- Moderator Band; from the Interventricular Septum to the base of the Anterior papillary Muscle, transmits the right bundle branch of Atrioventricular bundle to the Anterior Papillary Muscle
3) Conus Arteriosus:
- Infundibulum
- Smooth walled, leads into the Pulmonary Trunk
4) Pulmonary Valve:
- Semilunar Valve possessing Right, Left, and Anterior Cusps, separates Right Ventricle from the Pulmonary Trunk
A) Pulmonary Sinuses:
- Space between the wall of the Pulmonary trunk and the Cusps of the Pulmonary Vavle
13
Q
Cardia Cauterization Clinical Note
A
- Insertion fo a catheter into he Femoral Vein which is then passed up to the Inferior Vena Cava allowing Radiographic visualization of the Right Atrium, Right Ventricle, Pulmonary Trunk, and Pulmonary Arteries
14
Q
Internal Features of Heart (Left Atrium)
A
1) Left Auricle:
- Thicker-walled than the Right Atrium
2) Openings for the 4 Pulmonary Veins
3) Intertrial Septum
15
Q
Internal Features of Heart (Left Atrioventricular Orifice)
A
- Passage from the Left Atrium to Left Ventricle, variably occluded by the Bicuspid Valce
16
Q
Internal Features of Heart (Left Ventricle)
A
- Thicker walled thant Right Ventricle
1) Bicuspid (Mitral) Valve:
- Separates the Left Atrium from the Left Ventricle
A) Anterior Cusp
B) Posterior Cusp
C) Chordae Tendon:
- Attach free edges of the two cusps to Ventricular Surfaces
D) Anterior Papillary Muscle:
- Joined to the Anterior Cusp of the Bicuspid valve via Chordae Tendon
E) Posterior Papillary Muscle:
- Joined to the Posterior Cusp of the Bicuspid valve via Chordae Tendonae
2) Trabecular Carnae:
- Rough Muscular region
3) Aortic Vestibule:
- Smooth walled, leads into the Ascending Aorta
4) Interventricular Septum:
- Myocardial wall separating the two Ventricles, houses the Atrioventricular Bundle, Right and Left bundle Branches and Subendocardial Branches
5) Aortic Valve:
- Semilunar valve possessing Right, Left, and Posterior (non-Coronary) Cusps
- Separates Left Ventricle form the Ascending Aorta
- Occupies the Aortic Orifice
A) Aortic Sinus:
- Space between the Wall of the Ascending Aorta and the Cusps of the Aortic Valve, the Right and Left Aortic Sinuses house the openings for the Right and Left Coronary Artery
17
Q
Ventricular Septal Defects Clinical Note
A
- Due to the Embryologically divergent tissues that make up the Interventricular Septum that structure is particularly susceptible to defects.
- All defects are clinically relevant as they allow the mixture of Oxygen Rich and Oxygen depleted blood
18
Q
Conducting System of the Heart
A
- Consists of Cardiac Muscle Cells, specialized conducting fibers and two bundles of Nodal Tissue responsible for coordinating the Cardiac Cycle
1) Sinoatrial Node:
- Located in the Myocardium, where the Superior Vena Cava meets the Right Atrium, a small bundle of specialized cardiac muscle fibers that initiate and regulate impulses that propagates through the atrial walls, via Myogenic Conduction, producing DIASTOLE,
- “Pacemaker of the Heart”
2) Atrioventricular Node:
- Small bundle of Specialized cardia muscle fibers located in the Intertribal Septum near the opening for the Coronary Sinuses, response to the impulse from the Sinoatrial Node that distributed through the wall of the Atrium and distributes that signal through the Ventricles
3) Atrioventricular Bundle:
- Crosses the electrically insulated barrier provided by the Fibrous Skeleton of the Heart and distributes the impulse from the Atrioventricular Node into a Right and Left Atrioventricular Bundle which then distributes as Subendocardial Branches
4) Subendocardial Branches:
- Distribute the Atrioventricular Nodal impulse form the Right and Left Atrioventricular Bundle Branches first tot the Interventricular Septum, then to the papillary muscles, and finally to the rest of the ventricular Wall
- Also called the PERKING FIBERS
19
Q
The Cardia Cycle Helpful Note
A
1) Beginning of Diastole:
- Aortic and Pulmonary Valve close due to a drop in Pressure inside the Ventricles
2) Early Diastole:
- As the ventricles relax the Heart Lengthens and the Atrioventricular Valves (Tricuspid and Bicuspid Valve) open flooding the Ventricles with Blood
3) Diastole:
- Atrial contraction takes place in the late moments of Diastole and expulsion of blood into the Ventricles
4) Beginning of Systole:
- Atrioventricular Valves close due to an increased pressure in the Ventricles
5) Early Systole:
- Ventricles begin to contract thereby increasing the pressure, opening the Aortic Valve and the Pulmonary Valve
6) Systole:
- Full Ventricular contraction and expulsion of blood into the Ascending Aorta and Pulmonary Trunk
20
Q
Atrial Cardia Pacemaker Clinical Note
A
- Produces a regular electrical impulse that is carried to the Ventricles via electrodes which are inserted through a large vein to the Superior Vena Cava, into the Right Atrium past the Tricuspid Valve into the Endocardium of the Trabecular Carnae of the Right Ventricle
21
Q
Atrial Fibrillation Clinical Note
A
- Irregular twitching of the Atrial cardiac muscle fibers to which the ventricles respond at irregular intervals.
- Circulation usually remains satisfactory
22
Q
Ventricular Fibrillation Clinical Note
A
- Rapid irregular twitching of the Ventricles rendering the Heart unable to pump blood.
- An electric shock administered by electrodes can cease all cardiac movement (defibrillation), in hopes that the Heart may begin beating regularly after a period of time
23
Q
Cardia Referred Pain Clinical Note
A
- Ischemia stimulated Visceral pain sensory fibers in the hear of the Autonomic Nervous System
- These visceral sensory fibers often share a spinal ganglion with the somatic sensory fibers of areas such as the upper limb and superior lateral chest wall
- Anginal pain is typically referred to the area innervated by the Left Medial Branchial Cutaneous Nerve, the left substernal area, left pectoral area and medial aspect of the left upper limb are often involved in this variety of referred pain
24
Q
Pericardium
A
1) Serios (membranous)
A) Parietal (Adherent to Fibrous pericardium)
B) Visceral (Adherent to the heart, makes up the Epicardium)
2) Fibrous:
- tough and Fibrous
3) Oblique Pericardial Sinus:
- Wide recess posterior to the base of the Heart
4) Transverse Pericardial Sinus:
- Transverse passage transversing the origins of the great vessels
25
Surgical Significance of the Transverse Pericardial Sinus Clinical Note
- This space allows cardia surgeons to access the area posterior to the aorta and pulmonary trunk to clamp or insert the tubes of a bypass machine into these large vessels
26
Pericarditis Clinical Note
- Inflammation of pericardium, which can make the pericardium rough and produce friciotn.
- This friction called a Pericardial Friction rub can be observed with a Stethoscope.
- If left untreated the Pericardium can calcify
27
Pericardial Effusion Clinical Note
- Inflammation of the pericardium can result in the accumulation of fluid or pus in the pericardial sac which can compress the heart.
- Heart compression is know as Cardiac Tamponade!!!
28
Pericardiocentesis Clinical Note
- Drainage of blood, fluid or pus from the pericardial sac.
| - this is usually done to relive Cardiac Taponade
29
Aorta
- Distal to the Left Ventricle and Aortic Valve, travels superiorly as the very short Ascending Aorta, turns to the left as the Aortic Arch then travels inferiorly as the Descending Aorta through the Thorax (As the Thoracic Aorta), through the Aortic Hiatus on the Thoracic Diaphragm and not the Abdomen (as the Abdominal Aorta)
30
Ascending Aorta (Right Coronary Artery)
- Branch of Ascending Aorta travels anteriorly around the hear to the posterior aspect
A) Sinoatrial Nodal Artery:
- Arises from the right Coronary A 60% of the time and 40% of the time from the Circumflex Branch of the Left Coronary Artery, and it supplies the Sinuatrial Node!!!
B) Conus Branch:
- Supplies the Conus Arteriosus
C) Atrial Branch:
- Supplies Right Atrium
D) Right Marginal Artery:
- Travels along the Inferior Border of the Heart
E) Atrioventricular Nodal Artery:
- Supplies the Atrioventricular Node
F) Posterior Interventricular Artery:
- Travels along the Posterior aspect of the Heart between the Right and Left Ventricles
* ***Interventricular Septal Branches : Supp;y the Interventricular Septum!!!!!!
