Sternum
Manubrium, body, xiphoid process
Jugular notch at T2
Sternal angle at T4/5
Xiphoid process at T9
Vertebral levels
Denver F. Sapo, MD
Ribs
TRUE ribs
Attach to sternum
Ribs 1 to 7
Rib fracture (Clinical correlation)
TYPICAL rib
Ribs 3-9
ATYPICAL rib
Ribs 1, 2
FALSE RIBS
Attach to costal cartilage above
Ribs 8 to 10
Ribs 10, 11, 12
No attachment anteriorly
Ribs 11 and 12
HPEParadoxical chest
movement
MCribs 5 to 10
Cx?
Rxintercostal nerve block
Rib 1 and 2 fracture means?
Lower rib fracture
Cervical rib (Clinical correlation)
From the transverse process of C7
Cxthoracic outlet syndrome
Two separate fractures in 3 ribs
Costochondral junction
Angle
pulmonary contusionmajor cause
of respiratory compromise
RxPEEP
Thoracic outlet syndrome (Clinical correlation)
Just anterior to the angle of the rib
FLOATING RIBS
Flail chest (Clinical correlation)
What do you call this maneuver?
Manubriosternal joint
Dermatome vs Vertebral level
Vertebral level
Xiphoid process at T9
Nipple at T4
Umbilicus at L4
Xiphoid process at T7
Umbilicus at T10
Inguinal ligament at L1
EKG electrode placement (Clinical correlation)
Sternal angle (of Louis)
At the level of
V2left 4th ICS
V3?
V45th ICS MCL
V5AAL (same level as V4)
V6MAL (same level as V4)
Junction of superior and inferior
mediastina
Bifurcation of the trachea
T4/5 IV disk
Beginning and end of the aortic
arch
2nd costal cartilage
Azygous vein drains into the SVC
Dermatomal level
V1right 4th ICS
Costovertebral and
costotransverse joints
Headvertebral body
Costochondritis (Clinical correlation)
Costovertebral joints
Corresponding
Above
Aka Teitz syndrome
Tenderness over the costochondral
joints
Treatment?
Costotransverse joints
Tubercletransverse process
Corresponding
Thoracic outlet???
Superior thoracic aperture
Inferior thoracic aperture
Which aperture is affected in
thoracic outlet syndrome?
Intercostal muscles
Costal groove
V-A-N
Intercostal arteries
Posterior intercostal arteries
Superior intercostal artery (1-2)
Innermost intercostal
Intercostal arteries
Anterior intercostal arteries
Internal thoracic artery (1-6)
One finger breath lateral to
sternal margin
Divides in its terminal branches at
the 6th intercostal space
Musculophrenic artery (7-9)
Coarctation of the aorta (Clinical correlation)
Rib notching
PE?
Intercostal artery (3-11)
Subcostal artery
Intercostal space (Clinical correlation)
To enter the pleural cavity...
Posterior/Internal intercostal
membrane
Thoracic aorta
Anterior/external intercostal
membrane
Internal intercostal
Intercostal space
External intercostal
superior border of the rib
To perform intercostal nerve
block...
inferior border of the rib
Intercostal nerve block (Clinical correlation)
V-A-N
Cx
Pneumothorax
Hemorrhage
Needle thoracostomy (Clinical correlation)
Management for tension
pneumothorax
Anterior approach
Incision
2nd ICS MCL
Lateral approach
Tube thoracostomy (Clinical correlation)
Diaphragm
4th or 5th ICS (Snell)
5th or 6th ICS (Moore)
AAL or MAL
Indications
2nd ICS AAL
Air removal
Fluid drainage
Structures penetrated?
Diaphragm
Diaphragmatic apertures
Main muscle of respiration
Esophageal opening
Nerve supply?
Esophagus
Vagus nerve
THINKC3, 4, 5 keeps the
diaphragm alive
Which is higher?
Trauma (Clinical correlation)
The dome of the diaphragm can
reach the 5th rib!
