Thorax Flashcards by Nathan Ashburner

Where metallic valves are located on X ray

Aortic
Usually located medial to the 3rd interspace on the right.

Mitral
Usually located medial to the 4th interspace on the left.

Tricuspid
Usually located medial to the 5th interspace on the right.

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Root of lung - ant to posterior

Ant- phrenic
Pul vein
Pul artery sup post
Bronchus posterior to artery and superior to vein
Post- vagus

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Which muscles/nerves are closely related to the carotid sheath at

Above the level of the hyoid the vessels pass deep to the posterior belly of digastric and stylohyoid

Opposite the hyoid bone the sheath is crossed obliquely by the hypoglossal nerve.

Opposite the cricoid cartilage - crossed by the superior belly of omohyoid.

At its lower end -sternohyoid and sternothyroid.

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Aortic arches origins

1- disappears -maxillary
3- common carotid and prog internal carotid
4- aortic arch left, right subclavian prox
6- left and right pulmonary

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What is divided routinely in midline sternotomy

Interclavicular ligament

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If pleural reflections are divided in stenotomy what should be done

Chest drain inserted

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Chest drain inserted and blood apparent at site- which structure damaged

Intercostal artery
Most inferior

V
A
N

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Which nerve is often damaged in axillary surgery and what is the result

Intercostalbrachial

Parasthesia in armpit

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Each heart valve, number of cusps, number of anterior cusps, muscle attachments

Mitral- 2, 1 anterior
Attached to chord tenindae

Aortic-3, 2 anterior
No chordae

Pulmonary- 3,2 anterior
No chordae

Tricuspid- 3, 2 anterior
Attached to chordae

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Which fascia overlies apices of lungs

Sibsons
C7 to the first rib -It lies between the parietal pleura and the thoracic cage.

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How persistent SVC drains into heart

Via coronary sinus

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Foramen of Morgani contents

Superior epigastric artery and vein

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Ligaments of diaphragm

Central tendon

Left and right crus-Median Arcuate around aorta

Then medial arcuate - around psoas
then lateral arcuate

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Contents of Middle Mediastinum

P ericardium
H eart
A ortic root
A rch of azygos vein
Bronchi

BAAPH

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Contents Posterior Mediastinum

D escending aorta
A zygous and hemiazygos vein
T horacic duct
E sophagus
S ympathetic trunk/ganglia; splanchnic nerves
Vagus nerve

DATES V

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Where does the Great Cardiac Vein begin, run and drain

Begins at the cardiac apex

Runs in the anterior interventricular sulcus with LAD

Drains both ventricles and left atrium – to Left extremity of coronary sinus

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Where does the middle Cardiac Vein begin, run and drain

Begins at the cardiac apex

Runs in the posterior interventricular sulcus with PDA

Drains the areas supplied by PDA of right – to Right extremity of coronary sinus

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Where does the small Cardiac Vein begin, run and drain

Runs in the right posterior atrioventricular (AV) groove

Drains the posterior part of right atrium & ventricle – to Right extremity of coronary sinus near its atrial end.

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Receptors in heart and location

The ventricles: beta-1 adrenoceptors The atria: cholinergic receptors.
The aortic arch: contains baroreceptors. The carotid body: contains baroreceptors

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Unique feature of right atrium

Musculi pectinati

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CI to lung cancer surgery

SVC obstruction
FEV <1.5
Malignant pleural effusion
Vocal cord paralysis

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What do thebsian veins drain into

Atrium

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With SVC obstruction how many collaterals are there

Azygos venous system
Internal mammary venous pathway
Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)

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Which artery is likely encountered in axillary surgery

Thoracodorsal

If damaged lat flap can’t be used

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What prolapses in disc prolapse

Nucleus pulposus

Where does thyroid ima arise from

Brachiocephalic

At which level does the trachea bifurcate?

From which structure is the central tendon of the diaphragm derived?

Septum transversus

Which nerves are commonly damaged in axillary node biopsies

Thoracodorsal - problems painting etc intercostobrachial nerve

What is the outer layer of the intrathoracic oesophagus?

Loose connective tissue Adventita

What level is the apex of the middle lobe

6th interspace in MAL Where oblique runs up and meets horizontal Horizontal runs from 4thCC to 6th MAL

Where are the greatest proportion of musculi pectinati found?

Right atrium

What directly innervated the heart

Superior and inferior cardiac plexuses

What is found at sternal angle

T4-5 2nd CC Start/end of aortic arch SVC Bifurcation of trachea Bifurcation of pulmonary trunk Azygous arching to SVC Thoracic duct crosses midline

Lung projection in relation to first rib

Projects up and beyond constrained by SIbson fascia

Passage of sympathetic trunk into abdomen

Posterior to medial arcuate Over psoas major

Name of foramen IVC goes through in diaphragm

Caval foramen

What lies anterior and posterior to transverse pericardial sinus

Aorta and pulmonary trunk anterior SVC posterior

What does the oblique sinus go between

Blind ended sinus between pulmonary veins

Dermatome nipple sits in

Main arterial supply of breast

Internal thoracic

Surface location of lungs vs pleura at base

Lungs 6th MCL, 8th MAL, 10 posterior Pleural- 8th MCL, 10 MAL, 12 post

Anterior to posterior of heart valves

Pulmonary Aortic Mitral and tricuspid

Source of aortic valves

Left- left CA Right- right CA Posterior - nothing

Where is AV located

Koch triangle

Pleural location relative to clavicle and name

Cupola 2.5cm above clavicle in middle 1/3

What does the posterior descending coronary supply

Post 1/3 of IV septum Right and left ventricles

What does the left circumflex supply

Left atrium and ventricle

Which muscles retract scapula

Trap Rhomboids Lat

Which muscle protract scapula

Serratus anterior

Serratus anterior attachements

Upper 8 ribs Insert into medial border of scapula

Which part of the lung does azygous lobe effects

Right upper zone Super to hilum Reverse comma sign

What part of diaphragm foes IVC, oesophagus and aorta pass through

IVC- central tendon Oesophagus- Right crus Aorta- median arcuate

External intercostal action and attachment

Fibres run inferomedially Raises ribs and expands in forced inspiration

What path does the oblique fissure follow

Medial border of scapula when abducted Right- T4 to 6th rib Left- between T3/4- 6th rib