G) Right Posterolateral Artery:
- Supplies the Left Ventricle
31
Ascending Aorta (Left Coronary Artery)
- Branch of Ascending Aorta travels Superiorly around the heart to the Posterior Aspect
A) Anterior Interventricular Artery:
- Travels along the anterior aspect of the heart between the Right and Left Ventricles, most responsible for supplying the Atrioventricular Bundle as it passes through the Interventricular Septum
1) CONUS BRANCH: Supplies the Conus Arteriosus
2) LATERAL (Diagonal) ARTERY: Descends along the Anterior Surface of the Heart
3) INTERVENTRICULAR SEPTAL BRANCHES: Supply the Interventricular Septum, Atrioventricular Bundle and Right and Left Bundle Branches
B) Circumflex Artery:
- Travels Posteriorly around the Hear to the Posterior Aspect
1) LEFT MARGINAL ARTERY: Travels along the Left Margin of the Heart
2) POSTERIOR LEFT VENTRICULAR ARTERY: Supplies the Left Ventricle
32
Coronary Artery Bypass Grast Clinical Note
- Obstruction of the Coronary Arteries may necessitate replacement of a segment of the Coronary Artery, this process is called a Coronary Artery Bypass Graft.
- The Great Saphenous Vein is often used based on its comparable diameter to the Coronary Arteries, its easy of Dissection from the Lower lImb and the fact that it orders lengthy portions with no branching or Valves.
- Radial Artery is also used
33
Coronary Angioplasty Clinical Note
- Insertion of a small balloon catheter into the lumen of the Coronary Artery.
- The Balloon is inflated to flatten the obstructing plaque against the wall and increase the size of the lumen improving the blood flow
34
Arch of the Aorta
- Produces Brachiocephalic Trunk, Left Common Carotid Artery, and Left Subclavian Artery
35
Brachiocephalic Trunk
- Produces Right Common Carotid Artery and Right Subclavian Artery
36
Left Common Carotid Artery
- Head and Neck
37
Left Subclavian Artery (Region One)
- Branch of Brachiocephalic Trunk on the Right Side, branch of Aortic Arch on the Left Side
1) REGION ONE: Medial to Anterior Scalene Muscle
A) Vertebral Artery: Head and Neck
B) Internal Thoracic Artery: Travels Inferiorly to Posterior aspect of Anterior Chest Wall, between the Ribs and the Transverse Thoracic Muscle
I) Anterior Intercostal Artery: Segmental Branches of Internal Thoracic Artery. and travels in the Costal Groove
A) Perforating Branches (To the Breast)
B) Medial Mammary Branches (To the Breast)
II) Pericardiacophrenic Artery: Primary Blood supply to the Pericardium, also supplies the Thoracic Diaphragm
III) Musculophrenic Artery: Terminal Branches of the Internal Thoracic Artery, travels along the Medial Margin of the 7th-9th Costal Cartialges, supplies the 7th-9th Anterior most Intercostal Spaces and the Thoracic Diaphragm
IV) Superior Epigastric Artery: Terminal Branch of the Internal Thoracic Artery, travels to the deep surface of the Rectus Abdomens Muscle, forms anastomosis with eh Inferior Epigastric Artery
C) Thyrocervical Trunk: Head and Neck
I) Inferior Thyroid Artery: Head and Neck
A) Ascending Cervical Artery: Head and Neck
II) Suprascapular Artery
III) Transfer Cervical Artery
38
Left Subclavian Artery (Region Two)
- Deep to the Anterior Scalene Muscle
1) Costocervical Trunk: Head and Neck
A) Supreme Intercostal Artery: Head and Neck
B) Deep Cervical Artery: Head and Neck
39
Left Subclavian Artery (Region Three)
- Lateral to the Anterior Scalene Muscle and proximal to the 1st Rib
1) Dorsalscapular Artery
40
Axillary Artery (Region One)
- Continuation of Subclavian Artery distal to 1st Rib
REGION ONE:
- Distal to the 1st Rib, proximal to Pectorals Minor Muscle
1) Superior Thoracic Artery: Travels to the Thoracic Wall, supplies the 1st and 2nd Intercostal Spaces and the Superior Most Serratus Anterior Muscle
41
Axillary Artery (Region Two)
- Deep to Pectorals Minor Muscle
1) Thoracoacromial Trunk:
2) Lateral Thoracic Artery:
- Travels along the Lateral border of Pectorals Minor Muscle supplying Pectorals Major, Pectorals Minor, Serrates Anterior and Intercostal Muscles
I) Lateral mammary branches: To the Brest
42
Axillary Artery (Region Three)
- Distal to Pectoralis Minor Muscle, Proximal to Teres Major Muscle
1) Subscapular Artery
A) Circumflex Scapular Artery
B) Thoracodorsal Artery
2) Anterior Humeral Circumflex Artery
3) Posterior Humeral Circumflex Artery
43
Descending (Thoracic) Aorta
- Extends from the Aortic Arch, to the Aortic Hiatus, where it becomes the Decending (Abdominal) Aorta
- Can be divided into three Vascular Planes: Unpaired Visceral Branches, Paired Lateral Visceral Branches, and Paired Segmental Visceral Branches
44
Unpaired Visceral Branches
1) Mediastinal Artery
2) Esophageal Artery
3) Pericardial Artery
45
Paired Lateral Visceral Branches
1) Right Bronchial Artery:
- Supplies the structures of the Hilum of the Right Lung, arises from upper Posterior Intercostal Artery, Descending (Thoracic) Aorta, or Left Bronchial Artery
2) Left Bronchial Artery:
- Supplies the structures of the Hilum of the Left Lung, arises from the Descending (Thoracic) Aorta
46
Paired Segmental Parietal Branches
1) Posterior Intercostal Artieri:
- Segmental branches of Descending Aorta travel in the Costal Groove
A) DORSAL BRANCH: Travels with the Posterior Ramus of the Spinal Nerves
B) COLLATERAL BRANCH: Travels along the Superior Edge of the Rib Inferior to the Intercostal Space
C) LATERAL CUTANEOUS ARTERY: Travels through the Intercostal Muscles to supply an area of Skin and Subcutaneous Tissue on the Lateral Trunk
I) Lateral mammary Branches (To the Breast)
2) Subcostal Artery:
- Travels into the abdomen below the 12th Rib with the Subcostal Nerve
47
Superior Phrenic Artery of Descending Thoracic Aorta
- Supplies the Thoracic Diaphragm, does not fit into one of the three Vascular Plane Branching patterns
48
Pulmonary Trunk
- Exits Heart at the Superior Border, distal to the Right Ventricle passed the Pulmonary Artery, which travel with a corresponding Bronchus and similar branching patterns
49
Pulmonary Trunk (Right Pulmonary Artery)
- Branch of Pulmonary Trunk from Right Ventricle of the Heart enters the Lung at the Hilum, thick walled vessels which Convey Deoxygenated Blood
1) Superior Lobar Artery:
- To Superior Lobe
- Segmental Arteries (Apical, Posterior and Anterior)
2) Middle Lobar Artery:
- To Middle Lobe
- Segmental Arteries (Lateral and Medial)
3) Inferior Lobar Artery:
- To Inferior Lobe
- Segmental Arteries (Superior, Anterior Basal, Medial Basal, Lateral Basal, and Posterior Basal)
50
Pulmonary Trunk (Left Pulmonary Artery)
- Branch of Pulmonary Trunk from Right Ventricle of Heart enters the Lung at the hilum, thick walled vessels which convey deoxygenated blood
1) Superior Lobar Artery:
- To Superior Lobe
- Segmental Arteries (Apicoposterior, Anterior, Lingular)
2) Inferior Lobar Artery:
- To Inferior Lobe
- Segmental Arteries (Superior, Anterioromedial Basal, Lateral Basal, and Posterior Basal)
51
Pulmonary Embolism Clinical Note
- Obstruction of a Pulmonary Artery by an embolus, such as a blood clot, fat globule or air bubble.
