Sternu.u.

-
n _ _ __ _
-
~
~
T.;::o·rax ~
-~
o Differences in sex
---=::!====~sm~:J!:\tr:mroiSler in the female ' - '

. ONE MARROW BIOPSY

o [.,Manubnum

Has jugular notch - ­

• ~Rib 1 and half of 2 articulates here ---­

C~-'L---'

c::;: ;iQ~ ArtiC~la~ wit~Q~.9LtilC19~t:L ­ Body

TI 0 leveloc:::r

Ossifies slowly from the center out ­

~~c...-./"1 0 Sternal angle [angle of Louis) between monubrium and body

V . ~ 2nd rib articulates here:::;,

1~ 0$ At T4/T5 intervertebral level

....... Boun~_rx.'QeJ.w~en_SU.Re.r.iQLQD1.ilJ!eri0!.lD~di22.!i_I}"um

A~.vI ~TtI- LeTfT~®-tlt e _ oL'ill.9 US - ­

J v.
;~ •
V
~ 'N
',..
')
V Lv ,'C
Aortic Arch begin_s - ­
TrOCl:!ea_ ,i ur~ciTe~"-
Azygous arch __

Xiphoid
Process
..<" , Azyg'6us" e'nrer~ SVC -­
7k,~ ,~ _.0 J Th§CaclCdUcT crosses frQml to R side of body

I ./~bS(12i~ :::;

L.1-t, 0 Structure

'l1V\ Head that arliculates with vertebral bodies . ­

Body r-

Tubercle smjculgt.ElS't{jJbJr9r:!J':'.E?!i~ _p.LQ_<;;,ess9f .--­

ribse~ tforrib 11 and 12,' ,
T!1Ie
o True 1-7./'- ' ribs
o False 8-10 ..

~IOOlitl~2 ,­

( ~Iinic ols.-.--/

~ERARY -7 usua~ical or :::::>

~ F~lse
• Thoracic outlet syndrome: ~..s ribs
compression .2!...r1~.9.y.g1i.cular -:==:­
struc.,~Ig_~_mthor.QGic-outiet -7 causes
pain, numbness, lingling, weakness, ribs
~!atigue
~~-7 segment of thoracic wall moves freely due to
numerous rib fractures#t
4- Fracture' /
1f • Rib I can injure brachial glexus or subclavian vessels
Most commonly by-dl;ecibioy/"of'crushli-ig"inJurY"

~ • Often fracture at the angle

<...~
o External intercoslals
~ /'
/ Dow~ from lower edge of rib to upper edge of next rib going
0

,,/
/ antenor

"Hands in front pockets direction" ":

&>0 Internal intercostals

~
~,
Opposite of externals

"Hand in back pockets"

, ~.o<..vv.-t
o Innermost

sa404002 WWW.fotosearch.cJm >-vl'

~~ Down and forward
rYrb
~
o Clinical :
"Hand in front pockets" --... ­ ~

• ~horacocentesis
Insert needle properly to avoid neurovascular bundle between
internal and innermost (VAN) within costal groove of ribs
Insert n....e.eEi bove..l'!~t:...~argln o.!.!lb

Usuall __. ~ al9 ln to ovoid puncturing the lung. liv~

diaphr~ .-.-- ,~,

Blood supply: arteries '

 ~(cv~~
o
Anterior thoracic wall

• -:=;4FaeroollboroCic orteN --=-=­

From subclavian /"

---~,- Behind costal cartilages feeds IC 1-6

, , ---~-- \ Superior epigastric and musculophrenic branches

~ t o Pericardlophrenic goes to pleura, pericardium, diaphragm

\ \
, ! o Anterior perforalin branches ~ pectoralis major and subcutaneous

o nor Intercostal orlene

up ery anastomoses with posterior intercostal and lower
joins collateral branch

..~.
Supplies intercostal musfles. serratus OD.llll.OL pecto[9.!....~~cles
o Superior epigastric: descends on deep surface of rectus abdominus
-'"': .. Anosiomoses with inferior epigastric
Su plies anterior cibdominOTwali. peritoneum. diaphragm
o Musculo hrenic IC 7-9 - -- - - -­
. , FoUQ.~ costa "gr,ch

I
Anasiomoses with deep

circumflex iliac artery (from

extEir;:;o!inacartery)

Supplies pericardium.

diaphragm. abdominal wall

muscles
o Posterior

Subclavian to costoceNical trunk ICS 1-2 /

Descending thore'crrOortGlC3- T1 ..­

• Veins -.-------]
o ( AnterioU
~ ~hreniC to interQ8LlliPlacic to br2~ri!:;t9.ePh.ol~ to

~posterior R: IC I_II azygous to SVS •.,./'

L I :8accesmfYnemlOZygous to subclavian to SVS ...,,­
. L 9-11 hemiazygous to azygous to SVC a~
.~ ~=:i

o Stern or odes lie along internal thorocic artery V

"~ --- _.
Medial breast. ICS, diaphragm supra-umbilical all drain

.\ • Drains at jun.ction of internal ju~~.'9r and subclavi?n ..,

AniNiof' wiew
o Intercostal space drains to head 6rn5S
flgur-.1.41. A.lygot ~tlf'ln oIY1tirrs and r.h.oncic durt. RSy' nghf
" ICS and pleura into cisterna chyli or thoracic duct LYI br.l.chi.o«ph~lc vnn; lav, l('r1 b",)'hiOCt'p~hC' W"lrt .
o Phrenic nodes drain diaphragm surface
Lymph from pericardium. diaphragm, liver

\ Into sternal and posterior mediastinal nodes

o Breast

Nipple to lobules to subareolar lymph plexus

75% to axillary nodes,/

axilla",
nodes
./ • 25% to parasternal nodes !---'"

,I ~.
,­ o Body

'/
---
.
I The entire body except for the r:i.9J;l.U;.b.~ight arm

and right side of the head drains into the thoracic

axUIa",
nod..
J~ duct --- - ----­
i '- ;
. The iight upper half of the body drains into the right Pectoralis

~dim!jA:::> j - ---
minor
f I~ lymphatis.9.~ct

\ ~ .,
•
o Superior
Subscapular vein - - - - '

Between 1" rib and sternal angle

Contents: S\iC--:-brachiocephalic veins. aortic arch, thoracic duct. trachea.
esophagus. vagus n, phrenic neNe, left recurrent laryngeal
o Anterior

Between pericardiuD1.ocO...s.1erDurn

Remnants of~ymus, lymph. fa!, (:1-:)

o Middle
Between Rand L pleural cavities
Contains he..9.!LQ.bLe ni ~§.r:'::.~!l2.QLQ.'-.9reat vessels, azygQus arch. main bronchi
o Poslerior

Behind pericardium ~ lwN)

p- 1
 Esophagus, thoracic aorta, azygou?, hemiazygous, thoracic duct. vagus ner:'~, sympQtOE:).tic
trunk --. ~- _•.-'-_. - -- .-- --- .~----

EMBRYO
o Loyers V-­
• Endodel'TTi tracheal epitheliu~
• t \/iiceral;;;;!silllerrYl) trach~al s'ri{o2th musc~, con~ctive tissu~cartilage nngs
o~ Laryn~otracheal groove olvertJculOm)"7tracheoesophageal se tum separates foregut into
'y Ventral laryngotracheal tube: larynx, trac eo, __ ', lungs

, "'-) Dorsal laryngotracheal tube: o~harynx an~ophaw.s

o Penods.of development
• ~seudog~ar (7-16 weeks)