Horizontal fissure path

6th ICS MAL to 4th CC anterior border

Phrenic nerve relative to subclavian and scalene

Ant to subclavian artery Post to subclavian vein Anterior and Medial to lower border of scalene anterior

Where is the right coronary sulcus and what runs through it

Atrioventricular groove RCA

Which nodes are difficult to sample in cervical mediastinosocpy

Aortopulmonary Accessed via VAT instead

What is most likely to be affected in right bronchus lymphadenopathy in superior aspect

Azygous As loops over

Root of lung vertebral level

T5/6

Vertebral level of xiphoid

Liver biopsy, now pain on tip of right shoulder

Phrenic nerve- supplies here

Location of crest terminals and what is contained here

Posterolateral wall of RA SA node

Stenosis of what artery is most sever

Anterior inter ventricular - widow maker - widespread ST

Which artery supplies upper 1/3 oesophagus

Inferior thyroidR

Risk of pericardectomy

Phrenic nerve damage

What level does the aortic arch become descending

What covers arch of aorta anteriorly

Left pleura

Aorta relation to brachiocephalic veins

Apex of arch poster inferior to left brachiocepahlic

How many segments does right and left lung have

10 -R 8-9- L

What contains lingual lobe

Left upper lobe Anteroinfeiror projection

Level hemiazygous crosses over to join azygous

What is located in anterior wall of right atrium

Musclini pectin in auricle

Where coronary sinus sits

Postero inferior Posterior part of RA next to IVC

Smooth posterior part of RA

Sinus venarum Joins rough anterior at crest terminals

Level SVC joins RA

3rd CC

Types of joint that steno manubrium is

Secondary cartilaginous

Where is the coronary sinus opening located

located between the inferior vena cava and tricuspid valve

What organs foes subclavian supply

Thyroid gland- via thyrocervical Breast, RA, diaphgram- internal thoracic Brainstem, cerebellum- vertebral Upper limb

Vessel damaged in sternotomy

Brachiocephalic artery vein Left carotid and subclavian

% of AV branch supplied by RCA

70-80

Central venous cannulation landmark

1-2cm below and lateral to junction between medial 1/3 and lateral 2/3 of clavicle Subclavian vein location

What does the left marginal branch branch off of

Left circumflex

Level of carina

T4/5

What does the LCA pass between

Left atrial appendage and pulmonary trunk

Level thoracic duct passes posterior and to left of oesophagus

Right, co and left dominance stats

right 80 co- 10-20 5-10 left

Diagnosis of mesothelioma

Pleural biopsy

Defect in connective tissue disorder causing dissection

Fibrillin 1

Most common lung neoplasms

Mets

Heart transplant rejection types

Acute- T cell, cell death AB mediated- month to years Allograft vasculopathy- CA disease- months to years Diffuse proliferation of intima

Marantic endocarditis

Non bacterial thrombotic endocarditis Advanced malignancy Vegetations on mitral and aortic

Major + Minor criteria for IE

Echo findings 2 + blood futures , 1 if coxiella Fever Skin Vascular IVDU

What would suggest a small cell lung cancer is unresectable

SIADH

Mutation in primary small cell cancers

p53

Paraneoplastic of small cells

PTHrP ACTH SIADH

Differentiating TB and sarcoid

TB- caseated calcified lesion Sarcoid- non caseating

What cells does bronchoalveolar carcinoma rise from

Pneumocytes type 2

What way empyema cause

Frozen chest - pleural stick together

Cortisol after cardiopulmonary bypass

Fall

Tracheostomy effect on V/Q, dead space and secretions

Decrease mismatch and dead space Used for bronchial toiler- clearing of secretions those unable to cough

End management for IE with pan systolic murmur

Mechanical mitral valve

Type 1 vs 2 resp failure

1- V/Q mismatch 2- hyperventilated alveoli

Strep bovis IE, what next Ix

Colonsocpy as linked to colon cancer

CURB65

Confusion Urea >7 Resp >30 Bp <90 or 60 >65 2- admission

Most common complication of FNA lung

Pneumothorax

Acquired RF for atherosclerosis

HTN, hyperlipid, smoking, high fibrinogen, obesity, hypothyroid

Normal PAWP

6-12 mmHg

Artery for AV node

Posterior IV artery

Tension pneumothorax CVP and Bp

High CVP and low BP

Caveatting lesion lung

Staph aureus

BP and temp in bypass

Controlled hypotension and hypothermia To reduce dissection risk and metabolic rate

What is used for bypass

Left internal mammary If unavailable or not suitable - RIMA Better than. veins as withstand high pressure and flow during systole and diastole

Use of hyperbaric oxygen therapy

CO poisoning

Small peripheral lesion in healthy non smoker

Pulmonary harmatoma

Bypass coagulopathy

THrombocytosis

Tx of lung abcess

Prolonged Abx 4-6w Surgical if do not respond or complications

Where bypass machine works

Cannula in right atrium where it is then oxygenated and return in the ascending aorta Lungs are deflated to allow access

Mx of inhaled FB

Bronchoscopy if visualised Fibre optic bronchoscopy if not visualised

Mx of empyema

Simple-chest drain Disabling resp symptoms, fibrous peel, pleural peel for 4-6w -thoracotomy