- The Embolus usually passes from a vein through the right side of the heart into the Pulmonary Arteries
52
Pulmonary Veins
- Being as intersegmental veins between the Bronchopulmonary Sements, travel independently from the Pulmonary A and Bronchi, empty into the Left Atrium
1) Right Pulmonary Vein:
- Superior and Inferior branches exit the Lung at the Hilum and enter the Left Atrium of the heart
- Thin walled vessels which convey oxygenated blood
2) Left Pulmonary Vein:
- Superior and Inferior branches exit the Lung at the Hilum and enter the Left Atrium of the heart
- Thin walled vessels which convey oxygenated bl
53
Coronary Venous Circulation (CORONARY SINUS)
- Posterior aspect of the Heart
- Drains Great, Middle, and Small veins
- Empties into the Right Atrium of the Heart
1) Great Cardia Vein:
- Originates on the Anterior aspect of the Heart between the Right and Left Ventricles
- Travels with the Anterior Interventricular Artery
- Then travels around the Heart, traveling with the Circumflex Artery to empty into the Coronary Sinus
2) Middle Cardiac Vein:
- Travels along the Posterior aspect of the Heart between the Right and Left Ventricles
- Travels with the Posterior Interventricular Artery
3) Small Cardiac Vein:
- Travels along the Inferior border of the Heart
- Travels with the Right Marginal Artery
54
Coronary Sinus Circulation (ANTERIOR CARDIAC VEIN)
- Anterior surface of the Heart, crosses over the Right Atrioventricular Groove
- Empties directly into the Right Atrium of the Heart
55
Coronary Sinus Circulation (SMALLEST CARDIAC VEINS)
- Extremely small vessels, possessing NO VALVES
| - Exist in the Myocardium and communicate directly with the Internal Chambers of the Heart
56
Superior Vena Cava
- Union of Right and Left Brachiocephalic Vein and Azygous Vein
- Drains from Superiorly into Right Atrium of the Heart
57
Azygous Vein
- Drains Posterior Intercostal Vein from the right side of the Posterior Thoracic wall and travels superiorly until crossing over the Vertebral bodies to meet the Superior Vena Cava
1) Right Posterior Intercostal Vein:
- Travels with Posterior Intercostal Artery in the Costal Groove
58
Hemiazygous Vein
- Drains Posterior Intercostal Vein from the LEFT side of the Lower Posterior Thoracic Wall
- Communicates with the Azygous Vein via a COMMUNICATING BRANCH that divides the Hemiazygous Vein from the Accessory Hemiazygous Vein
1) Left Posterior Intercostal Vein:
- Travels with Posterior Intercostal Artery in the Costal Groove
59
Accessory Hemiazygous Vein
- Drains Posterior Intercostal Vein from the Left side of the Upper Posterior Thoracic Wall
- Communicates with the Azygous Vein via a communicating branch that divides the Hemiazygous Vein from the Accessory Hemiazygous Vein
1) Left Posterior Intercostal Vein:
- Travel with Posterior Intercostal Artery in the Costal Groove
60
Inferior Vena Cava
- Union of Right and Left Common Iliac Vein
- Travels through the Abdomen, through the Vena Cava Foramen of the Thoracic Diaphragm, then drains from Inferiorly into Right Atrium of the Heart
61
Thoracic Duct
- Originates as the CHYLE CISTERN in the Abdomen
- Drains Lymph from the Lower Extremities, Pelvis, Abdomen, Left half of the Thorax, Left Upper Extremity and Left side of the Head and Neck
- Superiorly empties into the Venous System near the Junction of the Left Internal Jugular Vein and Left Subclavian vein
- In the Thorax it drains the Subclavian Lymphatic Trunk and the Bronchomediastinal Trunk
1) Subclavian Trunk:
- Drains primarily the Subclavian Lymphatic Trunk and the Bronchomediastinal Trunk
- Empties into the Brachiocephalic Vein near its origin
2) Jugular Trunk:
- Drains the Cranial and Cervical Lymph Nodes
3) Bronchomediastinal Trunk:
- Drains Parasternal, Paratracheal, Paraesophageal, Superior Phrenic and Brachiocephalic Lymph Nodes
62
Thymus
- Primary Lymphoid organ located in the Anterior Mediastinum which is gradually replaced by fat after Puberty
63
Thoracic Lymph Nodes
- On the Right Side, Lymph drains from the Right Lymphatic Duct into Venous Circulation, on the Left Side Lymph drains from the Thoracic Duct into Venous Circulation
64
1) Axillary Lymph Nodes:
- Includes the Pectoral, Interpectoral, Deltopectoral, Supraclavicular and Inferior Deep Cervical Lymph Nodes
- Drains 75% of the Breast via the SUBAREOLAR Lymphatic Plexus
- Empties into the Subclavian Lymphatic Trunk, then into the Right Lymph Duct or Thoracic Duct
65
2) Parasternal Lymph Nodes:
- Drain the SUBAREOLAR Lymphatic Plexus, Parietal Pleura, and Thymus
- Empties into the Bronchomediastinal Trunk, then into the Right Lymphatic Duct or Thoracic Duct
66
3) Tracheobronchial Lymph Nodes:
- Drain the Bronchopulmonary Lymph Nodes and the Subepicardial Lymphatic Plexus( Inferior Tracheobronchial Lymph Nodes Only)
- Empties into the Birinchomediastinal Trunk
1) Bronchopulmonary Lymph Nodes:
- Drain the Superficial and Deep Lymphatic Plexuses of the Lung
A) Superficial Lymphatic Plexus of the Lung:
- Drains superficial Lung and Visceral Pleura
B) Deep Lymphatic Plexus of the Lung:
- Drain the Deep Lungs ad the Bronchi
67
4) Intercostal Lymph Nodes
- Drain the Parietal Pleura
68
5) Phrenic Lymph Nodes
- Drain the Parietal Pleura
69
6) Anterior Mediastinal Lymph Nodes
- Drain the Parietal Pleura
70
7) Posterior mediastinal Lymph Nodes
- Drains the Parietal Pleura, Esophagus, Posterior Pericardium, Thoracic Diaphragm, and the Middle Posterior Intercostal Spaces
- Empty into the Thoracic Duct
71
Afferent and Efferent Neurons
1) Afferent:
- Relays the Sensory information from the Periphery and into the Spinal Cord
- Dorsal
2) Efferent:
- From the Ventral side of the Spinal Cord to the Periphery and relays Corrective Information
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Reflex Arc
- At the simplest level, the Nervous System functions in a series of REFLEX ARCS:
1) Sensory input into the CNS
2) Triggers a response
3) Initiates a motor outflow to "do" something and CORRECT the Sensory Input
**We let the spinal cord control the Reflex Arcs because it would take too long for the Brain (Consciuous) to contemplate the reflexes and we could get severely hurt during the time it takes the brain to think about the reflex
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Steps of a Reflex Arc (Skeletal Muscle)
1) Nociceptors (Pain Receptors) in her hand are brought to the THRESHOLD and an Action Potential travels down he Nerve to her Spinal Cord
2) The Action Potentials travel to the Spinal Cord and Depolarize the Pre-Synaptic Membrane of bacon from the Nociceptors
3) And the Efferent Neuron (in this case a Motoneuron) is brought to the Threshold by the EXCITATION
4) The Action Potential in the Motoneurons going to the arm muscles pulls the hand out of the fire before serious damage can be done
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Autonomic Reflex Arc (Smooth Muscle)
- The Sensory information is sent to the Brain and then out to the Motoneuron.
- The Autonomic Nervous System is the equivalent of the neuron we have for the Muscle
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Autonomic Reflex Arc
1) May be the same as elicit other Reflexes:
- Visual Cues
- Auditory Cues
2) Often are Afferents within the Viscera
3) Stimulus is not as Discrete (Often)
- How much light coming into my eye?
- Do I need more Oxygen?
- Is my Intestine or Bladder Distended?
- How's my Blood Pressure?
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Autonomic Reflex Arc Cont.
- Unline the withdrawal reflex, the most of the Integration of Autonomic reflexes occurs within the BRAIN, although at lower levels (Brainstem, Hypothalamus) rather than the Cortex
- The ANS is the equivalent of the Motoneurons we used to produce the Withdrawal Reflex
***In the Autonomic Nervous System, we are controlling Smooth Muscle, Blood Flow, and the secretion from Glands (Amongst other things)
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Description of a Simple Reflex Arc involving Skeletal Muscle
1) Sensory Information (AFFERENT Information)
A) From the Periphery into the Spinal Cord
B) Gives rise to Sensory Perception, some forms (Painful Inputs) trigger reflexes
2) Central Nervous System
A) In this example, the Spinal Cord (Can be anywhere in Brian or Spinal Cord)
B) Simple or Complex
3) Efferent Neuron (the Alpha- Motoneuron)
A) Causes contraction of muscle to elicit effect
B) Ex: Remove Hand from Hot Pan
C) The ANS is the efferent arm of the reflexes that control the Viscera!!!
