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SSN ANATOMY Workshop 1: Thorax FEELING, BREATHING, PUMPING 1. ORGANIZATION OF THE SPINAL CORD AND ASSOCIATED STRUCTURES On the following diagram, label and draw in pathways for somatic afferent, visceral afferent, somatic efferent, parasympathetic, and sympathetic nervous systems. Be sure to label: dorsal / lateral / ventral horns, dorsal / ventral roots, dorsal root ganglion, white / gray rami communicantes, sympathetic chain, paravertebral ganglion, prevertebral ganglion, splanchnic nerve, and spinal nerve. 2. MOTOR INNERVATION OF LUNGS AND HEART Complete the following table: Innervation /function Lungs Heart Sympathetic THORACIC SPLANCHNIC BRANCHES FROM SYMPATHETIC CHAIN. CERVICAL SPLANCHNIC N., THORACIC SPLANCHNIC N. Symp. Function VASOCONSTRICTION, SECRETOMOTOR ACTIVITY OF BRONCHIAL GLANDS ACCELERATE HEART RATE, INCREASE STROKE VOLUME Parasympathetic VAGUS N. VAGUS N., RECURRENT LARYNGEAL BRANCHES Parasymp. Function BRONCHIAL SM. MUSC, RESPIRATORY REFLEX AFFERENTS SLOW HEART RATE AND REDUCE STROKE VOLUME Finish the sentence. Sympathetic innervation is (adrenergic/cholinergic), and parasympathetic innervation is (adrenergic/cholinergic) Adrenergic (uses noradrenalin); cholinergic (uses acetylcholine) 3. What is REFERRED PAIN? Pain felt at a specific dermatome that is of visceral origin. It is referred to the somatic dermatome associated with the particular spinal level that received the visceral afferent nerve. Where is it possible to have referred pain as a result of pleurisy (inflammation of the lung pleura)? [hint: what innervation does the diaphragm receive?] C3-C5 dermatomes (neck & shoulder). Early in development, part of the diaphragm forms in the neck region. Later, when it descends into the abdomen, it drags its innervation (the phrenic nerve) with it. Intercostal nerves T6-T11 innervate the diaphragm at the costal margin, and pain is referred to these dermatomes too. 4. What is the significance of LANGER’S LINES? Connective tissue bundles in the dermis have a prevailing directionality. Cut parallel to them minimal scarring. Cut perpendicular to them gaping wound. 5. LYMPHATICS Complete the following tables: Portion of breast Lateral / inferior (75% of breast tissue) Medial Superior Superficial Organ Bronchi, Trachea Hilus of Lung Esophagus Posterior IC Spaces Anterior IC Spaces Lymphatic Drainage AXILLARY NODES PARASTERNAL NODES SUPRACLAVICULAR NODES CONTRALAT. BREAST / ANT. ABDOMINAL WALL Nodal Drainage Entrance into Systemic Venous Circulation BRONCHOMEDIASTINAL HILAR PRE-AORTIC PARA-AORTIC PARASTERNAL (R/L) BRACHIOCEPHALIC VEIN (R/L) BRACHIOCEPHALIC VEIN THORACIC DUCT → L BRACHIOCEPHALIC V. THORACIC DUCT → L BRACHIOCEPHALIC V. (R)R LYMPHATIC DUCT, (L)THORACIC DUCT 6. MUSCLES OF RESPIRATION Complete the following table: Type of breathing Muscles responsible Relaxed Inspiration EXTERNAL INTERCOSTALS, INTERCHONDRAL PORTION OF INTERNAL INTERCOSTALS, DIAPHRAGM (Externals Elevate the ribs) Relaxed Expiration NONE (PASSIVE RECOIL OF RIB CAGE AND PULMONARY COMPLIANCE OF LUNGS) Forced Inspiration ALL MUSCLES OF RELAXED INSPIRATION + PECTORALIS MAJOR/MINOR, STERNOCLEIDOMASTOID, SCALENES Forced Expiration INTERNAL INTERCOSTALS, TRANSVERSUS THORACIS, QUADRATUS LUMBORUM (stabilizes 12th rib), ABDOMINAL MUSCLES Fill in the blanks: (see diagram in April, p.247) Synergist muscles act on the same side of the axis of rotation or are perpendicular to each other on the opposite side of the axis of rotation. Antagonist muscles act on the opposite side of the axis of rotation or are perpendicular to each other on the same side of the axis of rotation. 7. MECHANICS OF INSPIRATION Complete the following table: Aspect of inspiration Increase in which diameter (transverse or anteroposterior)? “Bucket-handle” effect TRANSVERSE THORACIC “Pump-handle” effect ANTERIOR-POSTERIOR Rotation effect TRANSVERSE THORACIC The bucket-handle effect is due to elevation of the ribs as they rotate upwards in inspiration. The pump-handle effect is due to elevation of the sternum as a result of upward rotation of the crossed axes. The rotation effect is due to rotation of the ribs (which are concave on their interior surface) on inspiration. 