'-=';;"~' tnaOaermal tubules present

o Each terminals in 15-25 t

'j(>~ •
Respiration not possible, preemiI?,2a~n~,rs::-:-u-::rv';"l;'v"";"-
• ~analicular (16-24 weeks)
• Terminal bronchioles branch into respiratory bronchioles
Respiratory bronchioles
. t Iveolar ducts
.LJ • If born after week 20.
ossibly can survi
~ Terminal sac (24-birth)

Alveolar ducts branch into terminal sacs

Terminal sacs dilate and expand into surrounding mesoderm
Type I and type II pneumocytes differentiate
Born between week 25-28 can survive
From The Reql1iste8~Pedia1ric Radio~
with intensive core
Alveolar (32 weeks - 8 yearsf

Terminal sacs partitioned into adult alveoli

After birth, lungs increase in size because

of increase in number of respiratory

bronchioles

Pulmonary agenesis -7 no lung or lobe or bronchi

, I
Respiratory distress syndrome R u)

• Deficiency or absence of surfactant

• Made'5'[fype lJ~neumocQU'#;
TracheoesophogWtlistlli V'"
Aberrant connection between trachea
and esophagus fA !lAd ~A !il!d'
Improver division of foregut by ....--­ dif401 fi..vJo no- l\milo
tracheoesophageal septum ..­
Can be associated with esophageal '~
atresia and polyhydramrfios
symptoms
o Baby will gag and turn cyanoticv­
after swallowing milk ~--
o Abdominal distension after
crying........­
o Reflux of gastriC contents into
lungs -7 pneumonitis \..-"""
Diagnosis
0/\ Can't pass catheler into
stomach NoEA fA ond
o Air in stomach on x-ray bill "H" MIlito 2 fjSl~IQ'

~P·tl---
o one a

Lines thoracic wall

In~ated by intercostal nerves and phrenic nerv~sitive t:~

o Visceral r

Invests lungs

• dtl>!#OSlflve to pa~
o Pleural
•
• Q,potentio space between parietal and visceral pleura
s
Costodiaphragmatic recess -7 fluid accumulates when standing

3
 o Allows lungs to expand during inspiration
• Costomediastinal recess ~. / / J
/
Mid-clavicular Mid-axillary / Mid-scapular
Where lung ends 6 8 10
Where pleura ends 8 10 12

o CliniC~~
• Pleurisy inflammation of pleura
• Hear friction rub _ /\
• ~pneum<¥thorax -7 accumulation o~ pleural cavity
• <J Leads to ~.nQcollapse
· j TensiOn pneum=Olhorax -7 increase in pressure dis~~F t~site
~de
I t Pleural efft7siOn -7 abnormal accumulation of excess fluid in pleural space
Structure ~
o Trachea

Storts at cricoids cartilage and goes to

T4/T5 ­
16-20 C shaped hyaline cartilage rings
[J Superior Lobes
'ltarina -7 downward and backward
~ Middle Lobe
projection of last -tracheal cartilage
Atlevelof slernoi angle 1mJ
~ 1 0 es
f ' L, b
n ertor
• Ridge separating Rand L bronchi
'~
\ Compress trQ(;:h~ortic

) arch aneurysm ~ ­
o Bronchi ' ­
Ri~Tnchus : shorter, wider more vertical

• -, fAore aspirations here Cardiac

• ~nder arCh of azygous notch
,..3 lobar/secondary bronchi
.-Eparterial into right superior lobe
and the rest are hyparterial
• P Left

• ~ferior to arch of aorta, anterior

to esophagus and thoracic aorta

2 lobar/secondary bronchi

Larger and heaver, shorter and _

Hilum of trachea
wider than left

Ob,lique fissure _ r'"'

o Heas;! 2L5th rib

o FOllows line of 6th rib

horizontal fissure ~'-

o from oblique fissure in mid axillary line to 6th rib lev~

~~obar bronchi into lQ terminal bronchi (3 lobes, 10 subdivisions)

c..---:-~
• Oblique fissure .. '
• Lingual -7 tongue shaped portion of upper lobe
2 lobar bronchi into 8-10 terminal bronchi (2 lobes, 8- 10 subdivisions)
Clinical _ v'"
Impre s ~ lung
o~
o /"R' ~ Cardiac notch, aortic arch, descen~ ing aorta, left subclavign

\..Y. SVC, arc~ofa ous vein, esophagus V-

o Identify which lun yR "
• RIGHT lung, pu monary artery is ANTERIOR to everything else in
hilum

4
 LEFT lung. pulmonary artery is SUPERIOR to everything else in
hilum
~A LS:

PuJrr.l'lfiory
arUry .

~LUnglymph
o ~pleural plexus to interlobular nodes to
pulmonary/intrapulmonary and bronchopulmonary nodes to
inferior carinal and superior tracheobronchial nodes to tracheal
nodes to bronchomediaslinal nodes to thoracic duct
ON RIGHT: to bronchomediastinal nodes to right
~ lymphatic duct to subclavian lymphatic trunk
o~
• ..:.:> Cancer in c:wicallobe presses on~pat~
causing Horner's Syndrome .
-..£..;:,..--- ftOsrs----­
• Miosis

anhydrosis

Blood sup pi

ulmonary trunk_
Upward {rom conus arterio~
Deoxygenated btood V"
SUPERIOR and POSTERIOR to ascending aorta
Left
Arches over left primary bronchus
• Connected to aortic arch by ligamentum
arteriosus
Right

o
\ Pulmonary veins
Horizontal under arch

.2.Q.u lmonary veins leave lungs L

- • Righ t upper and middle jo~
• On~nter Jeft atrium
• OXYGENATED VEINS"
o \ Bronchial arteries V
• From thoracic eorte
ne arle to right lung
oeftlun V
Go 0 n n-respiratory tissues
o Bronchial veins
Into azygous on right
Accessory hemiazygous or superior intercostal on leH
Innervation

5
 o c:rulmonary P~-7 sympathetic Idilate bronchi) and parasympathetic Iconstrict bronchi and
~~ene~O~ - . ---- ~ .
• C3-C5 ~

Anterior to root of lung and vagus goes posterior to root .......­

•
~- -
Innervates fibrous pericardium and mediastinal and diaphragmatic pleura
._-- -- - -, ­
Lesions -7 may produce complete or partial paralysis of a ~gJIlH;jjgJ2br.Qgm

~
- - ----

J
PericardiuI!l.
____ Heart=:>
..::::;.;P 0 ~ middle mediastinum aort:t ;lnd
pulmonary trunk
o ~~~sinus~
• Transverse

Subdivision of p!?}i.sardial sac

Posterior to asceQQing aorta and pulmona!YJLy.nk

Anterior to SVC

Supeii5riOi:A and pulmonary veins

Surgeons use to make ligature to stop blood flow

• Oblique " ' --­

~
. . • Subdivision ~[ic.9r.d~c~~rt

o Clinical ­
Cardiac tamponade

• Acute heart compression as fluid accumulate sin pericardium

Compresses venous return, reduces cardiac OJ.lJput

Pericardiocentesis -7 surgical puncture of pericardia I cavity

• Insert needle into cavity through ~S lef~~ternum@ ./

External s u r f a c e , ~----.-- ../ t-e-.~

o ~uICUS terminals J J..~ J '$

• RA ~«.:
• ~inus venosus with atrium

Crista termlnolis on the internal heart surface

o Coronary sulcus

Division between atria and ventricles

.. - •.=.. '-- .- .
o Cardiovascular silhouette -7 cardiac shadow

Posterior-inferior chest radiographs

Right border -7 SVC, RAe 1'lC

• Left border -7 aoriic arch, pulmonarx trunk, left auricle, LV

~ Aortic arch aneurysm presents as dysphagia, dyspnea, and horse voice if recurrent laryngeal
is compressed - -­
Aortic dissection con occur in Marfan's
syn,grome -7 tear between Iinfr1g of aorta
~ Blood goes oetwe~E§J9.y§rs.