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Sympathetics System and Parasympathetic System
Sympathetic:
- Fight or Flight
Parasympathetic:
- Rest and Digest
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The Autonomic Nervous System- Anatomy
- The outflow of the ANS has two neurons in series that will go to the Effector Cell
NEURON #1: The Pre-Ganglionic Neuron
- Starts in the CNS (So it gets the Message from the Brian)
- Leaves the CNS
- Travels to a Ganglion
- Where it will Synapse on the second neuron in the Pathway
***The Ganglion is a CLUSTER of NEURONAL Cell Bodies. The Pre-Ganglionic Axon Synapses on the POST-GANGLIONIC Neuron here
***The POST-GANGLIONIC neuron then travel to the Target Organ and Synapses on it
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We can distinguish between the Parasympathetic and Sympathetic Systems based on:
1) Where the Pre-Ganglionic Fibers leave the CNS
2) The location of the Ganglion
3) The Lengths of the Pre- and Post-Ganglionic Axons
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Where the Axons of the PARASYMPATHETIC Axons leave the CNS
- The axons of the Parasympathetic Pre-Ganglionic Axons leave the CNS from the:
1) Cranial
2) Sacral
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The Location of the PARASYMPATHETIC GANGLION
- In the Parasympathetic Nervous System, the Ganglia are located on or near the Target Organs
83
The Length or the Pre- and Post-Ganglionic Fiber in PARASYMPATHETIC
- In the Parasympathetic Nervous System, the Pre-Ganglionic fiber is LONG, while the Post-Ganglionic Axon is SHORT!!!!
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Where the Axons of the SYMPATHETIC Axons leave the CNS
- The axons of the Sympathetic Pre-Ganglionic Axons leave the CNS from the:
1) Thoracic
2) Lumbar
85
The Location of the SYMPATHETIC GANGLION
- In the Sympathetic Nervous System, the Ganglia are Located in the Sympathetic Chain, JUST OUTSIDE the VERTEBRAL COLUMN
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The Length or the Pre- and Post-Ganglionic Fiber in SYMPATHETIC
- In the Sympathetic Nervous System, the pre-Ganglionic fiber is SHORT, while the Post-Ganglionic Axon is LONG!!!!!!!
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Autonomic Nervous System- Parasympathetic Biochemistry
- In the Parasympathetic Nervous System, the Neurotransmitter released by the Pre-Ganglionic fiber is ACETYLCHOLINE!!!
- The NICOTINIC ACh Receptor is expressed on the POST-GANGLIONIC cells' Dendrites!!!!
- The POST-GANGLIONIC Cell also releases ACETYLCHOLINE from its Pre-Synaptic Terminal
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What happens when Acetylcholine is released by the Pre-Ganglionic fiber bins to the Nicotinic AChR on the Post-Ganglionic Cell Membrane?
- nAChR is a LIGAND-GAED SODIUM CHANNEL, so Sodium enters the dendrite of the POST-GANGLIONIC Cell, causing an EPSP and eventually leading to an ACTION POTENTIAL in that Neuron!!!!
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Autonomic Nervous System- Efferent Synaptic Structure
- Instead of the Specialized Synaptic Structure we saw in the CNS, these Synapses are EN PASSANT (in Passing)
- Its more like the Mailman thrown your mail out of the window as he/she goes by your house because the Neurotransmitter will find a receptor on the Smooth Muscle because of the wide distribution of the Receptors in the Smooth Muscle
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Autonomic Nervous System- Efferent Synaptic Structure Cont
- Autonomic nerves have VARICOSITIES, little swellings along the length of the axon
- The vesicles containing the Neurotransmitter are located within the Varicosities
- VESICULAR FUSION occurs as the Action Potential passes along the Axon, just as we saw with the Synapse
- The NEUROTRANSMITTER then DIFFUSES to the Effector Cell (in this case a Smooth Muscle Cell), binds to a Receptor, and causes something to happen
***Because the "Synapse" is not as protected as we saw before, there is substantial LEAKAGE of the NT into the Systemic Circulation!!!!!!
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Autonomic Nervous System- Parasympathetic Biochemistry Cont
- On the Target Cell, we have a MUSCARINIC RECEPTOR
- It inhibits Adenylate Cyclase
- cAMP can be use to Increase tor Decrease the Activity level
***Inhibitory G Protiens!!!!!
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Muscarinic Receptors
- Four or Five different types, all Activated by ACETYLCHOLINE (in the Body) and the Exogenous substance Muscarine
- SERPENTINE Receptor (one Gene, Big protein with 7 Membrane Spanning Domains)
G Protein Coupled:
1) M2 (Cardiac): Gi-Coupled --> Decr cAMP --> Incr gK+
2) M3 (Widely distributed in body): Gq coupled
3) M4 (Autoreceptors on neurons): Gi-coupled --> Decr cAMP --> Decr ACh Release
*** 1,3,5: Lead to an Increase in IP3 and therefore an Increase in Intracellular Ca2+
*** 2,4: lead to a Decrease in cAMP (Adenylate Cyclase Inhibitors)
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Autonomic Nervous System- Sympathetic Biochemistry
- In the Sympathetic Nervous system, the Neurotransmitter released by the Pre-Ganglionic Fiber is ACETYLCHOLINE!
- The Nicotinic ACh Receptor is expressed on the Post- Ganglionic Cell's Dendrites!!!
*** The primary synapse between the Pre-Ganglionic axon and Post-Ganglionic cell is biochemically the same in both the Parasympathetic and the Sympathetic Nervous System!!!
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Autonomic Nervous System- Sympathetic Biochemistry
- In the Sympathetic Nervous System, the Neurotransmitter released by the Post-Ganglionic fiber is NOREPINEPHRINE!!!
** ATP and Neuropeptide Y is also released with Norepinephrine!
****Adrenaline, Epinephrine, and Norepinephrine are the same things!!!!
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Autonomic Nervous System- Sympathetic Biochemistry Cont
Only two receptors that the Norepinephrine can bind to:
1) Alpha- Adrenergic Receptors (of which there are several)
2) Beta- Adrenergic Receptors (of which there are three)
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Autonomic Nervous System- Sympathetic Biochemistry Cont
- All the NE/ Epi Receptors are SERPENTINE Receptors that connect to G Proteins
1) Alpha Adrenergic
- High Affinity for NE from Epinephrine
- 1a, 1b, and 1d: Increase in IP3 and DAG --> Decrease in gK+
- 2a, 2b, 2c: Decrease in cAMP ---> Decrease in Ca2+ and Increase in K+
2) Beta- Adrenergic: 3 subtypes, all Increase in cAMP
- Higher AFFINITY for EPINEPHRINE
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Compare and Contrast the Anatomy and Biochemistry of Parasympathetic and Sympathetic Divisions
SYMPATHETIC:
1) Location of Ganglion:
- Sympathetic Chain
2) Length of Post-Ganglionic Axon:
- Long
3) Neurotransmitter released by Pre-Ganglionic Fiber:
- Acetylcholine
4) Receptor subtype on Post-Ganglionic Neuron:
- Nicotine Cholinergic
5) Neurotransmitter released by Post-Ganglionic Neuron:
- Noradrenaline (Norepinephrine)
6) Receptor Subtype on End-Organ:
- Alpha or Beta Adrenergic Receptors
PARASYMPATHETIC:
1) Location of Ganglion:
- On/ Near End-Organ
2) Length of Post-Ganglionic Axon:
- Short
Acetylcholine
3) Neurotransmitter released by Pre-Ganglionic Fiber:
- Acetylcholine
4) Receptor subtype on Post-Ganglionic Neuron:
- Nicotinic Cholinergic
5) Neurotransmitter released by Post-Ganglionic Neuron:
- Acetylcholine
6) Receptor Subtype on End-Organ:
- Muscarinic Cholinergic Receptors
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Autonomic Nervous System- The Adrenal Medulla
- Within the MEDULLA, we have CHROMAFFIN Cells that PRODUCE EPINEPHRINE!!!!!
*** The Adrenal Medulla is the EQUIVALENT of s SYMPATHETIC GANGLION
What neurotransmitter acting at that receptor type is going to tell the Adrenal Medulla to secrete Epinephrine?
- Since this is a Pre-Ganglionic Neuron coming in, we have ACETYLCHOLINE acting at NICOTINIC Receptors
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Autonomic Nervous System- The Adrenal Medulla Cont
- ACh binding to the nAChR causes the CHROMAFFIN Cells to release Epinephrine along with Dopamine and Norepinephrine as well!!
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Explains the role of the Adrenal Medulla in Sympathetic Responses
1) Innervated by a Pre-Ganglionic Axon that has travelled THROUGH the Sympathetic Chain Ganglion WITHOUT SYNAPSING!!!!