Injury below the nipple line may
involve abdominal and/or chest
organs
Septum transversum
Esophageal mesentery
Pleuroperitoneal membrane
HeartT1-T4
Referred to intercostal nerves and
intercostobrachial nerve (T2)
Aortic hiatus
Aorta
Thoracic duct
Azygous vein
aortic hiatus (12 letters)
Caval opening
IVC
Right phrenic nerve
vena cava (8 letters)
Transverse diameter
AP diameter
Vertical diameter
Contraction of diaphragm
Intercostal nerve (Clinical correlation)
Mesoderm of body wall
Cardiac pain (Clinical correlation)
Oesophagus (10 letters)
Mechanics of respiration
Congenital diaphragmatic hernia
(Clinical correlation)
Herpes zoster
EtiologyVZV reactivation
Vesicular eruptions
Dermatomal pattern
Dormant within what structure?
Inferior mediastinum
Anterior mediastinum
Contents
Thymus
Sternopericardial ligament
Inferior wall MI
LN
Epigastrium
fat
Referred to epigastrium
T7, 8, 9
Inferior mediastinum
Middle mediastinum
Heart
Thoracic aorta
Roots of great vessels
Esophagus
Primary bronchi
Azygos and hemiazygos vein
Phrenic nerve
Vagus nerve
Arch of azygous
Thoracic duct
Sympathetic trunk
SVC
Brachiocephalic veins
Arch of the aorta
(L) RLN
Thoracic duct
Esophagus
(R) and (L) vagus n
(R) and (L) phrenic nerve
Thymus
SVC syndrome (Clinical correlation)
Obstruction of SVC
MCCmalignant tumor (lung
cancer)
Thoracic aorta
Ascending aorta
Aortic arch
Formed behind the lower border of
the 1st costal cartilage
What is the other name of the
brachiocephalic vein?
Question
Descending aorta
Which part of the mediastinum?
What is the first branch of the
aorta?
Thoracic duct
Starts as the?
Enters what hiatus?
Identify its course in the
mediastinum?
Empties where?
What part of the mediastinum?
Vagus nerve
Phrenic nerve
(R) RLN
Aortic dissection (Clinical correlation)
THINKKnow your ABCs
Contents
SVC
Pemberton sign
Posterior mediastinum
Contents
Contents
Superior mediastinum
Inferior mediastinum
Treatment?
Stanford classification
DeBakey classification
B-A-D
Azygos system
Communicates with the internal
(epidural) vertebral venous
(Batson) plexus
valveless
Azygos lobe (Clinical correlation)
Anomalous lateral course of the
azygous vein
Not a true lobe!
Incidental finding
Mediastinal masses
(Clinical correlation)
Mediastinal shift (Clinical correlation)
Tracheal shift
Atelectasis?
Pleural effusion?
Pneumothorax?
Asthma?
Pneumonia?
Diagnose?
Pleura
Parietal pleura
Visceral pleura
Sensitive to pain
Not sensitive to pain
Pleural fluid 5 to 10 mL (Snell)
Pneumothorax (Clinical correlation)
What is the lining epithelium?
Parietal pleura
Parts and innervation
Spontaneous pneumothorax
HPE
Pleura?
Sucking chest wound
Pleura?
Cervical/cupula
Costal
Diaphragmatic
Tension pneumothorax
Ball-valve effect
Clinical dx
Intercostal nerves
Centralphrenic nerve
Peripheralintercostal nerve
Mediastinal
Medisatinal shift VR
Sternal lines of reflection
Open pneumothorax
Phrenic nerve
Pleurisy (Clinical correlation)
Shoulder?
Anterior abdominal wall?
Costal and vertebral lines of reflection
Right
SC joint midline at MS joint
Bottom of
lung
XS joint
SC joint midline at MS joint
deviates laterally at the 4th
costal cartilage 6th costal
cartilage
6th rib
8th rib
MAL
8th rib
10th rib
Paravertebral
line
10th rib
12th rib
Pericardiocentesis (Clinical correlation)
Becks triad
Distended neck veins
Distant heart sounds
Decreased blood pressure
Intercostal approach
5th or 6th ICS near the
sternumbare area
Cxhemorrhage from internal
mammary artery or its branches
Bottom of
parietal pleura
(Costal line)
MCL
Left
Pleural cavity
Vertebral lines of pleural reflection
parallel the paravertebral lines from
T1 to T12
Water bottle heart
Initial management?
Definitive treatment?
