2 pulmonary cavities with the lungs

mediastinum with heart and vessels

larynx - extends to cricoid cartilage

trachea - cricoid (C6) to T4/5

carina

Principal (right and left) bronchi - at sternal angle, opposite T4/5

1. junction of pharynx and esophagus. 6 in from upper incisors.

2. aortic arch and left bronchus cross. 10 in from upper incisors

3. esophagus passes through diaphragm into stomach. 16 in from upper incisors

food can lodge here

common site for esophageal carcinoma

thoracic duct.

chyle cistern.

L internal jugular and L subclavian

esophageal

vena cava

aortic

when the thoracic duct is cut and lmph enters the thoracic cavity

happens due to malignancy or trauma or is congenital

T9

4/5 intercostal space

inf vena cava

azygous

L ventricle to 2nd R intercostal joint

becoems Aortic arch, which extends to 2nd L intercostal joint and becomes the descending aorta

brachiocephalic

L common carotid

L subclavian

posterior intercostal arteries

subcostal artieries

phrenic arteries

visceral branches (esophageal)

1st part - vertebral artery (neck), internal thoracic artery (pericardiophrenic, mediastinal, pericardial, sternal, anterior intercostal, perforating, musculophrenic, sup epigastric), thyrocervical artery (inf thyroid, suprascapular, superficial cervical)

2nd part - costocervical

3rd part - dorsal scapular

retroesophageal right subclavian (esophagus sits in the middle of the arch)

double arch

variations of arteries branching off arch

Aneurism of ascending aorta

coarctation of aorta

diaphragm.

musculotendinous and centrally placed aponeurosis

1. caval opening (T8) - inferior vena cava, right phrenic nerve (!), lymphaticus

2. esophageal opening (T10) - gastric left artery and vein, lymphaticus, esophagus, vagus nerve (!)

3. Aortic opening (T12) - aorta, thoracic duct, azygous vein

Superior surface:

1. pericardiophrenic and musculophrenic - branch of Internal thoracic

2. superior phrenic- branch of Thoracic aorta

Interior surface:

1. inferior phrenic - branch of abdominal aorta

Superior surface:

1.pericardiophrenic and musculophrenic - branch of internal thoracic vein

2. superior phrenic - branch of inferior vena cava

inferior surface:

1. inferior vena cava and left suprarenal vein (left side only)

phrenic nerve at C3-5. Motor and sensory supply

Intercostal nerve of lower 6 or 7 ribs - sensory supply for peripheral diaphragm

superior surface: phrenic nodes --> parasternal nodes --> mediastinal nodes

INferior surface: lumbar nodes

lymphatic plexuses of sup and inf surface communicate freely

Right and left vagus

Right and left phrenic

Recurrent pharyngeal

right pulmonary, cardiac, and esophageal plexi

lateral

white ramus communicans, grey ramus communicans

sympathetic

post ganglionic

preganglionic

Greater splanchnic

lesser splanchnic

least splanchnic

1. thoracic cage (skeleton)

2. Intrinsic muscles and those that connect the chest wall to the limbs, abdomen, and back

3. blood vessels, lymphatic vessels, nerves

superior - made by first rib and upper manubrium

and inferior - made by 11th & 12th ribs, T12, 7-10th costal cartilage, and xiphoid process

Clinically, the superior aperture is the outlet, anatomically, it's the inlet.

True: connect directly to sternum (vertebrocostal ribs). 1st-7th

False: 8th-10th ribs. attach to costal cartilage, which attaches to the sternum (vertebrachondral ribs)

Floating ribs: (vertebral/free ribs) not connected to cartilage. 11th & 12th, sometimes 10th

Head: inferior facet to attach to corresponding # of T vertebra and the vertabra above. (#7 attaches to superior facet of T7 and inferior facet of T6)

Tubercle (and neck): articular part attaches to transverse process of corresponding vertebrae

Body: Inner surface has groove at lower border (costal groove with intercostal vein, artery, and nerve)

3-9

have head, neck, tubercle, and body with a costal groove with the vein, artery and nerve

1 - broadest, widest, shortest, has superior and inferior surface instead of external and internal, has scalene tubercle on sup surface for scalene muscles, groove for subclavian vein & artery

2 - more typical than 1, thinner less curved body, has tuberosity for serratus anterior

10 - closely resembles typical but is shorter

11&12 - short, no neck or tubercle

1. cleft sternum - sternal bars don't fuse, so heart is not contained (ectopia cordis)

2. Small perforation from bars not entirely fusing - no symptoms

angle of louis

at T4-5

go accross the body

from where the sternal bars fused

sternal angle - T4-5

body - T5-9

xiphoid - T10

1. vertebrae (intervertebral) - between vertebral bodies and between articular processes