2) Synapse is between the Pre-Ganglionic Fiber and the CHROMAFFIN Cells of the Adrenal Medulla
- Neurotransmitter is Acetylcholine
- Receptor is Nicotinic Cholinergic
3) Activation of the Nicotinic Cholinergic Receptor allows Sodium in and Depolarizes the CHROMAFFIN Cell
4) CHROMAFFIN Cell releases Primarily EPINEPHRINE!!!
- Dopamine and Norepinephrine are also released in measurable quantities because we make Epinephrine by make Dopamine, then converting it to Norepinephrine, then going to Epinephrine
5) The epinephrine is released as a Hormone into the Blood
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Parasympathetic System "Rest and Digest"
- Have plenty of Oxygen
- Heart beating Slowly
- Blood Pressure is Relatively Low
- Digesting food, so Intestine gets the Blood
- Getting fuel from the GI Tract
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Sympathetic System "Fight or Flight"
- Needs lots of Oxygen
- Gets O2 to the Muscle
- Heart pumping Fast, Hard
- Aren't going to worry about Digesting (since being digested is much more immediately on your mind)
- Need the fuel to run with
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Radial Muscles of IRIS
- Alpha-Adrenergic
- Contraction of muscle leads to DILATION of PUPIL
- Allows MORE LIGHT IN
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Ciliary Muscle of Lens
- Beta2-Adrenergic Receptor
- RELAXATION of muscle leads to FLATTENING of LENS
- Focus on FAR OBJECT (Where is that exit?)
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Heart
- Beta 1 and Beta2- Adrenergic Receptors
- INCREASE Heart Rate
- INCREASE Strength of Contraction
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Simple Rule of Thumb
- Alpha receptors cause CONTRACTION of Vascular Smooth Muscle and lead to Vasoconstriction
- Beta receptors cause RELAXATION of Vascular Smooth Muscle and Lead to Vasodilation
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Most Arteries and veins have both Alpha and Beta Receptors on them
- Heart (Not a Major Player)
- Skeletal Muscle (Strong Effect)
- Lungs (Not a Major Player)
- Abdominal Organs (Huge Deal)
- Kidneys
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Some Arterial System ONLY have ALPHA Receptors on Them
- Skin and Mucosa (So you don't bleed as much if T Rex gets a nip in)
- Salivary Glands (Dry Mouth)
- Brain (Not a Major Player under these Circumstances)
- Can Restrict blood flow to the Brain to limit damage to the Capillary Beds hut this is a last ditch effort and a really bad sign
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Bronchial Smooth Muscle and Bronchial Glands
Bronchial Smooth Muscle:
- Beta 2 Receptors
- Smooth Muscle relaxation
- Bronchodilation
Bronchial Glands:
- Alpha 1: DECREASE Secretion
- Beta 2: INCREASE Secretion
*** Need Bronchial secretions to keep the airway moist!!!
*** Protect airway from dry air but need to put the breaks on the secretions because they make the airway smaller
***ALBUTEROL: Beta 2 Agonist so a Bronchial Dialator
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Digestive Tract
1) Motility:
- Alpha 1 and Beta
- Usually DECREASES Motility
- Don't move the food so we don't have to absorb it now
2) Sphincters:
- Alpha 1 cause Contraction
- Clamps down hard do we don't get food moving into the Intestines
3) Secretion:
- Alpha 2: DECREASE Secretion
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Energy
1) Liver:
- Alpha 1 and Beta 2 receptors
- Increase Glycogenolysis (Release of Glucose)
2) Adipose Tissue
- Alpha 1, Beta 1, and Beta 3 Receptors
- INCREASE Lipolysis
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Describe "Fight or Flight" Response
1) Eyes (Dilate in Fear- Get more light in, Focus on Distance
- Radial Muscle- Alpha Adrenergics; DILATE PUPIL
- Ciliary Muscle- Beta 1 Adrenergics; Allow DISTANCE VISION
2) Cardiovascular:
- Heart:
- Beta2 Adrenergics- Increase Strength and rate of contraction (more blood)
- Vasculature:
- Alpha- Adrenergics to VASOCONSTRICTION and SEND Blood Away
- Beta Adrenergics to DILATE and INCREASE Blood Flow
3) PULMONARY:
- Bronchodilation: Beta 2 Adrenergics- easy to get AIR IN
- Secretions- Beta 2 Adrenergics- HUMIDIFY MORE AIR
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Describe "Fight or Flight" Response Cont
Energy Supplies:
1) GI Tract:
- Alpha 1 Adrenergics- INCREASE Sphincter Tone
- Alpha 1 and Beta- Adrenergics- DECREASE Motility
- Secretion: Alpha 2- DECREASE Secretions
2) Liver: Alpha 1 and Beta 2 Adrenergics to INCREASE Glucose release from Liver
3) Adipose Tissue: Alpha-1, Beta-1, and Beta-3 Adrenergics to INCREASE Free Fatty Acid Release
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parasympathetic System "Rest and Digest"
- The action of the Parasympathetic System is easy: Via the MUSCARINIC RECEPTORS we will:
1) Slow the Heart
2) Constrict the Pupul
3) Where we don't have an effect, it is because we don't have Innervation. receptors
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Autonomic Nervous System- Rest and Digest
We See:
1) Activation of Radial Muscle of Eye (CONSTRICTION of PUPIL)
2) Contraction of Ciliary Muscle of Lens (NEAR VISION)
3) Decrease Heart Rate/ Contractility of Heart
4) Vasodilation (except for Abdominal Viscera, Kidneys, and Veins)
- No Muscarinic Receptors There!!!!!!!!!
5) Bronchial Smooth Muscle Contraction/ Gland Secretion
6) Digestive Organs
- Increase Motility (Sphincters RELAX Too)
- Increase Secretion
7) Microurition (Urination)
- Relax Sphincter and Increase Detrusor Muscle Contraction
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Under Normal Conditions
- Under normal circumstances, the Parasympathetic and Sympathetic systems are both active to varying degrees and do a "BALANCING ACT"- a little up/ a little down!!!
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Division of Mediastinum Helpful Note
- Superior and Inferior Mediastinum are separated by the Sternal Angle
- The Inferior Mediastinum is further divided into Anterior, Middle, and Posterior Mediastinum.
- The Anterior Mediastinum is Anterior to the Heart.
- The Middle Mediastinum is the Heart.
- The Posterior Mediastinum is Posterior to the Heart
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Esophagus
- Joining the Laryngopharnx to the Stomach, double layered, muscular tube with an Internal circular layer and external longitudinal Layer
- The upper two thirds od the Esophagus is a combination of Smooth and Skeletal Muscle
1) Regions of the Esophagus
A) Cervical Part
B) Thoracic Part:
- Between T1 and the Esophageal Hiatus of the Thoracic Diaphragm
- Travels through the Posterior Mediastinum
C) Abdominal Part
2) Constrictions of the Esophagus
A) At the Cricopharyngeus Muscle:
- Clinically referred to as the Upper Esophageal Sphincter
B) At the Aortic Arch
C) At the Left Bronchus
D) At the Esophageal Hiatus of the Thoracic Diaphragm:
- Clinically referred to as the Lower Esophageal Sphincter
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Cranial Nerves Associated with the Thorax
1) Vagus Nerve
- CN X
- Enters the Thorax through Superior Thoracic Aperture
- Produces the Left Recurrent Laryngeal Nerve
- The Pulmonary and Inferior Cardiac Branches then ravels to the Posterior Mediastinum to produce Esophageal Branches on the Esophagus
- Immediately proximal to entering the Abdomen the Vagus nerves become an Anterior and Posterior Vagal Trunk on the Anterior and Posterior Surface of the Esophagus
A) Left Recurrent Laryngeal Nerve:
- Loops under Aortic Arch and Ligamentum Arteriosum to return to the Larynx
B) Pulmonary Branches
C) Inferior Cardiac Branch
D) Anterior Vagal Trunk:
- Derived primarily from the Left Vagus Nerve, Posterior to the Esophagus
- Enters the Abdomen through the Esophageal Hiatus
E) Posterior Vagal Trunk:
- Derived primarily from the Right Vagus Nerve, Posterior to the Esophagus
- Enters the abdomen through the Esophageal Hiatus
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Cervical Spinal Nerves associated with the Thorax
1) Phrenic Nerve:
- Anterior rami of C3-5
- Travels through the Superior Thoracic Aperture, into the space between the Mediastinal Parietal Pleura and Fibrous Pericardium
- Innervate the Thoracic Diaphragm
- Conveys sensory information from central Diaphragmatic and Mediastinal Pleura and the Pericardium
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Intercostal Nerves
- 1st through 11th paid of Anterior Rami of Thoracic Spinal Nerves
- Travel along the Inferior edge of the Superior Rib in the Intercostal Space between Internal and Innermost Intercostal Muscles
- Innervates Skin, Subcutaneous Tissue, Musculature and Costal and Diaphragmatic Parietal Pleura
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Typical Intercostal Nerves
- 3rd through 6th!!!!!
