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