2. costovertebrale joints - between true ribs and vertebrae

3 - costochondral joints - between false ribs and cartilage

4 - sternoclavicular

5. sternocostal

6. manubriosternal and xiphisternal (are sometimes fused in elderly)

in front of sternal angle - weakest point

very rarely break the first rib bc it's attached to the clavicle

Origin of clavicular head: Anterior surface of medial half of clavicle

Origin of sternocostal head: anterior surface of sternum, superior 6 costal cartilages

Insertion: lateral lip of intertubercular groove

Innervation: Medial and lateral pectoral nerves

Action: together, both heads adduct and medially rotate humerous. Clavicular head (alone) flexes glenohumeral joint. Sternocostal head (alone) extends glenohumeral joint

Origin: 3rd to 5th ribs near costal cartilage

Insertion: coracoid process of scapula

Innervation: Medial pectoral nerve

Action: lowers lateral angle of the scapula and pulls shoulders forward

Origin: lateral surfaces of 1st-8th ribs

Insertion: anterior surface of medial border of scapula

Innervation: Long thoracic nerve

Artery: Lateral thoracic

Action: Protracts scapula and holds is against thoracic wall when you push outward = "Boxer muscle"

Origin: 1st rib, near costal cartilage

Insertion: inferior surface of the middle clavicle

Innervation: Nerve to the subclavius (5th and 6th)

Artery: Clavicular branch of thoracoacromial

Action: draws clavicle down and forward, stabilizes clavicle in movement of upper limb

Origin: inner surface of xiphoid process, lower part of body and adjacent costal cartilage (5,6,7)

Insertion: posterior surface of the 2-5th costal cartilage close to their costal ends

Innervation: intercostal nerve

Action: Depress costal cartilage in forced expiration

thin musculoaponeurotic slips around the inner surface of the lower ribs

Origin: inner surface of the rib near its angle

Insertion: inner surface of the 2-3 rib below

Innervation: intercostal nerve

Action: Depress ribs

Intercostal space

Intercostal muscles and membrane

Named according to the superior rib (11 spaces total)

Pump handle - oblique-downward orientation allows their elevation to increase the AP diameter of the thorax and push the sternum forward

Bucket handle - ribs are pulled up by the intercostal muscles, which increases the transverse diameter of the thorax

12 - T1-T11 are ventral rami

T12 (subcostal)- passes into anterior abdominal wall inferior to 12th rib

3rd-6th intercostal nerves are "typical"

Passes along the costal groove

5 branches:

1. rami communicans (sympathetic ganglia)

2. collateral branch (at the angle, intercostal muscle)

3. Muscular branch (intercostal muscles)

4. Lateral cutaneous branch (mid-axillary line supplies skin over pectoral and scapular region)

5. anterior cutaneous branch (anterior aspect of thorax and abdomen)

1 & 2 - on the internal surface of the 1st and 2nd ribrib

1st has no anterior cutaneous branch

2nd has large lateral cutaneous branch (axilla)

7th to 11th - continues as thoracoabdominal nerve (abdominal skin and muscles)

12th or subcostal - inferior to 12th rib

posterior intercostal (11) plus one subcostal -- all branch from thoracic aorta

anterior intercostal (9)

Posterior intercostal (11): 1st drains into brachiocephalic vein

2nd, 3rd, sometimes 4th drains form superior intercostal vein, which drains into azygous

All others drain into azygous or hemiazygous

Anterior Intercostal (9) - all drain into internal thoracic

Parasternal nodes (on edge of sternum between costal cartilage)

Diaphragmatic nodes - 1 on each side of xiphoid

Intercostal nodes - between each rib on the transverse processes of the vertebrae

superficial

suspensory ligaments

2-6

lymphatic drainage of cancer may cause lymph edema (excess fluid in subcu) which causes orange-peel

Fast-growing tumor has large vascular demand which dilates blood vessels

Carcinomal involvement of mammary ducts may cause duct shortening and retraction or inversion of nipple.

Dimpling of skin over a carcinoma is caused by involvement of suspensory ligaments.

Fibrocystic change - occurs in ~80% of women and is related to cyclic changes in maturation and involution of glandular tissue

Fibroadema - 2nd most common tumor of breast after carcinoma. Benign neoplasm of glandular epithelium and is usually accompanied by a significant increase in connective tissue stroma

polymastia - 90% of the time it's just inferior to the normal breast. 5% in axilla, 5% in abdomen

Polythelia - extra nipples anywhere along the mammary ridge from axila to groin

1.5%

pectoral fascia, pec major, apical nodes

1. visceral - covers lung

2. parietal - covers body wall, is pain-sensitive, has 4 parts:

a. costal

b. mediastinal

c. diaphragmatic

d. cervical - cupula, covers apex of lung

Suprapleural membrane - extends above clavical to C7

potential space at the posteriormost tips of the cavity, located at the junction of the costal pleura and diaphragmatic pleura. It measures approximately 5 cm vertically, and extends from the eighth to the tenth rib along the mid-axillary line.