8. BREATHING DIFFICULTIES Why is breathing more difficult for the elderly? How do they (and children) compensate for this? Calcification of costal cartilages reduced thoracic compliance. Both elderly and children tend to breathe diaphragmatically (vs. costal breathing). What type of breathing do obese people favor and why? Obese people, persons wearing girdles or corsets, and women in advanced pregnancy cannot effectively contract the diaphragm and therefore favor costal ventilation. If a patient is bed ridden and having difficulties breathing, name one simple, non-invasive procedure you could perform to help. Why is this procedure so successful? Sit her up in bed. Gravity will pull down on abdominal organs, decreasing resistance on diaphragm. 9. PLEURAL RECESSES What are pleural recesses and name the two of them? Potential spaces between the parietal and visceral pleura filled by a thin layer of fluid. Costomediastinal and L&R costodiaphragmatic. What might you find in them in a pathological situation? Air (pneumothorax), Blood (hemothorax), Lymph (chylothorax), Pus (pylothorax) Where do you tap a patient with hemothorax to sample the fluid and why? Posterior to midaxillary line above ICS 9 (to avoid liver) but 1-2 ICS’s below fluid level and just above superior surface of rib (to avoid neurovascular bundle). Complete the following table: Type of Symptoms pneumothorax Consequences Sucking Mediastinal flutter Lung collapse b/c fluid monolayer gone vent/perfusion of lung in affected side cyanosis Tension Mediastinal shift Same as above but vent/perfusion of both lungs since air that enters pleural space doesn’t leave pressure compression of unaffected lung 10. STRUCTURE OF THE LUNG AND CLINICAL CONSEQUENCES Contrast the size and shape of the Right and Left Lung. R: 3 lobes (vs. 2 on left), greater capacity, wider and shorter (b/c of liver, and more of heart being on left side) What are the differences in shape and position of the left and right main stem bronchi and what clinical significance does this have? The right main stem bronchus is shorter, wider, and MORE VERTICAL than the left. It is the probable resting place for large aspirated objects. Specifically, the right lower lobar bronchus is the most vertical division of the right main stem bronchus, and small aspirated objects will likely rest here. What section of the lung is most likely to be involved in aspiration pneumonia (Mendelson’s syndrome)? Superior segmental bronchi of both lobes because they face posteriorly when a person is lying down. What is a Pancoast tumor and what are its clinical sequelae? A lesion of the upper lobe of either lung. It may compress: a) Subclavian or brachiocephalic vein ipsilateral venous engorgement / edema of face/arm b) Subclavian artery diminished pulse in ipsilateral arm c) Phrenic nerve compression results in paralysis of a hemidiaphragm d) Recurrent laryngeal nerve compression results in vocal hoarseness e) Sympathetic chain compression results in Horner’s syndrome (miosis, pseudoptosis, anhydrosis) What structures would be found at the hilus of the lung? Main stem bronchus, pulmonary artery, pulmonary veins, bronchial lymphatics, bronchial arteries, hilar lymph nodes. What are the main components of a bronchopulmonary segment?. Segmental bronchus, segmental artery, intersegmental veins. 11. JOINTS Joint Type Movement (Y/N) Examples Synarthrosis No Sagittal suture, tibiofibular joint Amphiarthrosis Yes (limited) Pubic symphisis, intervertebral discs Diarthrosis Yes (free) Shoulder, elbow, wrist joints 12. DIAPHRAGMATIC HIATUS Complete the following table: Hiatus Structures transmitted Location Aortic Aorta Thoracic duct Azygos vein Midline, between crura (T12) Esophageal Esophagus Left & right vagus nerves Slightly left of midline (T10) Caval Inferior vena cava Branches of right phrenic nerve On right, in tendinous portion (T8) 13. CARDIAC CYCLE 14. FETAL CIRCULATION Complete the following table: Prenatal Shunts blood Circulatory from: Anatomy Umbilical Veins Ductus Venosus Foramen Ovale Ductus Arteriosus Umbilical Arteries MOTHER VIA UMBILICUS UMBILICAL VEIN R. ATRIUM Shunts blood to: PORTAL V./ DUCTUS VENOSUS INF. VENA CAVA L. ATRIUM L. PULMONARY ARTERY AORTA L/R INTERNAL ILIAC ARTERIES MOTHER VIA UMBILICAL ARTERIES Homologous adult structure LIGAMENTUM TERES LIGAMENTUM VENOSUM FOSSA OVALIS (PULMONARY SHUNT) LIGAMENTUM ARTERIOSUM (PULMONARY SHUNT) PROXIMAL: SUPERIOR VESICULAR ARTERIES (TOP OF BLADDER) DISTAL: MEDIAL