Pericardiocentesis (Clinical correlation)
Xiphisternal approach
250 mL diastolic filling is
Thoracentesis (Clinical correlation)
Site9th ICS MAL
compromised
Pleural effusion (Clinical correlation)
Costodiaphragmatic angle
Posteriormost dependent
Lateral
Anteriorleast dependent
Left shoulder pain
Splenic rupture Hemorrhage
within the peritoneal cavity
300 mL
Endothoracic fascia
Kehr sign (Clinical correlation)
Respiratory system (Histology)
Loose connective tissue separating
the parietal pleura from the thoracic
wall
Suprapleural membraneSibson
fascia
Respiratory system (Histology)
Conducting portion
Respiratory portion
Upper respiratory tract
Lower respiratory tract
Clara cells
Trachea
Bronchi
Bronchiole
Club cell (January 1, 2013)
Pseudostratified
ciliated epithelium
Pseudostratified
ciliated epithelium
Simple cuboidal
epithelium
Bronchioles
C-shaped
Irregular plates
none
Function
Glands
++
none
Smooth muscle
yes
yes
yes
Epithelium
Cartilage
Differentiate terminal bronchiole
from respiratory bronchiole?
Alveoli
Type I pneumocyte
Simple squamous epitheliul
Type II pneumocyte
Cuboidal
Regenerate and divide
Synthesize surfactant
Surface tension
Compliace/Elasticity
Start at 20-24 weeks (Nelson)
Alveolar macrophage
Differentiate to ciliated cells
Secrete GAGs
Metabolize airborne toxins
Blood-gas barrier
What forms the blood-gas barrier?
Trachea
Extent?
What type of cartilage?
EA and TEF (Clinical correlation)
Type B
1%
AXRgasless abdomen
Type D
8-10% (2nd MC)
SSx?
Dxfailure to pass NGT
AXRgasless abdomen
EA and TEF (Clinical correlation)
Type C
EA + distal TEF
THINKCommon
85%
EA and TEF (Clinical correlation)
Type EH-type
TEF without EA
THINKDouble connection
THINKEyts
2%
Principal/Primary/Main bronchi
Right
excessive secretions
Eparterial bronchus
Right upper lobe bronchus
Narrower, longer, more horizontal
Tertiary/Segmental bronchus
8%
Left
Secondary/Lobar bronchus
Wider, shorter, more vertical
How many?
How many?
Foreign bodies tend to lodge in which
bronchi?
Endotracheal tube placement
(Clinical correlation)
Placement?
Complications?
Fissures
Fissures
Oblique/Major fissure
THINKAtresia Alone
EA + proximal and distal TEF
Bronchi
Type APure esophageal atresia
THINKBlank
EA and TEF (Clinical correlation)
EA + proximal TEF
EA and TEF (Clinical correlation)
Preferred site for trachesotomy
tube insertion?
Root of the spine of the
scapula6th rib 6th
costochondral junction
Horizontal/Minor fissure
4th costal cartilage meets
the oblique fissure horizontally
at the MAL
THINKRALeS
Lobes
Right lung
2 lobes
Right lung
Standing/sittingposterobasal of
RLL
Supinesuperior segment of
RLL
Right side-lyingmiddle lobe or
posterior segment of RUL
Segmental vein lies in the
connective tissue between adjacent
segments
Blood vessels of the lungs
Pulmonary artery
Pulmonary vein
Bronchial artery
Bronchial vein
Oxygen content?
Left side-lyinginferior lingular
Hamptons hump
Wedge-shaped
Pancoast tumor (Clinical correlation)
Surgically resectable
Left lung
Lingula
Foreign body aspiration (Clinical correlation)
Independent functional and surgical
units
Cardiac notch
3 lobes
Left lung
Bronchopulmonary segments
Tumor of the apex of the lung
Horner syndrome
Ptosis
Anhidrosis
Mio
Westermark sign
Oligemia
Lymphatic drainage
Superficial plexus
Deep plexus
(pulmonary nodes)
Bronchopulmonary
nodes
Tracheobronchial
nodes
sis
Bronchomediastinal trunk
Right lymphatic duct or
thoracic duct
Pericardium
Fibrous pericardium
Indistensible!
Serous pericardium
Parietal pericardium
Visceral pericardium
Pericardial fluid50 mL (Snell)
What is the difference between
visceral pericardium and
epicardium?
Lining epithelium?
Pericardial sinuses (Clinical correlation)
Oblique sinus
Transverse sinus
Allows clamping of great vessels
during cardiac surgery
Pericarditis (Clinical correlation)
Primitive heart tube
HPE
Pain?
Pericardial friction rub
EKG?
Rx?