fills during forced inspiration.

used for thoracocentesis

most common: cervical pleura because it extends above the clavicles

Also:

- Right part of infrasternal angle at xiphoid process

- Right and left costovertebral angles, during kidney surgery

Pneumothorax, hemothorax, hydrothorax, hemopneumothorax

by thoracentesis (pleurocentesis or pleural tap) - done above superior border of inferior rib to avoid VAN

short incision made at 5th/6th intercostal space at midaxillary line (nipple level)

Tube directed superiorly to collect air, inferiorly to collect fluid/blood

Done to remove large amounts of exudate

Collapse of a lung (pulmonary collapse) - occurs if distention is not maintained bc of the lungs' inherent elasticity.

Primary atelectasis - lungs never inflate at birth

Secondary atelectasis - collapse of previously inflated lung

Segmental atelectasis - segment of lung collapses due to blocked bronchus - other segments compensate for collapsed one

principle bronchus

one pulmonary artery

two pulmonary veins (sup and inf)

bronchial arteries

bronchial veins

branches of vagus nerve

superior vena cava, trachea, esophagus, azygous vein

left: aorta, cardiac impression

Formed by tertiary (segmental) bronchi - one tertiary bronchi + one pulmonary artery per segment.

9 on right lung

8 on left

pneumectomy - removal of one whole lung

lobectomy - removal of one lobe of a lung

segmentectomy - removal of one segment

bronchopulmonary - cancer of bronchus

squamous cell carcinoma - arises in epithelium of larger bronchi and tneds to form masses

adenocarcinoma - originates in the peripheral areas of the lungs as solitary nodules that develop from bronchial mucous glands and alveolar epithelial cells

small-cell carcinoma - contains small epithelial cells that originate in the main bronchi and grow aggressively in cords of grapelike clusters

Pancoat's (superior pulmonary sulcus tumor) - are either lesions of lower trunk brachial plexus or lesions of cervical sympathetic chain ganglia

deposition of substantial amounts of particles in lungs. causes irritation, inflammation, breathing disorder, cough, chest pains, lung cancer

anthracosis - accumulation of carbon

silicosis - crystalline silica dust

asbestosis - asbestos fibers

R & L bronchial artery

R & L pulmonary artery

2R and 2L pulmonary veins

obstruction of pulmonary artery by a blood clot - results in obstruction of blood flow to whatever part of lung is supplied by the affected artery and causes lung atrophy

cause: blood clot, flat globule, or bubble travels in the blood to the lungs from a leg vein - often happens following compound fracture.

Parasympathetic afferent and efferent fibers from the vagus nerve

Sympathetic - 2nd-5th thoracic spinal nerves

motor to the bronchial muscles and causes bronchospasm

secrotomotor to mucus glands of bronchial tree - increases glandular secretion

sensory fibers for stretch reflex and cough reflex

inhibitory to pulmonary vessels

An imaginary line runs from the sternal angle to T4/T5 IV disk to separate the superior and inferior mediastinum

The inferior mediastinum is further divided into:

1. anterior mediastinum - in front of pericardium to sternum. contains lymph and lower part of thymus

2. Middle mediastinum - pericardium. contains heart and ascending aorta.

3. posterior mediastinum - behind pericardium to vertebrae. contains esophagus, descending aorta, azygous and hemiazygous veins, thoracic duct

1. Fibrous - protects lung

2. serous - 2 parts:

a. parietal layer - covers visceral

b. visceral layer - encloses heart

pericarditis - inflammation of pericardium - causes chest pain, in severe cases can be calcified

pericardial effusion - blood goes into pericaridal caivity. fibrous pericardium cannot expand so too much fluid compresses heart = cardiac temponade. treated by pericardiocentesis, which is done in teh 5th-6th IC space where there is no pleura (bare area) or at infrasternal angle at xiphoid process

Artery: pericardiacophrenic artery - branch of internal thoracic

Vein: Pericardiacophrenic vein drains into brachiocephalic or internal thoracic veins

Nerve: Phrenic (C3-5) - pain sensation

Vagus - function uncertain

Sympathetic trunks - vasomotor

2 atria, 2 ventricles

interatrial septum

interventricular septum

apex - formed by ventricle at 5th IC space. 9cm from medial plane at mid-clavicular line

Base - T6-T9, formed by left atrium

Surface: sternocostal (right ventricle)

diaphragmatic (left ventricle)

Left surface (left ventricle)

right surface (right atrium)

1. coronary sulcus - coronary sinus (main component), circumflex branch of LCA, RCA, small cardiac vein. Located between right atrium and ventricle