Internal anatomy
o RA
--­
ofao~
.r

/n~s venarum -7 posterior

Opening of venae cavae

Crista termTrlOlif separCiTes from

... muscle- " - ' - '

• / Auricle -7 muscotor pouch on supe(ior

anteriorpqrl ­
.... " Covers first part of right

/ coronary artery

• /peclinate muscle
• Venae cordis minimae -7 small cardiac
../ veins emply into RA

Fossa ovalis -7 used to be foramen ovale J

o RV
Trabeculae carneae cordis /

Anastomosing muscular ridges

of myocardium

valve
(closed)
 £J~~~
.~lIary muscles -7 cone shaped muscle enveloped by endocardium
From anterior and posterior ventricular walls and septum attached to chordae
tendinae
• Contract to tighten chordae, preventing tricuspid valve from opening
• /Chordae tendinae from opillory muscle to more than one cusp of tricuspid
,conus arterlosu In! n' u
• Smooth wo led por
• tSeptmarglnal trabecu ar 0 erator bon
Trabeculoe corneoe bon orms bridge between IV septum and base of
papillary muscle
• Prevents over-distention of ventricle

~
2eptum

Most posterior port of the heart (ffJ {,....~

o LV

Apex goes downward, forward, and to the left

Aortic vestibule

2 papillary muscle with chordae tendinoe and trabeculae carneae cordis

Thicker

•
Mnemonic for remember locations

APT M (apartment M) 2245 (intercostal spaces 2, 2. 4, 5)

HJila;~~ds
First sound (S1) -7 t(i~~~pid ond mitLOLclosesv
S2 -7 A V and PV clos~
o
S3 -7 filling of ventricle
o The Electrical System of the Heart
Normal In kids and athletes Bachmann's Bundle

Pathological In adults over 50

o S4 -7 otrial contraction

/ • Always pathological

• ../ conduct~ of heart

AntS(tor _
O~, ../ Inlemodal
• Upper end of cristo terminalis
Tract
Pacemaker../ -----­
Has Sinus node artery _

~pply -= __ =:>

o~_
• ~ I nterotriol
septum, superior and medial to coronary
sinus opening

-"AV nodal artery from right coronary artery (MOST OF

~
ETIME)
AtI;owntricular
o un (AV) Conduction
Righi Bundle Pathways
Node
~ __._.. -- Down interventricular septum Branch

~ .-£QLQnqry arlerj'Ol£ :::::>

o - Right~onary
f?cer "(tt SA node artery between RA and root of
~oo~
MQfuif!QL~ Inienoi'border toward apex
Lef\ main
Supplies inferior margin of RV
corollary artery
Pgal eripr II( artery -=-­ AOIia ----~-
• Supplies IV septum and LV and AV
node --- - ~

WAV nodol artery \.

Right ---.:::..;.,~~:a l: :;.....----Lett
• Opposite origin of posterior IV artery
corollary circum(-1cx
artery

~
Supplies AV node
branch
o eft corona

nterior IV artery
Righi
• ~ Right and left ventric les ~ marginal --T~~t~~~
Len llllterior
descending
• IVseptumv bmnch branch
• Apex
Circumfle d

In coronary sulcu).-""

• LA and LV v
• Left marginol artery ""
• Cardiac veins

7
 Cfow.Vh.. VC\W~

~oronary~

• Largest vein --­

In coronary sulcus
Opens in RA between Ive and AV ,..-- - - - Aortic arch

o
\ Superior vena cava - --o.f­ '-S:I!r*- ' - - - - - Pulmonary trunk

Ro- - ' - - - Left atrium

Right atrium --- ------l'--,-~ - r - ' - '- Coronary sinus

o
Middle cardiac vein --..--':3
\
Great cardiac veir
o Small cardiac vein

\ o-rcroltltIm@inofheartwithmarginal
arte1lo--­
o Oblique vein of LA

Rigf1t ventricle - - - - '

Le11 ventricle

Descends and empties into coronary

sinus

o\. Anterior cardiac vein V

(b) Coronary veins
Anterior RV

Crosses coronary groove

Into RA

o ~ma\lest cardiac veins v

~----~ Wall of heart and go into chambers

Heart Embryoto
o earttube~
Late.19LPJ91§.mas..aderm (cephalic area of embryo)
splits into somatic layer and selanchnic layer
• Form~cordlal cavitY,
Bulbus Carois (COOll
,,",oull STructure
/"ffiJnr-.
'<:::
'v~u~ Aorta
Pulmonary trunk r1> £,Vi- I ,
1rl1
0 ~Bulbus cordis Smooth part of RV (conus arteriosus)
Smoolh pari of LV [aortic vestibule)
d- Ventricle

.­ Primitive ventricle Trabeculated pari of both Rand L V

...­ Primitive atrium Trabeculated pori of Rand L afrium

- _Sinus venosus Smooth pari of RA (Sinus venarum)

Coro nary jigus stnus V~I)OSU5
Oblique vein... of LA
~ ,,·t
~.

Blood flow In heart tube

Dny23
Sinus venosum '"1""

Primitive atrium / ..-­

Left ventricle ;l.­
• Right ventricle~~
• Bulbus cordis
~~riOSUS-
~OoPing . ./
eonvergenceCI::fi~rioventricu~nal and
conoventricular cClllClt
Wedges to neslle conoventricular canal between
tricus ° nd formation of
.r_ _ _o =copulmonary septum
epositlon ave atrioventricular canal to straddle
ri nd left ventricles
o u monary septum
Trunca ar ridges invaded by neural crest cells

~
Rid es row and twist around each other in spiral fashion
I 01
• Per istent truncus art °

. 0 nl
o

---­
.r. __
--.. . . . ~ .- ,. ...
,
 o R~!~~~
• ~itif u;t vesseiS')
o ~onspiral AP septum development
o Aorta arises from RV and pulmonary artery frQm LV
o Ind5mpatible'Wffh life unlesS"fFiereT'fanother shunt -7 VSD