UMBILICAL LIGAMENTS 15. CARDIAC MALFORMATIONS Complete the following table: Defect R Auricular Appendage L Auricular Appendage Cardiac Atrial Septal Defect Small VSD VSD w/ pulmonary artery stenosis Ventricular Septal Tetralogy of Fallot Vascular Pathology Sequelae POTENTIAL SITE OF THROMBI FORMATION PULMONARY EMBOLISM POTENTIAL SITE OF THROMBI FORMATION SYSTEMIC, CEREBRAL EMBOLISM PATENT FOSSA OVALIS INCOMPLETE INTERVENTRICULAR SEPTUM INCOMPLETE INTERVENTRICULAR SEPTUM AND PULMONARY ARTERY STENOSIS A. VSD ALLOWS INTERVENTRICULAR COMMUNICATION B. ↑ PRESSURE IN LV TRANSMITTED TO RV CAUSING RV HYPERTROPHY C. HYPERTROPHY OF SUPRAVENTRICULAR CREST CAUSES PULM. STENOSIS AND FORCES BLOOD THROUGH TO THE LV ASYMPTOMATIC: L→R SHUNT B/C L ATRIAL PRESSURE > R ATRIAL PRESSURE ASYMPTOMATIC L→R SHUNT R→L SHUNT LEADING TO CYANOSIS THE FUNCTIONAL OCCLUSION OF THE PULMONARY OUTFLOW TRACT FORCES A R→L SHUNT SENDING DEOXYGENATED BLOOD TO THE LV AND THEN INTO THE AORTA. 16. VALVE DEFECTS Complete the following table: Type of Valve Pathology Atypical Sounds Pitch Atrioventricular INSUFFICIENCY SYSTOLIC MURMUR LOW PITCHED Atrioventricular STENOSIS DIASTOLIC MURMUR LOW PITCHED BEFORE 1ST HEART SOUND Semilunar INSUFFICIENCY DIASTOLIC MURMUR Semilunar STENOSIS SYSTOLIC MURMUR HIGH PITCHED 17. CORONARY CIRCULATION Complete the following table. Variation Balanced (60-65% of the population) Left Preponderant (10-15%) Right Preponderant (20-25%) Arterial Supply RCA gives off posterior descending branch, supplying the septum but not significantly supplying the left ventricle. Circumflex artery gives rise to the posterior descending branch, so that both arteries supplying the septum arise from the same stem lower chance of survial w/infarct RCA reaches into typical distribution of the circumflex artery, supplying a substantial portion of the left ventricle. 18. CLINICAL QUICKIES AND OTHER QUICKIES What spinal nerve innervates the nipple? T4 The umbilicus? T10 . How can you diagnose a breast tumor by observation only? Breast will dimple due to compression of suspensory ligaments of Cooper, which connect skin to Scarpa’s fascia and separate lobes. What happens to the costal groove with coarctation with the aorta? Narrowing of descending aorta leads to decreased blood flow through aorta and posterior intercostals arteries, which must be compensated for by increased blood flow through the internal thoracic artery and anterior intercostals arteries. Therefore, scalloping of ribs occurs due to expansion of intercostals arteries. What are the two routes used to perform pericardiocentesis? Subcostal: needle into sternocostal angle (rib/xiphoid), angle up at 45° and L. (avoid marginal br. of RCA and avoids pleural cavities. Parasternal: into L 4th or 5th ICS adjacent to sternum, avoiding Int. Thoracic Artery, Ant. Interventricular Artery, and pulmonary pleura (cardiac notch). What are the first arteries off the aorta, and when does blood flow through them? R/L Coronary arteries. Only during diastole. What veins of the heart DO NOT drain into the coronary sinus? Anterior Cardiac Veins (directly into RA), Thebesian (least cardiac) Veins (into closest chamber of heart.) What is the function of the papillary muscles? Tighten chordae tendinae to prevent eversion of valve cusps (NOT to close valves.) What is the Bundle of Kent and what is its clinical significance? Abnormal muscle bridge (modified cardiac tissue) electrically connecting the atria and the ventricles. Excitatory impulses bypass the A-V node disrupting the normal synchonry of the heart. The Left brachiocephalic artery… Does not exist. Esophageal varices are often associated with what condition? Portal hypertension caused by diseased liver. Finish the sentence. Cervical spinal nerves exit just (above/below) the corresponding vertebrae; thoracic spinal nerves exit just (above/below) the corresponding vertebrae. Cervical spinal nerves exit just above the corresponding vertebrae, i.e. 3rd cervical spinal nerve emerges through the intervertebral foramen between cervical vertebrae 2 & 3. One exception is the 8th cervical spinal nerve, which exits between the 7th cervical vertebra and the 1st thoracic vertebra. Thoracic spinal nerves exit just below the corresponding vertebrae, i.e. 3rd thoracic spinal nerve emerges through the intervertebral foramen between thoracic vertebrae 3 & 4.