A) Rami Communications:
- Connect Intercostal Nerves to Ipsilateral Sympathetic Trunk
B) Collateral Cutaneous Branches:
- Become Anterior and Posterior Branches and supply the skin of the Thoracic wall
- T4 through T6 supply the Breast
C) Lateral Cutaneous Branches:
- Become anterior and Posterior Branches and supply the Skin of the Intercostal Space
D) Anterior Cutaneous Branches:
- Supply Anterior aspect of the Thoracic Wall
- T4 through T6 supply the Breast
E) Muscular Branches:
- Supply Intercostal Muscles, Subcostal Muscle, and Transverses thoracic Muscle
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Atypical Intercostal Nerves
- 1st and 2nd, 7th through 11th
1) 1st:
- No cutaneous branches and Majority Superior portion joins the Brachial Plexus
2) 2nd:
- Majority travels in the Costal Groove as a Typical Intercostal Nerve with a small part joining with Brachial Plexus
- The Lateral Cutaneous Branch supplies the Skin and Subcutaneous Tissue of the Axilla and is called Intercostobrachial nerves
3) 7th through 11th:
- Begin as Intercostal Nerves but as they travel anteriorly cease toe exist between Ribs and Transition over the Abdomen to become Thoracoabdominal Nerves
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General Principles of the Autonomic Nervous System Helpful Note
1) Typically Sympathetic Stimulation is CATABOLIC, "Flight of Flight"
2) Typically Parasympathetic Stimulation is ANABOLIC, normal function and energy conservation
3) The Parasympathetic Stimulation has a limited distribution:
- Head, Neck, and Trunk Viscera
- Never in the body wall or extremities
Where as the Sympathetic Nervous System distributes ALL VASCULAR AREAS of the Body
4) Glandular Secretion is stimulated by the Parasympathetic Nervous System, except sweat glands, the Sympathetic Nervous System can indirectly decrease non-Sweat Gland Glandular secretion through VASOCONSTRICTION
5) VASOCONSTRICTION is SYMPATHETICALLY STIMULATED, except Coronary Arteries
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Sympathetic Divison of Autonomic Nervous System
- Thoracolumbar T1-L2
1) Presynpathetic Fibers (SHORT):
A) Cell bodies exist in the LATERAL HORN of the SPINAL CORD
B) Always travel in the VENTRAL ROOT
C) Always travels into the VENTRAL RAMUS
D) Quickly exit VENTRAL RAMUS and enters the PARAVERTEBRAL GANGLIA
2) Synaptic Options:
A) Presynaptic Fibers can enter the paravertebral Ganglion and synapse onto a Postsynaptic Neuron in the SAME spinal level
B) Presynaptic Fibers can enter the Paravertebral Ganglion ascend or descend to synapse on a Postsynaptic Neuron a DIFFERENT level
C) Presynaptic Fibers can enter the Paravertebral Ganglion and exit without synapsing and continue on through the Abdominopelvic Splanchnic Nerve on their way to the Postsynaptic Neuron in Prevertebral Ganglion
3) Postsynaptic Fibers (LONG)
A) Cell Bodies exist in the Paravertebral or Prevertebral Ganglia
1) Paravertebral Ganglia:
- Linked vertically to form Sympathetic Trunks on either side of the Vertebral Column
- Three Ganglia also exist in the Cervical, Lumbar, and Pelvic regions
2) Prevertebral Ganglia:
- Ganglia and corresponding Plexuses surrounding the Main unpaired Branches of the Abdominal Aorta
I) Celia Ganglion
II) Superior Mesenteric Ganglion
III) Aorticorenal Ganglion
IV) Inferior Mesenteric Ganglion
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Sympathetic Presence in the Thorax
1) Thoracic Sympathetic Trunk:
- Paravertebral Sympathetic Ganglia
- Location of Presynaptic Sympathetic Nerve Fibers synapsing onto Long Postsynaptic Nerve Cell Bodies
2) Cardiopulmonary Splanchnic Nerves:
A) Cardiac Splanchnic Nerve:
- Presynaptic Cell Bodies in the Lateral Horn of the Spinal Cord as levels T1-5 or 6 Synapse onto Postsynaptic Cell Bodies in the Cervical and Thoracic Sympathetic Trunks which send fibers to the Superficial and Deep Cardiac Plexuses
B) Pulmonary Splanchnic Nerve:
- Presynpathetic Cell Bodies in the LateralHorn of the Spinal Cord at levels T2-3 Synapse onto Postsynaptic Cell Bodies in the Thoracic Sympathetic Trunk which sends fibers to the Pulmonary Plexus
3) Abdomenpelvic Splanchnic Nerves:
- Travels from the Thoracic Sympathetic Trunk to corresponding Paravertebral Ganglia in the Abdomen
A) Greater Splanchnic Nerve:
- T5-9 or 10
- Sends fibers to the Esophageal Plexus and to the Celiac Ganglion in the Abdomen, which then feeds into the Celiac Plexus
B) Lesser Splanchnic Nerve:
- T10 and T11
- Sends Fibers to the Celiac and Superior Mesenteric Ganglion in the Abdomen, which then feeds into the Superior Mesenteric Plexus
C) Least Splanchnic Nerve:
- T12
- Sends fibers to the Aorticorenal Ganglion in the Abdomen
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Parasympathetic Nervous System
- Craniosacral CN II, VII, IX, and X, S2-S4
1) Presynaptic Fibers (LONG)
A) Nuclei in the Bran Stem and Sacral Spinal Levels
B) Cranial component exists as Cranial Nerves
1) Oculomotor Nerve (CN III)
2) Facial Nerve (CN VII)
3) Golssophanryngeal Nerve (CN IX)
4) Vagus Nerve (CN X)
C) Sacral Component exists Spinal Levels as Pelvic Splanchnic Nerves
2) Postsynaptic Fibers:
- Usually short, with Ganglia/ Postsynaptic Neurons near or in the Target Organ
A) Nuclei are in Four Specific Cranial Ganglia or in the wall of the target Organ
1) Ciliary Ganglion:
- Receives fibers from Oculomotor Nerve
2) Pterygopalatine Ganglion:
- Receives fibers from the Facial Nerve
3) Submandibular Ganglion:
- Receives fibers from the Facial Nerve
4) Otic Ganglion:
- receives fibers from the Glossopharyngeal Nerve
B) Intrinsic Parasympathetic Ganglia:
- Postsynaptic Parasympathetic Cell Bodies located in the walls of the Target Organs
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Parasympathetic Presence in Thorax
1) Vagus Nerve: Presynaptic Parasympathetic Innervation to the Lungs, Bronchi, Pleurae, Heart, and Pericardium
A) Superior Cardiac Branch:
- Originates in the Neck descends through the Superior Thoracic Aperture, and with the Cardiac Splanchnic Nerves forms the CARDIAC PLEXUS
B) Middle Cardiac Branch:
- Originates in the Neck and descends through the Superior Thoracic Aperture, and with the Cardia Splanchnic Nerves and forms the CARDIAC PLEXUS
C) Inferior Cardiac Branch:
- Originates in the Thorax, and with the Cardiac Splanchnic Nerves forms the Cardiac Plexus
D) Pulmonary Branches:
- Originates in the Thorax, and with the Pulmonary Splanchnic Nerves forms the Pulmonary Plexus
E) Esophageal Branches:
- After producing Pulmonary Branches the Vaguds nerve becomes Indistinguishable from the Esophageal Plexus that covers the Inferior 2/3 of the Esophagus
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Thoracic Autonomic Plexus (Pulmonary Plexus)
1) Pulmonary Plexus:
- Mixed Sympathetic and Parasympathetic
- Sympathetic input from the Pulmonary and Splanchnic Nerves
- Parasympathetic input from the Pulmonary Branches of the Vagus Nerve
- Innervates the Lungs, Bronchi, and Pleurae
A) FUNCTIONS:
- As a Bronchodilator to the Bronchi and Bronchioles
- As an Inhibitor to the Glands of the Bronchi and Bronchioles
- As a Vasoconstrictor to the Pulmonary Vessels
- Visceral Sensory from Lungs, Bronchi, and Pleurae
- AS a Bronchoconstrictor to the Bronchi and Bronchioles
- Secretomotor to the Glands of the Bronchi, Bronchioles and as a Vasodilator to the Pulmonary Vessels
- Sensory from the Bronchial Mucosa (Cough Reflex)
- Stretch Receptors from the Bronchial Musculature
- Reflecxive from the Interalveolar connective tissue
- Pressure sensory from the Pulmonary Artery
- A Chemoreceptor from the Pulmonary Vein
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Thoracic Plexus Cont (Cardiac Plexus)
2) Cardiac Plexus:
- Mixed Sympathetic and Parasympathetic
- Sympathetic input from the Cardiac Splanchnic Nerves
- Parasympathetic input from the Superior, Middle, and Inferior Cardiac Branches of the Vagus Nerve