' " Corrected transposition of great ve

. monary trunk are transposed ")
o RV andDL..o.c.e inverted ~-~
.~y of Fallot---/ Normal heart Tetralogy of Fallol
o Pulmonary stenosis '-~'
q7 li?-o-.J e> 0 Right ventricular hypertrophy \ /
. , 'J 0 Overriding aorta ,/
o VSD "'/
o R7 L shunt

o_~~~
C::=~p~ from roof of primitive atria towards AV
~;.;;Io"-n
,,,-_~
s
~en Rri~etween cushions and septum primum
~en sec~ -7 hole in the middle of the septum
primum
• ~~I-m-se-c-u-n-Cil:Im:from just to
the right of the septum primum ..... ___ Septum secundum
From AV cushions and
roof of atria and grow Ostium secundu tn
toward each other but
don't meet Septum p rimum
J,.-<' ~ova~pening
between septum secundum V cushions
porti ~~~.;
J~irth -7 ssures presses ~
tum primum into septum
secundum to close off foramen

~~~'4
'. Defect in foramen secundum
• Common atria -7 cor trilocular biventricuJare = complete failure of septum primum
or secundum to form
Probe patency of foramen ovale -7 incomplete anatomic fusion of septum primum
with secundum
Premature closure of foramen ovale -7 durin renatallife
o Hypertrophy of right sideof t;E;Ort a nd un er evelopment

~__=-~_--"'ilf::lio"'->.Qlood clot con pass Into systemic circulation through ASD

o tricular septu
......::r=~i"iTi~r!...o:":r'icushion and ventral AV cushion approach each other

I ure of fusion
o large hole in the center of the heart -7 tricuspid and bicuspid valve are
one common valve
o\ t of blood
Ive regurgilatio

o
ramen primum defect cushions don't fuse with septum primum
.---~~~~!..'n·or I ral valv~e_ _ _ _ _ _ _ _ _ __

ricuspid atres ' ­ - _____ .

ypoRla~ic right h e a r ! . ~
o Not enough AV cushion tisSUG ( \
o No communication betwee R an'<t9 exist ~
of tricuspid valve
--~<:~ J~) tl~~".y

~. - .
... • r:..,:. ,. .. .
~

............... ....
.... ~.:"....-""
 o ~SiS

Can a-truncus
Can a-truncus

V cushions

openings

Venlricula r
septum

35 days

28 days

o Int~......,..:.:.:"

----""'e~~branous VSD

Bad fusion of righl bulbar ridge, lefl

bulbar ridge, and AV cushion

L -7 R shun I and pulmonary

hyperlension

Can evenlually increase pulmonary

pressure and cause pulmonary J.,I
resislance 10 be higher Ihan 12fii!'
syslemic -7 reverse shunl l\~
<==-.. R -7 L s:~l,. \f entrici
~ ... ~~x
,--­ Single or mulliple perforations in
musculor IV septum
.~ Common ventricle
~ 0 No meeiing of membranous and muscular septum
~ Arch Derivative ~
1 Part of maxillarv artery
2~ Part of stapedial artery ----
3 \
.i Rand L cO~!l1moq carotid
. , ..­
Rand L internal carotids
4\ RighI: j$igjlt subclavian and 7
,--"",,'/ brachioc~ - -
LefCL>';:~" --:- . -:7
'­ L n .J: /­ -
-~))
Rand L pulmonary arteries
( ~s ortenosu~
-.~

o 'rc

get o:r(genated blood from placenta

• ~oramen ovale
01 , 0 - oxygenated blood from placenta from RA to LA to bypass lungs
~ ductus arteriosus
o becomes ligamentum arteriosum after birth
o blood from pulmonary lrunk into aorla -7 rets.1 Circulation
bypass lung~ . - ~ ' -'-"

o if it 'persists, shunts oxygenated bloQ..dJrom

• ..fkductuGt:e~~:~si~,~ pulmo-~aiY,fr0iik-- --"'--­
bilical vein to Ive to bypass liver
0
, \ ecomes ligamenlucn ~ enOS.J,im
0
~ umbilical arteries lake back deo'xygentiletfl)lood to placenla
• umbilical veins corry oxygenate.d blood to fetus

right vein ~uring embryonic period

.. L-"'frllt:-(I-t~ J.ljt.lt'l&>,\ f-i1,.., ,~ ~~'I

 ..-·l'n·... i.t.il't. f.'!"Wf
S~cll'tr;"'rt\

• 'te, i vell i ) IigeJl: ,9~h::11¥1 tSFS§ hengJis

veins in embryo V .- . L>.~ oj Olll>i<T
'. JliWli",
vifelline veins -? refurn blood fo yolk sac
o righf -? hepafic veins and sinusoids, ducfus venosus,
hepatic porlaL SMV, IMV, splenic veins, part of IVC
o leff -? hepatiC veins, sinusoids, ducfus venosus
J62ib.gersists In adult and are functiona®
umb~veJns
o blood form placenta
o right vein obliferates
o leff vein -? ligamenfum teres hepati<f [J
cardinal veins "\...:/
.::-_=~,-=":,-"",,e~n;..::a:..:.te::::.d~b:.;:lo;:o:::.:-d to placenta .'
SVC
, common Ilac f

subcardina , reno, gonadal Y .

. ~ 0 supracardinal -? IVC, intercostals, azygous, hemiazygous V-
o ~nJcals _---='
~O"" Abnormal origin of right subclavian artery -? right aortic arch 4 and dorsal aorta abnormally
regress
Right subclavian lies left inferior to left subclavian artery
~-=-_-'-'-'::::'>'><:<'>".I.lL!~trachea
or esophagus

t Ductus arteriosus oesn't obliterate

~ L -? R shunt

Machine-like whir on auscultation

• / pos~uctal coarcfation

G Aorta is abnormally constricted

Strong pulse in upper limbs but no femoral pulses

~
Istal to origin of left subclavian artery and inferior to ductus arteriosus
o Turner's syndrome
S e rib notching on x-ray from intercostal blood vessels dilate to compensate and
~. end blood inferior
~reductal -? congenital ...
Embryology of the Diaphragm
o 4 parts
• ~eptum transversum -? thick mass of mesoderm between heart and liver
51f~ lMV-f o Central tendon of diaphragm

(,,.~ L~ 0($ Pleuroperitoneal membrane

o Somatic mesoderm

U7M-'~
b) 0 Develop from dorsal and dorsolateral body wall
• (!)(Dorsal mesentery of esophagus -? myoblasts to form crura

~r~.~
Gi
_~-..B;;:;Ody wall -? muscle of periphery

o
diaph,agmatic hemia
bdominal contents hernia Ie into pleural cavity
eur0s,eOI membrane failure

o - C sit : left osterolateral side

o Compr slung buds-? pulmonary hypoplasia

Newborn born with flat abdomen, breathlessness,
dyspnea, bowel sounds over left chest
~ 0 cyanosis Septum