2. anterior interventricular groove - aterior interventricular branch of LCA, great cardiac vein

3. Posterior interventricular groove - posterior interventricular artery branch of RCA, middle cardiac vein. Located at diaphragmatic surface

Sinus venarum - smooth part

atrium proper - rough part, contains pectinate muscles

suclus terminalis - separates sinus and atrium proper on outside

crista terminalis - separates sinus and atrium proper on inside

Infundibulum (conus arteriosus) - smooth part

Ventricle proper - rough part, everything besides infundibulum

supraventricular crest - muscular ridge, like crista terminalis

septomarginal trabecula - moderator band, part of conducting system

Mostly smooth

Rough part = auricle - contains pectinate muscles

interatrial septum - divides forament and limbus fossa

Foramen ovale - opening

limbus fossa ovalis - membrane that covers foramen ovale

Proper (rough) - most of ventricle - contains trabechulae muscle

aortic vestibule (smooth)

Interventricular septum - upper part is membranous, lower part is muscular

Tricuspid - right side. 3 cuspid valves. at 4/5th intercostal space

Mitral (bicuspid) - left side. 2 valves. 4th costal cartilage.

cusps held by chordae tendinae.

Pulmonary semilunar - at 3rd costal cartilage

Aortic semilunar - at 3rd intercostal space.

Held by papillary muscles

S1 ("lub") - closing of tricuspid and mitral valves

S2 ("dub") - closing of semilunar valves

Stenosis - failure of the valve to open fully, causing resistance to flow. slows blood flow from atrium to ventricle. Is congenital or due to Ca2+ buildup due to rheumatic fever or radiation.

Insufficiency/regurgitation - failure of valve to close completely, causing blood flow back in the chamber. Mitral valve prolapse is most common. Also common in young women.

In both cases, the turbulent blood flow causes murmurs

valvar - valve leaflets are thickened and/or narrowed.

supravalvar - pulmonary artery just above the pulmonary valve is narrowed

infundibular - muscle under the valve area is thickened, narrowing outflow from the right ventricle

valvar - valve opening only has one or two leaflets instead of three

subaortic - narrowing just below the valve

supra-valvar - narrowing just above the valve

Branches: Marginal

posterior interventricular (descending) - supplies 1/3 of interventricular septum

nodal branch -

AV nodal branch

Terminal branch

Distribution:

right atrium

most of right ventricle

diaphragmatic surface of left ventricle

1/3 of IV septum

SA node in about 60% of people

AV node in about 80% of people

1. anterior interventricular artery - follows anterior interventricular groove (LAD)

2. circumflex artery - left marginal artery branches off. sometimes SA/AV node branches off

Distribution:

Left atrium

2/3 of interventricular septum

most of left ventricle

most of right ventricle

Coronary sinus - drains into right atrium

Tributaries -

great cardiac vein - follows anterior interventricular groove with LAD

middle cardiac vein - follows posterior interventricular groove with posterior interventricular artery

small cardiac vein - follows right marginal vein

small cardiac vein

small, middle, and great cardiac veins

drain the blood of the heart and take it to the right atrium where it is oxygenated

Parasympathetic:

Vagus nerve - slows heart rate, reduces force of contraction, constricts arteries

Sympathetic:

Cardiac accelerator and thoracic splanchnic nerves (T1-T5) - increase heart rate, impulse contraction, force of contration, and blood flow

Conducting system is specialized muscles that conduct impulses through the heart

SA node (pacemaker) - located at junction of superior vena cava and crista terminalis

-->

AV node - located at IV septum

-->

AV bundle - follows membranous IV septum

-->

left bundle in left ventricle, causes papillary muscle to contract

right bundle in right ventricle, causes papillary muscle to contract

blockage of artery from clots or lipid deposition

results in that part of the heart not receiving blood. painful

occurs due to a sudden occlusion of a coronary artery by an embolus. area of heart loses blood flow (infarcted) and will eventually lead to tissue necrosis with tissue being replaced by scarring.

LAD (40-50%)

RCA (30-40%)

Circumflex (15-20%)

a - septum primum

b - foramen primum

c - foramen secondum

d- foramen ovale

e - septum secondum

situs inversus dextrocardia

isolated dextrocardia

Foramen ovale - closes after birth, by one year. become fossa ovalis

ductus arteriosus - closes after birth, becomes ligamentum arteriosum at about 3 mos

ductus venosus - ligamentum venosum

Umbilical arteries - medial umbilical ligaments

Umbilical vein - legamentum teres

ventral part: doesn't say

Laryngotracheal tube: larynx, tracheo, bronchi, lungs

Dorsal: oropharynx, esophagus

Pseudoglandular = 6-16 weeks

Canalicular = 16-26 weeks

Terminal saccular (26 weeks - birth)

Alveolar = 36 weeks to 8 years