- Postsynaptic fibers terminate near the Sinuatrial and Atrioventricular Nodes
A) FUNCTION:
- Sympathetic: Innervation of NODAL Tissue
- Increases Heart Rate and the force of the Heart Contractions
- Vasomotor to the Pericardium
- Parasympathetic: Innervation DECREASES Heart Rate
- Reduces the force of Heart Contraction and Vasoconstrictors Coronary Arteries
B) Superficial Cardiac Plexus:
- Covers the Anterior Surface of the Aorta
C) Deep Cardiac Plexus:
- Exist Anterior to the Aortic Arch
- Superior to the Bifurcation of the Pulmonary Trunk
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Thoracic Autonomic Nervous System (Aortic Plexus)
3) Aortic Plexus:
- Mixed Sympathetic and Parasympathetic
- Continues Superiorly with the Superficial Cardiac Plexus
- Continues Inferiorly as the Aortic Plexus in the Abdomen
- Feeds into the Intermesenteric Plexus
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Thoracic Autonomic Nervous System (Esophageal Plexus)
4) Esophageal Plexus:
- Mixed Sympathetic and Parasympathetic to the Esophagus
- Sympathetic input from the Greater Splanchnic Nerve and Aortic Plexus
- Parasympathetic input form the Esophageal Branches of the Vagus Nerve
A) FUNCTION:
- Sympathetic: Inhibit Peristalsis and Esophageal Glands
- Parasympathetic: Stimulates Peristalsis and Esophageal Glands
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Blood Clotting
- Blood circulates in a Closed System of Vessels
- An injury or cut results in Bleeding
- To minimize Blood Loss, platelets and dissolved proteins in plasma form an insoluble mass (Clot) that occludes the damaged vessels
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Hemostasis
- The process of forming a barrier to blood loss is called Hemostasis
- Barrier mass is a Hemostatic plug, blood clot or thrombus
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Hemostasis Three Steps
1) PRIMARY HEMOSTASIS:
- Formation of a Primary Plug- clumping of blood platelets at site of injury to create a Physical Plug (VASOCONSTRICTION Occurs to REDUCE Blood Flow)
- Platelets interact with Broken Vessels and each other forming PRIMARY HEMOSTATIC PLUG
2) SECONDARY HEMOSTASIS:
- Formation of BLOOD CLOT
- Insoluble strands of Fibrin become deposited on primary plug making it strong- SECONDARY HEMOSTATIC PLUG
- Aggregation og FIBRIN into an Insoluble clot-covers the RUPTURE and PREVENTS BLOOD LOSS
3) FIBRINOLYSIS (3rd Stage):
- REMOVAL of Clot
***We are going to focus on the formation of the Fibrin Clot which comes from the CLOTTING CASCADE
**FIBRIN is formed by a series of Complex Biochemical Reactions from the Soluble Plasma PROTEINS called COAGULATION FACTORS as they associate with INJURED Blood Vessels and the Platelet Plug
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Hemostasis Definition
Hemostasis: Stoppage of Bleeding
- Must be fast, localized, and carefully controlled process; Occurs within minutes of the Injury
- Deficient function of this system can lead to Fatal Bleeding following even a Minor Injury
- OVERACTIVITY of this system can produce UNWANTED CLOTS, resulting in blockage of Blood Vessels, as occurs in Heart Attach and Stroke
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Fibrin Clot
- Goal is ALTERING FIBRINOGEN (Soluble) into FIBRIN(Insoluble)
Fibrinogen:
- Constitutes approximately 4 percent of Plasma Proteins
- Largest of Plasma Proteins
- Involves many proteins involved in the Clotting Cascade
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Clotting Cascade
- Fibrin is formed in a Cascade Fashion
- Circulating Inactive Coagulation factors (ZYMOGENS) are sequentially activated to enzymes
- ZYMOGEN is an INACTIVE form of an enzyme that can be activated by PROTEOLYSIS
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What is a Zymogen?
- a ZYMOGEN is a biologically Inactive Protien or Enzyme that is ACTIVATED by SITE-SPECIFIC PROTEOLYSIS
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Clotting Factors IN LIVER
1) Pre: For SECRETION
2) Pro: to KEEP it INACTIVE
**Biologically Inactive: Zymogen!!!!
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Clotting Factors IN BLOOD PLASMA
1) Pro: To KEEP it INACTIVE
**Biologically Inactive: Zymogens!!!
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Clotting Factors in COAGULATING BLOOD
**** NO PRE or PRO segments on the Protein!!!!
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Clotting Cascade
- Each Zymogen serves first as a SUBSTRATE, then as an ENZYME
- Final SUBSTRATE is FIBRINOGEN
- When acted on by Final Enzyme, THROMBIN, Fibrinogen is Converted to FIBRIN!!!
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Goal: Fibrin Formation
Prothrombin (Factor II) ------> Thrombin (Factor IIa)
Thrombin is a PROTEASE which cuts Fibrinogen into FIBRIN!!!!!
Fibrin:
- Polymerizes into Clot
- Clot formation: INSOLUBLE Crosslink Dam at site of wound!!!!
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Clotting Factors
```
Factors:
I (Fibrinogen)
II (Prothrombin)
III (Tissue Factor)
IV
V
VI
VII
VIII
IX (Christmas Factor)
X
XI
XII (Contact Factor)
XIII (Plasma Transglutaminase)
```
**Activated Factors have "a" following the name
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Factor IX Deficiency
- Called CHRISTMAS FACTOR DISEASE
- After Stephen Christmas, the first patient describe with this Disease
- In addition, the FIRST REPROT of its Identification was published in the CHRISTMAS edition of the British Medical Journal
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Thrombin
- Prothrombin (an inactivated Zymogen) is ACTIVATED to Thrombin by proteolytic cleavage with a SERINE PROTEASE (Prothrombinase)
- Serine Proteases catalyze HYDROLYSIS of peptide bond- Serine resides is in the ACTIVE SITE
- THROMBIN is itself a SEIRNE PROTEASE and its at site with ARG-GLY!!!!!!!
- Thrombin cuts FIBRINOGEN to form FIBRIN
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Fibrinogen
- This protein is made up of 3 Subunits (Alpha, Beta, and Gamma) that exist as DIMERS with DOMAINS D and E
- Thrombin CUTS OFF A and B sites, left over portions of A unit fit into GAMMA SUBUNIT of ANOTHER FIBRINOGEN
149
Fibrinogen Cont
- Cut and release FIBRINOPEPTIDES
- Significant cause these small peptides prevent self- aggregation
- Release of A FIBRINOGENPEPTIDE exposes sites in the E domain that match complementary sites in D Domain
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Fibrin Aggregation
- Remove peptide preventing Self-Aggregation- Self Association between FIBIRN Subunits
- Staggered arrangement- bricks in a wall
- Forms "SOFT" CLOT!!!
**E doman (A sites) interacts with D Domain (Gamma Subunit) over and over!!!
**Left over A fits into Gamma Subunit!!!
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Fibrin Aggregation
- Also cut off ends of B sites
| - B chains interact to form 3 dimensional wall
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Hard Clot formation
- Interactions between D and E domains are H-Bonds (Nice but not a Hard Clot)
- Next form Hard Clot- covalent bonds formed between Fibrin Subunits (Slower Process)- COVALENT BODN formed between NH2 of GLUTAMINE and NH3 of LYSINE!!!!!!
- Factor XIIIa- TRANSGLUTAMINASE!!!!!!!!
153
Hard Clot Formation
- THROMBIN activates TRANSGLUTAMINASE!!!!!!!
**Factor XIII---> Factor XIIIa
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Step Back: Prothrombin
- PROTHROMBIN must be modified by POST-TRANSLATIONAL MODIFICATION, important for CLOT LOCALIZATION!!!!!!!!
- Glutamic Acids get MODIFICATION, get EXTRA COO- group attached to them!!!!!
- There is CARBOXYLATION of Several GLUTAMIC ACID residues, adds ANOTHER CHARGE to R-group on Amino Acid- "-2" Negative Charge, called GAMMA CARBOXYGLUTAMATE!!!!!
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Prothrombin
- Why is this Negative 2 charge important?