~sophageal ~ hWa Iransversum
Stomach through esophageal hiatus
~sophagastric sphincter become incompetent -? reflux
~igns : vomiting (often projectile) when infant lies on its back aHer feeding
What vessel passes through where

Inferior VEL ..-r V r - f'I,~\.

Phrenic nerve 4- L­

\~
Aorta ~ T12
• Azygous

Thoracic duct

Mnemonic
• I Bte 10 eggs at 12 (noon)
/

12
_, . : --- - - --~,if.. - -------j-;-il1
~/ I
. I
!
I
i
_Location of Thorax ? I
I
i
I,
iI

Thorax is between the lower end of the Neck

and

the upper most part of the Abdomen

I
I
I

. -. .-----.-- ------.------------.---.-----..- ---- - - .- - -.------------------ --l

:
i

Function of Thorax

• To House and Protect the Heart and Lung

• Accommodates volume changes during

respiration by Mobility of thoracic cage

• This is accomplished by the ribs and

intercostal muscles

.-- ..- -.- --- --.. --. --.---- -.- ------ __._________ __ _.__________._____._________....___ J

 I
I
I
!

Layers of the Thorax

is1
i J~ €~i~erfiCi~asCia and its Contents
! • Muscle and Fascia on the chest wall
~ Breast in the females
• Bony cage of Thorax ..._.~

and

• Intercostal space & its contents: intercostal

muscles, Vein, Artery and Nerve (VAN)

-- .- -- .--. ----.-~- . . -.. --.. -,, - -- ----- ~------ - - - --- -- - - -- -----.- -. -.---- . ---- - -.--- -- -----. - -- - - --.-. - -~
I
J
I

I
Female Breast & Thoracic Wall
Suspensory
ligaments lV

~
Lactiferous
sinus

Pectoralis minor m.

4th intercostal
space

I
. - - - _..... _._. _._-- - -------­ _ _ _ _ _ _ _ _ _ _ _ _ ____ J i
 - - - - - - - - - -_ .._ - - -- --,
I

I
:.J - . " - ... -. • v

;, ,,' : Quadtarits'.-'of Breast

-~ . - - '
" I
!
• - " , T o

12 .o'clock

,Lower · . Inner

T Right breast J
Tumor of Breast in Quadrants & Underlying Muscles - Pectoral & Serratus

.,,,---.. . .----., -- ------ -' -- ------ -----, - --_·_,,---------,----,,----1

I
I

Breast - Lymphatic Drainage

Sut)¢/avian
• lymphatic
CeNfco. trunk Fh9h1,
axillary canal - ~ (01 Ie t)
. . . venous
'\ angle

Suprac~vlClJfar
na<Jes
Apical nDde-s

Pectoral (anl0rior)
J'\o(!e-s

.. -,,"""-'- - " - - - -,- - - -_. ----- - - - - - - - - - - - - - -- ,,-

" - - - - - -- -- - - - ,,-- ------,----,
 Muscles of the Chest (Ant)

Coracoid process
Pecloralis major m.
Clavicular head ~",*-f---'=- Cut ends of
pectoralis major m.
SIClnocoslal head

Pectoralis minor m.
...----'
External
intercostal muscles
'+serratus anterior m.
Serratus
anterior m.

Intercostal membrane
Ant. Ext. Intercosal M.
between costal cartilage

1._ __ ... ____ .... _ ___ . _.__ __ .______ •____ ._ _ _ _ _ _ _ _ _ _ ___ . ___ _. ______ ___._ ______ _ _ _ .____ _ _ _ _ _ _ _.. _ . _ _ ._ ____._ _ _ ..

Il

I Pectoral Region: Blood supply

Subclavian a.

Lateral 1I1Oracic a.

L_.____ ________ ____._ ________ - -_ _ __________._ _ _ _ _ _ _ _ _ _ ._--...1 !

 "I
I
I
I
!

Surface Anatomy of Thorax

Jugular notch
Clavicle

Acromion

L~ ~r-----'

{
~
('
. . ..... '\
~ .---. ,

- '

I~ .
Vi 1/V")'',"
/1

Seventh costal cartilage

r
Costal marnin

I
i
\._- _. __ -- .- - _._- - - ...-._-
... -.----------.-----.~

I
I
Boundaries of the Thorax

I
I
!
I

e Posteriorly: Vertebral column T1 - T12

o Anteriorly: the sternum

• Joining from posterior (vertebral spine)

to the sternu m anteriorly are the ribs

,
-- -~ -- -- -- -- - - - .- ~
 , "

. Biopsies of the Sternum •.

, ' ­

Sternal'"BiQPsies
The stern nlbodyis. often useq _Fo r~oJftl marrow~tte~dle '
bloW , because~ ·Qfit5 bre:adth -a,nd,-subc,utane9uS
positio,~; The .nr:,edJe pierc~5 the thin cortlcbo~e and 1
. e~(ers :he viJ,sculartrabecular€onW.pone. Stemai 2
blOPSY'l$commol1lyused to obtrunspeClmenso{bone
tn arro\v fa r transp la nttl t.i 0 n 'and fo rdet,ecti on .of
metastatic ranee ti

• ,,_ _. _ _ " . _o_ _ _ ,, _ _ __ • _ __ _ _ _ _ _ _ _ _ _ _ _ • _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ • _ __ _ _ _ _ ,, _ _ , , _ . _ " _ _ _ __ _ _ _ _ _ _ ,, _ _ _

I
_ _ _ _ _ _ _ -\

I
I
I
Classification of -RIBS

• True ribs: 1 .. 7

• False ribs: 8 - 10

., Floating ribs: 11 - 12

-,,- ,- - - - -- ---­
 Lateral View of the Thorax

Thoracic Inlet

Manubrium

Bodyo[
stornum

Xiphoid
pro~s5

Dlaphragrn~'- - - I

Thoracic Outlet Anterior View of Sternum

and its costal notches !
I
____
....-- .... - ._- _ . _ -- - _. . .----- - .... _-------- --_._._-----_._._._ - -- ------- --_._ I\
II
I
i

. Thoracic Outlet Syndrome ­

.,'Wh~n: ~fi nfcr~[lS r~fer.[Q '·tH,~.s.u pe'r;pt::di :oracica.Rer~ .
.. ~urt(~~.tfre·;t69~Fic:~ouH~t,j~:;t.hey: ate>emphasi~ng;
.· ·the:i.m eOr,tan.t:QetVe$and -arterie.5: ·i:hat·R~s :through ·
.tha$ :ageh:ureititoth€ 'owerneck'~nd upp eiH mho .
'Hencey,ari ous·typesof. thoradc:oud{i syndromes..
exT 5t~ <SU ch ·.as ~het:(Jsto-cltrfli'i1!!!!!!I/ulrdme-:p~lJQ.r
andc,Q!anessofthe ·skif'lof the upper Ii'm.b and:dl­
minished.~~u Ise-~suttlngtrom ~ com pt.essido. .
ofche su bdavian <irref):betMtcert:'dte CJav,de and·tQ'~
19 d1>t' par-deu} ct lIy whf n. theangleb~t\ve en 'chi!
neck and the shoulder 15 in(:r~,ase(L . .

;
i

- -----.-.----- ~
 --- -- - - - ------1
I

Intercosatal Muscles I

Q elevates

-~ Int!1roosta~ veln. I
_&7I~~~~:~ artery. and nerve ('f\) - i . Kl/t~
Inlem-a' Intercostal \2/ depresses -CC.~I{ .,r1f"7 )
~'i=1-lnliermo$t intercostal 0- I\d~"P,tJ 3 epresses
,
l
1: r.;.
-~~~~~ColiatGraJ _
br.anches I
I

CDs~al groove

Later~l view

NOTE: The site of the (VAN) in the intercostal space I

I
I