Truncus arteriosus
Adult structure
Aorta
Pulmonary trunk
Persistent truncus arteriosus (Clinical correlation)
Neural crest cell
AP septum
Transposition of great arteries
Nonspiral development of AP
septum
Most common cause of cardiac
cause of cyanosis in the neonatal
period
Tetralogy of Fallot (Clinical correlation)
Skewed development of AP septum
THINKPROVe
PS
RVH
Overriding of the aorta
Ventricular septal defect
Trilogy?
Pentalogy?
Primitive ventricle and atrium
Adult structure
Partial development of AP septum
Egg-on-a-string sign
Bulbus cordis
Adult structure
Infundibulum/conus arteriosus
Aortic vestibule
Sinus venosus
Adult structure
Primitive ventricle Trabeculated
Sinus venarum
part of the ventricles
Coronary sinus
Primitive atrium Trabeculated
Oblique vein of LA*
part of the atrium
Fetal circulation
Ductus arteriosus
Remnant in adults
Functional closure--immedeately
(mediated by bradykinin)
Fetal circulation
Umbilical arteries?
Umbilical vein?
100% functional closure at 96
hours (Moore)
Anatomic closure--1 to 3 months
Foramen ovale
Functional closure--immedeately
Anatomic closure--1 year
Ductus venosus?
Foramen ovale?
Ductus arteriosus?
IVC FO LA
SVC LV
*Langman
Borders
Surface projections
RightRA
3rd right costal cartilage
LeftLV + LA
6th right costal cartilage
InferiorRV
2nd left costal cartilage
ApexLV
5th left ICS MCL
Surfaces
Base/PosteriorLA
AnteriorRV
DiaphragmaticLV
Auscultation areas (Clinical correlation)
bicuspid valve
tricuspid valve
pulmonary valve
aortic valve
Triangle of auscultation?
Arterial supply of the heart
(L) 5th ICS
4th ICS to the (L) of the sternum
2nd ICS to the (L) of the sternum
2nd ICS to the (R) of the sternum
Internal features
LCA
RA
Circumflex artery
Anterior IV artery
Supplies
AV valves
S1closure of AV valves
vestibule
Rough
Pectinate
muscles
(Auricle)
Trabeculae
carnae
papillar
y
muscle
chordae
tendina
Moderator
e
band
Trabeculae
carnae
papillary
muscle
chordae
tendinae
Tricuspid--Anterior, septal, posterior
Semilunar valvesTHINKLARP
S2closure of semilunar valves
Aorticright, left, posterior
MitralAnterior, posterior
Pulmonaryanterior, right, left
Where do the coronary arteries
originate?
Fossa ovalis
Crista
terminali
s
Sulcus
terminalis
Pectinate
muscles
(Auricle)
Supraventricular
crest
Arterial supply of the heart
LV
Infundibulum
conus arteriosus
Unique features
RV
Sinus venarum Entrance of
PVs
IV septum?
Heart valves
LA
Smooth
RCA
Origin?
Marginal artery
Posterior IV artery
Supplies?
SAN, AVN
IV septum?
Wall is 3x
thicker
Arterial supply of the heart
LCA
Circumflex artery
Anterior IV artery
Supplies
Myocardial infarction (Clinical correlation)
Occlusion
CABG
LAD > RCA > LCx
10-year patency
IV septum?
Diabetic
Elderly
Heart transplant patients
Infract localization
(Clinical correlation)
Septal wall MI
Lateral wall MI
Artery occluded?
Artery occluded?
Seen in what leads?
Seen in what leads?
Infract localization
(Clinical correlation)
Variations in arterial supply
Inferior wall MI
Artery occluded?
Seen in what leads?
Right dominant (80%)
Left dominant
Codominant
PDA arises from RCA
Venous drainage of the heart
Radial artery
Silent MI
Infract localization
(Clinical correlation)
IMA95%
Long saphenous vein50%
Coronary sinus
PDA arises from LCx
Septa
Interatrial septum
Interventricular septum
Great cardiac vein
Middle cardiac vein
MembranousMC site of defect
Small cardiac vein
Muscular
Smallest cardiac vein (thebesian)
Anterior cardiac vein
Conduction system
Slowest velocity?
Fastest conduction?
Only connection
between atria and ventricles?
SAN
AVN
AV bundle
Bundle branches
Purkinje fibers
Triangle of Koch