- Helps LOCALIZE Prothrombin to DAMAGED VESSELS
- Damaged Vessels release Ca2+, so modified PROTHROMBIN (with Negative 2 Charge) has Perfect BINDING SITE for Ca2+!!!!!!!!!
- Provides SPECIFICITY- PROTHROMBIN binds to Ca2+ at WOUND!!!!!!!!!
- Ca2+ in turn binds to PLATELETS which have EXPLODED Uncovering Negatively Charged PHOSPHOLIPIDS as the INVERT
SLIDE 33 of CLOTTING CASCADE!!!
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Vitamin K
- Modification of PROTHROMBIN (Carboxylation) requires VITAMIN K
- Recycling Vitamin K essential!!!!!
***Epoxide Reductase is IMPORTANT!!!!!
**Therapeutically Important!!!
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Vitamin K
- WARFARIN (Coumadin) and DICOUMEROL, Competitive INHIBITORS of EPOXIDE REDUCTASE
- ANTI CLOTTING DRUGS
- Drugs similar in STRUCTURE to VITAMIN K
- Enzyme (EPOXIDE REDUCTASE) binds them but the INHIBIT Enzyme Activity
- Inhibits the ADDITION of CARBOXYLIC ACID Groups to PROTHROMBIN!!!!
158
Warfarin and Dicomeural
- Dicomeural and Warfarin are COMPETITIVE INHIBITORS of Epoxide Reductase
- These DECREASE Prothrombin Levels!!!!!
159
Warfarin
- Warfarin is RODENTICIDE: Active Ingredient in RAT POISON!!!!!
- patients must be watched CAREFULLY!!!
***Patented by university of Wisconsin
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Clotting Cascade
- Enzyme Cascade of SERINE PROTEASES
- Contain SERINE RESIDUE in ACTIVE SITE of PROTEASES
- Exist as ZYMOGENS, Inactive Enzymes made ACTIVE by PROTEOLYTIC CLEAVAGE!!!!!
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Clotting Cascade Cont
- Occurs in Two Pathways:
1) INTRINSIC
2) EXTRINSIC
- which lead to a COMMON Pathway
- The Intrinsic Pathway is the WORKHORSE in this process
- The Extrinsic Pathway is the SPARK to get the process started
INTRINSIC PATHWAY: does not Require a PROTEIN OUTSIDE of Blood to be ACTIVATED
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Intrinsic Pathway
1) Broken Vessel ---> XII
2) XIIa: XI----> XIa
3) XIa: IX ---> IXa
4) IXa + VIIa (From Thrombin): IXa/ VIIa Complex (Also called TENASE)
- PF3: Platelet Factor 3: Phospholipids
- On INTERIOR of Platelets
- Become exposed when Platelet Disrupted
- Phospholipid surface of Platelets and Damaged vessels essential
*****HEMOPHILIAS: VIII---> VIIIa-----> IXa
SLIDES 40-45 of Clotting Lecture!!!!!
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Start of Common Pathway
1) IXa/ VIIA Complex: X ---> Xa
- Needs PFE, and Ca2+
2) Xa + Va (From Thrombin): Xa/ Va Complex (Also called Prothrombinase)
3) Xa/ Va Complex: Prothrombin ---> Thrombin
- Needs PF3, and Ca2+
164
Amplification of Cascade
- Activation of a handful of Factor XII activates hundreds which activates thousands
- There is amplification in terms of number at each stage
- Small signal get large response
165
Extrinsic Pathway
- Extrinsic Pathway requires an Active Component that is NOT PART of the Blood Under Normal Conditions
- This is TISSUE FACTOR (FIII), found on Surfaces of cells lining Blood Vessels, TRANSMEMBRANE PROTEIN!!!
- Extrinsic Pathway is ACTIVATED by contact of Factor VII with Tissue Factor (FIII)
Extrinsic Pathway:
- Simpler Pathway
- Major Pathway
- Converges with Intrinsic Pathway in Common Pathway
166
Common Pathway
- The Extrinsic and Intrinsic pathway converge at the Common Pathway
- Common Pathway: From FX to Fibrin Clot formation
167
The Thrombin Mystery
- If in this pathway you REQUIRE THROMBIN to activate certain factors BUT Thrombin is not made until you reach the end of the pathway, how do you get the Thrombin in the First Place?
Answer:
- Usually about 1% of FVII circulates as FVIIa
- Normally this FVIIa DOES NOT come into contact with Tissue Factor until DAMAGE OCCURS
- After damage, Factor VIIa joins with Tissue Factor
- TF/ FVIIa Complex ACTIVATES FX
- Platelets have some activated FVa, released from Platelets
- Forms FXa- FVa PROTHROMBIANSE Complex
- Get THROMBIN BURST to get things STARTED!!!
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The Thrombin Spark
- Some Thrombin, a MICROBURST, gets created from the Extrinsic Pathway in association with Platelets to get the WORKHORSE (Intrinsic Pathway) going and amplifying
- Extrinsic Pathway very Important!!!
169
Vitamin K dependent Factors
- Not only Prothrombin has to have ADDITIONAL Carboxyl (COOH) groups added to GLUTAMIC ACIDS!!!
- There are 3 other factors that require this process and are Vitamin K Dependent:
1) X
2) IX
3) VII
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Positive Feedback
- There is Positive Feedback that greatly accelerates the RATE of CLOTTING
Example Include:
1) Thrombin
2) FXIa
3) FXa
4) FVIIa
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PARTIAL THROMBOPLASTIN TIME (PTT) "Coagulation Test"
- Clotting time from Factor XII to Fibrin Clot---> Intrinsic and Common Pathways: Reference 35 sec
- Activator substance such as KAOLIN added to PLASMA to ACTIVATE CONTACT FACTORS
172
PROTHROMBIN TIME (PT) "Coagulation Test"
- Clotting time from Factor VII to Fibrin Clot ---> Extrinsic and Common Pathway: Reference Time = 10 to 12 Seconds
- Addition of Tissue Factor (Tissue Thromboplastin)
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Clotting Cascade: Two Types
- What is tested for in lab and what really happens in the body
174
Clotting in Vivo
TF = Initiating Component
- Similar Steps between IN Vitro and In Vivo Clotting Models
- No Factor XII in IN Vivo Model (No disease associated with its Absence)
1) VIIa- TF Complex: IX----> IXa
- PF3, Ca2+
2) VIII---- (Thrombin)----> VIIIa
- FVII is helper Protein (Cofactor)
3) IXa + VIIIa= IXa/ VIIIa Complex (TENASE)
4) IXa/ VIIIa: X-----> Xa
- PF3, Ca2+
5) V----(Thrombin) ---> Va
6) Va + Xa: Xa/ Va Complex (Prothrombinase)
7) Xa/ Va Complex: Prothrombin ----> Thrombin
******3-7-8-9-10-5!!!!!!!!!!!1
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Regulation I
- Turn process down so do not get uncontrollable clotting
- Thrombin actually binds Fibrin, INACTIVATES Fibrin (Kinects)
- Thrombin can cut FVIIIa to INACTIVE form FVIIIi, also Xa ------> Xi and Va ---> Vi
- Thrombin can cut Prothrombin to create an Inactive form!!!!
176
Regulation II
- Thrombin can complex with THrombomodulin to create a TTM Complex
- This cleaves a protein called Protein C into Active Protein Ca
- Protein Ca plus other proteins can INACTIVATE FVa and FVIIIa, DECREASES production of THROMBIN
- Activated Protein Ca's are decorated with GAMMA-CARBOXYGLUTAMATE, so will localize to Platelet areas with PF3!!!!!!!
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Anticlotters- Preventing Clotting
- WARFIN and DICOUMAROL
- Protect Platelet Integrity- ASPIRIN
- Decrease Ca2+, CALCIUM CHELATING AGENTS
- HEPARIN- Activates Antithrombin II- binds to Thrombin and Xa- INACTIVATES
- End Game: Tissue PLASMINOGEN FACTOR (TPA), Precursor to Plasmin, DISSOLVES CLOT, FIBRINOLYSIS!!!!!!
- TPA: First genetically engineered human protein to be approved for use in Humans: given to remove clot also after stroke if given early
178
Diagnostics (Hemophilia)
PTT: 55 seconds (Abnormal Intrinsic)
- Factors II (Prothrombin), V and IX Normal, FACTOR VIII LOW!!!!!
***HEMOPHILIA A!!!!!
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Diagnostics (Vit K Deficiency)
- PT: 35 Secs (Abnormal)
- PTT: 70 Secs (Abnormal)
- Low Factor IX, VII, X (Vitamin K Dependent), and Normal Factor VIII