- - -- ---- ----- ------ ----- - - - - -- - ---- ---- ------ ------ --.------ - ---- - - - - ---- -- - --- ------------- ----,i
I
!
I
i

Structures in Intercostal Space I

Innermost intercostal m.

Rib~-_-I.:

Intercostal:
rr.o---Vein ---~'t.l
Artery~ .--f
~-- Nerve - - \\
Innermost intercostal m.------'~
External Intemal intercostal m.
intercostal m.. External. intercostal m.
reflected Collateral vessels ~
'ft'---IJU:>lCIl groove B !~-
intercostal m.
(cut edge)

A. Anterior View B. Coronal section at mid axillary line

- -- .--- - ---- _.- - - .. --- -- --- - - -- - --- ----... _--- - --- --- - --- ---- - -­ _____ -- - _ _-- _ __ 1
 SOlTletimes it: is necessary t:o ins-erc a h)-'poderrnic n.eedle
~hrough an i .nrercosraI spac~into the pleural cavity-the
p~t:ential spac~ bet.wecn t:he. parietil.i pleura lin·ing
t'h:e : pulrnO~ary :Ca!l~..jEyar'dt:he; vi!jc.e:raJ pleura' covering '
th~dt.i E}g-:-t;b 6l,::t~~in aS3 rri.ple.: ofpJ€!-l~ I fluid . 01' to re~
mov.eb.lpodorp,tjs.. Tq:av~i d d arn.<ige 1:0 thein~e ..costa I
nelv~· andvesSels.. the . needle is inserted super-lor co t:.b~
rib •. highcr}ough i:b~i:vold · the coll.a t eralbranches .

. PariEl la I pleura

~-..,......- . Pleural cavity

; r : - , - - - - - FluiClln
.pleura!'cavity

- - . -, - ,

Anatomical Relationship· &Thoro'cocentesis

Skin and subcu1aneous tissue

Intercostal muscles
Aspiration of fluid (effusion)
from pleural cavity

Rib 8 with intercostal

nerve and vessels
Abdorninal cavity
with brga'ns :
Needle in Mid axillary line
 Surface Marking of Thoracic Wall

. id procetss
.maphtarn

1 ".

. '

-, '" ~. Clinical"Correlation ,.

Anterior Thorack Wall

1 2
The anterior and lateral approaches are the two most common
surgical agDroaches to the contents of the thorax. In the,ante­
rior approach, the steroLLm is split vertically in the midline. This
approach does not'crossmajor vessels and allows good access
to the heart. The incision throughtne ~~E~~~ is c!osedwi:th
stainless steel wires. In the lateral approach, £!lJD.~rsQgarB
space is incised to provide access to the lungs or to structu res
>1..1<£.... :...""'"-'... :':".,

posterior to the heart

.. - ------- _... ------- --- --_._--._------, -~-

 1

!
I

iI

Intercostal Nerve I

Local,anesthesia of an inrercoscal space is produced by, i

HI1tpe5zostcr (sh;i1gf~)~aviraI 'disease ofspJnal ganglia­ I

is a demlatomallyJjs~bllreds,~;n les;on:Thehetpes viM in: ir.je~tinga local anesthetic agentarou~ndd)e}nterc6sral

vades a spinal ganglionandistran~ported'fllong the axon n!rves.,This, procedure, aii 'jlltsrcostafneYVe bto(k, in­
volves infiltration of theallesthcoc,aroundtlle inrer­

to the skin, wherelc pr,oduces an ilJ(eccioll ~hatcau5esa

sharp bumingpa\n'inthe;~e.fma'rorrie.supptiedbythein "
c()seal. n elVe and itscollate'ral br<i.~Cl1cs ' (Fig. 61 (5).
Because anypari:iC1,Jlar are,a ,of skiri ~suiillyrec~iv.es 1ri­
II

volvec,i nerve. Afew days ia~,ei'j che ~!<InofdH~; dcimawmc I

nervation fri:l'm [\YQ ,a djacent neJ:Ves, cOnSi,derablc over­

~ccome5 red ;;Ind vesicular etirpti~nsapp,eiir " "
I~ppingof contiguous LIE~rma,tomes ol=i:urs. Thi!i'cfore,

complete loss ofsensacionusuaUy:does rioc"o<:~r, \In­

liss . tWO or more in~ertost~1 nerves in aifji.lc~nt in~er- I

costa! spaces arc,ancsthetizeCl. ' . . ' .

- --_._-- - - -- ------- - - - - - - ­
 ~~1~tiJJt.~~.~~A' "
Cross Section of Mediastinum
Parietal
Pleura
M
E
/J_
o
I
A
s
T
I
NUM
WI. . .
Visceral
Pleura

Schematic Diagram: Cross Section of Thoracic Cavity

Parietal and Visceral Pleura Recess & Reflection of Pleural Cavity

~ , Costomedistinal recess

CPSiOd~~n~r~9m,~ti~:r~'c~~~;
Visceral;"­ Pleural Cavity

~l~~

Parietal Pleura and Subdivisions

Pleural Cavity and Clinical Application

, ~.".

, . ::,- ,: ,~!,\."
Haematoma
Parietal
:~·~ ~-g.Z~'f".r,)1 Pneumothorax
Visceral
Pleural effusion

!
The potential space
Costo diaphragmatic race~s
becomes real space

~r

';' ,

Collection in Pleural Cavity and

Relationship of Mediastinum & Pleura & Lungs
Lung Collapse

Mediastinum '11."1

Line of re!!eclion between

dlaphragmalic ami COSlal pleura

J;/r

Lungs Surfaces and Location Anterior View of Thorax

lungs are not in the mediastinum

Lungs have 3 surfaces

.... Wf.\\t Aorlicarcn

• Costal

4th rib laterally

costal cartilage~1\i
III Mediastinal 4th
anteriorly Oblique
fissure

• Diaphramatic Infcrior
lobe

Lung Fissures: Clinical Significance Mediastinal Surface of Lungs

Apex
Horizontal fissure (Rt) corresponds to
~b laterally and anterior
to 4th costal cartilage

Groove lor superior vona caya~

Posterior
border
Cardiac Impression IE',. ;,.' impression

Right Lung Lett Lung

Oblique fissure corresponds to 5th rib mid axillary
& anteriorly to~starCa'i1:ilage

1'1/7

 Pleural Reflection Lung Level and Pleural Reflection

and Corresponding Rib
Location Pleural Lung
Midclavicular 8th rib 6th rib
line

Midaxillary 10 th rib 8 th rib

Line

c::=t OutihiCl' 01 lung

=:> lIno~' of rOllactlon of parietal pleura J;
. ') " : '
Midscapular 12th rib 10 th rib
'----- --
Line
- -­

Thorococentesis Lung and Pleural

Reflection Relationship Bronchogram
Skin and sub~utaneous tissue

Intercostal muscles Cll Wlcla

Aspiratlonof fluId (effusion)

from pleural .

Archae
aorte.

Loll mt11n
b,onr.:h us

~icop 05t 0 60 (
segmont.al
bconc:hoG
tete $\lpa-riOI
lobar bloncl'ltlt)

lert intorior
lobnr t>Ionch119

AbdQ-n\fnalciJvi~" " .

.· 0irh; Qrg~rit· .'

GaGbu bblo
In fvndu~
P06tttrollintcrfor view 0( Gtomacll

1~

 Bronchoscopy Parietal Pleura: Pain

Inj~ry .t~~le~.~~
-".;=
D~ ' TI,evjScey.alp;ei,.ra~;~;;,1$ei.iitiv~ to paf,-r ' becausei c:s in n er­

. t·.. . ·. :~~;~~f~~~;~~1~~~~f~0~:~;:fc~e~~~:~~r::~.p~;
;.' .....nl:h:~th~ b"0t:·chi~'. yess~l.s'·::T:hc y!sccr:a!: pl:eu.-:a . re~e Ives

, ;;d;!t;~itti~~~~~;t~~~~~d~:t:tr~~1:t:b~;:~:: ~:':~ 8
...i,i c:JqY~u.PPJj~~:··· p.~~J?,~p,:.&:~s:\ i?§1:b.e:' S:9r,p~dG-: Inee rcost'al

' ;" \'" ,"

~L "
f:lliil'tliitft!~!t&
. ' d fii!'.~hr;if.i'ma p

;
~,
..
.
c",.¥'s:Qf~'7h e · 'Pa:r"H~tai' .p I e~m reS.Ltlt:!' • n
n
a

.:,':'

Bronchogenic carcinoma Lung: Lymphatic Drainage

II

fJ

KnCiWledge of Lymphatic Drainage of lung .

6/t

 - ,.,;,-, '
_ ~"""'''''~' '~ '~ r""
Sup. Iymp. Plexus
(under visco pleura)
1:' Lung Parenchyma
'2. Visceral pleura '
."il>e" tCi""dlTO
'!il;'},"'-'-ih~"
"<'-'hrlona ,' ,
" "0.,.,,, PIt . ,'" . ' ry
des'[(hil 'r,) :
",,,!;~g\.pgo "7 ;"'-" i·,lY~~L" "
Xray of Chest (AntPost View)

L Clavicle

Coracoid

­
Deep Lymp. Plexus p'ocess
(submucosa of bronchi
, Root of th'e lung
and peribronchial ­ Arch o~ ilona
Connective tissue) , mainly
Pulmonary
.r'ery "
lell auricle f<4 ::)ii
.r -;,",:" .
lefl bordo I ,', ' 7 '"

ol \1 ll!'rlll~11 -;':,3::.:'
'Ienlricle) ,;, ,', '

Apex 01l'cOot

Inf~fior L"<1rder

01 lI o~n ",'2 .

.... ~ .

LYInPh~tic6raina;ge of Lung , '

Xray Chest: Cardiac shadow description

(cardiac shilouette

Clavicles '
Right
brach1<r
~f:
.,
' ~ aor1a
; "
Arch of

. CX!phal!c " ;.( . ~ Pulmonary

Rl~hl j
bord~r< 1vena
vein
Superior
cava
1,___ lef~

.~.

,'j
trunk

aunclo
" , Loft 5 bordol
4 left

" ventricle
Inferior ," , ', " ';~. , Exjta;.
'J$r'i!.i: cava 3 Diaphragm~ i~ricardral /

~r
 ~-e: II
~

location of the Heart Heart: Surfaces

" The Heart is located in the middle part of

the inferior mediastinum

o The Heart is covered with two layers of

pericardium
1· ----A

., Superiorly in the middre part of the 3

inferior mediastinum are the roots of
great vessel arising or ending in the 2
heart 1. Sternocostal (Anterior): Rt. Ventricle

2. Diaphragmatic (inferior): Lt Ventricle & small part of the Rt. Ventricle

3 Pulmonary Ll Surface Lt. Ventricle

Heart Surfaces
AnteriorThqta~t ;' .
.. .
c Srernocostal (anterior) surface - formccimainlv .,.
by rhe right ventricle.
The antedor..ang~i:ate;~I;!~RP:rq?l,<r!)~s; .a.re::;fffl~tWi:thiOst;cprnxnpn
e Diaphragmatic (inferior) surface - formed
surgic?I ..apprQa~h~sitQ}t6$~~QriJ~6.t$:>cifthg·1@q.r;~~!~ i, O;;~IJippte­
Ill<lillir by rhekft v~ntrjcle and a small part of the
rlorapproadh; 'ib.~~st~rj;j,tIrii::f$::s~lrt&,~r1ri~lIy\iOlb¢· o1\dWrfe,;':This .
rig'hr ventricle.
,,,,,,d approa(h.: dde~:·~~,;·,9r.q~s;rnaf()li;:¥.~$s~,s~:a.q#:~ all()yiJfi:g.g~qi~~<r~ss ·
o Pulmollary (left) surf.'1ce - fOJ'fIled mainlv by the
1 to thehe.ar.t· ·the:;i.nGi?r0h :tl1r0t:1~g.h:>t,ye: st~rmllliTS':~ld~~W,:~Wth
I,err: \'cntl'ic1e. The pulmonary surl1we of the he,lrt is stainless steeh;~il:~s;J~Ah~-iate(dbappr0atli, .aiJ :'lhtercosicit· 2.
ill contact with the cilrdiilc impression of the left space.is Jnci$eq.: !q~,p.r¢Xi~I~ .~.§~~.~td.:ti~e;)t1dgspri(f~tr4·~tJ.res
lung'.
, . posteriqr toth:e ;h·eatt~,. :
. ..' .
..

I /~,

 '#-11

Surface Anatomy of the Heart

Auscultation Areas
1 = Mitral area (5 Lies)
yd Costal Cartilage
2nd Costal Cartilage
2 =Tricuspid area (4L1GS)
3 =Secondary pulmonic
it'Border: Lt;Ve~tricle,~ area (3L1CS)
Ri~aordi!r': :RdAt;iun:I:'
, -1
F,1-.' 'J,,-< .. :I
"tr'.. , "1 ~ '" .j • ~

4 =Pulmonic area (LUSB)

5 th Inte rcostal
Space
5 =Aortic area (RUSB)
6 'il Costal Cartilage

Apex of (LlGS) = Lt. intercostal space

Heart (RIGS) = Rt. intercostal space
(Part of Lt. Ventricle)
(LUSS) = Lt. upper sternal border
Mid. clavicular Line (RUSS) = Rt. upper sternal border

Heart, Pericardium & Vessels Pericardium

~ The pericardium is a sac that encloses the Transverse
heart Pericardial sinus

Line of reflection

" The peldcarditllm is pierced by the great

vessels to enter or leave the heart. These Oblique
1
vesse~s indude: Pericardial sinus Parietal layer

Aorta 2
Pulmonary trunk Visceral layer

Sup. vena cava 3

Inf. vena cava Pericardial
cavity
4 pulmonary veins

r&L/q
 .. ,-,' ''' ' / /

Pericardial Cavity Clinical Correlation

" Percardiai Cavity is a potential space and Cardiac Tamponade:
does not have more the 50 ml of fluid
UlJormally Collection of fluid in pericardium:

• (Blood) Haemopercardium
6) Main ~19q9..§.y ppIY i~J?~Xic~~.gi2P.tt.r~r.!i_c
artery which , lies , ~1g!J,Rt~~ p.~r~.~~c nerve (S!:::r:J·us. fluid) Pleura! effusion
" (Pus) Pyopericardium
c' Also supplied by branches of b~·orH':.h~H~ , • Fibrosis of the pericardium
.>;:,,,,, onh'llgeal
I ....... ~
i"" a , 'y!! \!,',c'c'llop!-'renic
~ ~ ~
JI ,, \),...
it ... I Ii, ",,. ..; , ~,'l ,·'!..J, h·'.-:..
I . .... •. " !,( '.; c
1' ..j~ fi"~ ~ '.'"

This collection impairs the (contractibility) of

" Pericardiophrenic veins drain in internal the Heart
thoracic vein

Cardiac Tamponade Cardiac Tamponade

Infiamrnalorydiseases can catr~e fluidto accur\1ulateinthe A build-up of b ~ ood Or other
r1uld In t~e peri'ca rd'ia I sac
pet'icardiai cavity (pericardial:e,ffusion)i Blee,qing }ntothe peri­ puts pressu re on the 11eart,
wh!dl may pre.lleotiUmD)
cardial cavity.(hemopertcardiu:n~·r·m'atr~stJlt;;f~om:penei(ating pumping: erfedlve,IY.

heart wounds or perforati6n., .qf~a:w~$e:m~p:;,h~att:tutJ$([e.·a rter Fluid build-up

myocardial infarction. Becaus'eHf1e:: peif~ardrtlb+;istomposed of w~thln
sac
per(car(Jial

fibrous connedlve tissue, it cannbtst(,etCb;i :~8dli(Jids'Collected

in the pericardiai cavity compressesthe:i1eart(cardtac t~r]pon· Parietal layer

ade) , Visceral layer

. . .:~ . . .' . ~

Effect of Cardiac Tamponade on the Ventricle - Pressure of Pumping Blood.!

3/1

 .t; II

Tamponade - Pericardial Effusion

Pericardiocentesis
• Draining fluid collected in pericardial
sac too relieve cardiac tamponade.

o To remove this collected fluid, a wide­

bore needle may be inserted throug h
the left 5th or 6th intercostal space near
the sternum "i~~~;;'-J~ .
~~.2'~/
\~~1~:n
: ~~~;;;: i'
i ,;:::..=:.r;f"p~"-,a;
I '-""_JA I.
. -'"r'
~1:.
,,~'/ I
. . 'VV
. '/
~'/)
,-:// .r.
-1 :',
I,

Study this slide in combination

with Surface Marking of Heart - Slide 3 and X ray Slide Heart and Great Vessels

X'IJ'f 01 Ctu.' !'l fAAI Po,' VIC'w)

., .,..J:r~·, 2:
....' ' ( '. _.­
II' ~" '~,---,

r. i" fnIJ~ pcr i c ~r('htlltl

SUf':U:t: Anal amy ot (he- HeOlrt (el.1 edg'~)

:- ,f~~:-~ "'::,'~'--!c-<>=
Aigl"lt Coronarj' ~rte'y
coron.Jri 9mo\'o

.I\nlcrJOt vil!w

;fr

 4-C-1/

Posterior inferior View

f orrnatfion of Superior Vena Cava
50 ....'.:.-..:..
" ./
/.

Loft

Coron~ry sinus

~ "'~ ~l",j:tu
AIgl1t ventricle ;v.-;:~~,., ." ';"~t~\s

Middle cardia c '.loin

1 Azygos Vein
AR,,1r,'h Or Aort~: BT. hrachitX~ohali( mtn~: /Ve inferiorvma cava:LBV, lef[ br,\chiocen/i'lli< \'cin: [,CA, Hr coml1lDn wotid illt~r,.;
2 Superior Vena Cava
l.eA. lefl common wotid artcC\,; LPA.I~t DultnonalY artery; LPVj krt pulmollill), ve~; (SA, kft slIbd;nQ/n JIUI)'; PT, pulmolla~ :1.""-", k~
t:ft ects of Ligating ot Obstruction 'of Superior Vena Cava
RBV, ri~ht b(,\dliQ(('D~,II!\ vtin: RCA, 0cnt COilllllOIl carotid arret}';R/V, right internal jugular will; RPA, right pllIOl0n~~1 ~rtaf;
Unitateral or Bilateral Lesio.n
RP~ n~llt pulmonary \'~I1l; ~VC,lll~riorvcoa c~va,

Orugin of Right & Left Coronary Artery Coronary arteries and branches
lb
Sinuatrial noclalbranch Semilunar Cusps
Superior
Aortic villve/ Rt Lt. & Post.
vena cava

I I:' ;

1
Circumflex branch II
Anterior 0
interventricular
branch
~ LAD: Lt. Ant.
Descending artery
Most Common Artery
to be affected in MI
1
Inferior velln cava
Posterior interventricular
3.
2 Marginatbiallcll I)ranch
PDA: Post descending Artery

5/1

 #//

Clinical Correlation Angiogram

.
~\" ..',; .. 11
-~

','
j,

Obstru ctio n

of LAD (Lt. A nt.

Desce nding

aite ry
'/,n1erlor (
,!n!crvcntl!cu!ar ---........
arleri
Myocard ia l

In farcti o n (MI )

Summary Sum~mary
\i'eins. OJnd A rteries lie in 3 sulcus namely: The anterior interventricu!av branch (LAD) is a
branch of the Lt coronary artery
Coronary groove (arterioventricular sulcus)
The po sterior intervent ricu lar bra nch (PAD) is a
,r .n;: & P'ost interventicular sulcus or groove branch of the Rt coronary artery

Rt. Coronary artery arises from the Rt. aortic PAD arises predominately arises from the Rt.
sinus and lies between ascending aorta and the coronary artery and therefore is called Rt.
rL crc f~um . Its fi rst branch is Ant. Rt. atrial branch dominant circulation

Lt. co ronary artery forms from the Lt. aortic sinus However, when PAD arises from Lt. cornonary
between the pulmonary trunl{ and the left atrium artery it is called Lt. dominant circulatio n

?1

 .l-f-' 1/

Cardiac Veins Clinical Correlation

" :; .' :'..":- ~.""a').7a;
·~W~~·lfa· "C ~".;m;·e ··, ..t ':'j/r
' ." r.e
' · ·",a" A · ;','"",....:...: ~ ; .
: ~",/;'Ii\,:: . l . .v i ~ :,, ' .u -,,:·r.::a ~ :fr .:: '" ...'.....\.
. ," '

Superior ven3 cava Thc.hcart: is j.nsens.iciv~ : tcotducb. CUt:cilH~, cold and

/\nterior c··
0" T5.csp e,Cia"yoncch~,'lef~-:S1d C:~. . . ' .

Coronary pain , js . apheno"nenon ·'~·hc' ..eby noxioLIS' si:;rniJri

sinus originatin.g .'" thc'.hcar't: :"r-cpC:fceived bY' the person
"'$ pain arising fr6 ';-n a s·uper,r.ciu!p::l11: ofchc body­
the ski n on ~he .m ed ial.,.,sp~<:;t .;of'the lefuJl?.:Bedj m b,
lor i:.-':3mpte. Visccrul. pain ist:ransmt.rtcd b>' v'scc.. nl
.dfe.'cnt fjbers:acc:Orrlp~lIri)'lng sYrripachcl:ic fibers
and · is ' typically ...e fe,r:','ed to so.:".at:ic !>tcr"uccu,'C$ Or"
,(lrC<tS s .uch as ,:th~ . .~pp~r. Ji.nb- .havtog i:J.ff'c.'eoc fil:ic."S
..§11i;J1I•.CilfU;;1C vein
Middle cardiac vein
withc~U . b6dies : inl:he . s . .tn,e:
spit',;.; I ganglron, and
Inferior vena CClVil
cc n tral p ,'pcess,c s. t:h at: ehter" ,"he 5pi nal .;o-r'd d:i r"ough
t.he same posi:e~·io ... r"oots~ " ..

Right Coronary Artery Branches Arterial Supply of Heart: Summary

' Iincf)yOrnii(h;:! :9~giij "~.~~;~:'';;;~,$:
. . . .....{ ~ ~~ : ~:''<~ . ~f'::rt:-{:v.il ...

Ri~(;{(~rL'r."·rJ n;~:lll ;:'(1r[1( sirr.;s rt>l k"'l (QlQnarf('W) groo\~ R~~fl ,1(Jium, $A il!ld AV!lOth ar.llmlh ,,,d .1mlliorl'!
ltfi IOIDnd,), lefl aonic linll! Rum in Al'woo\~ ,1 n&gi~~ ofi MII!1 aildl wiun JIID \'~n(riC!C, Right coromrl anti)'
bCI,,~n ,{OJ ,nd \'(nlricil! Jnd I'\'mrior pJtt oill' )('1'111111 hrjlldl~5 (fcit (l)IdJl~'i' .11tl'f:"
anterior 'N Jnd (irrumnrx brull(hl'l ~r irptllr.1, ,1nd AV hUIII!lc\; Iftly
S.:~I:I:;i,~1 HI!:IIIIV ~('IlJry M(L'fId,1O SA r"~l' Plf.ffJ(lll"ry lomk ~,ul $A IIod" supply I,V node
5. ;:Ih'r;':H'ui l';
(!rl~in tin nfJ.-; ,~) 1 ,'roll'riL'fll' ld, (orill1~~' PIlSI> l~nr.lnh'fior ~I f,'O(l',tio RiF.!~ and Itft WniricilS; liliflior POIII'l'iix' IVbrlJ11h otidl
:: ~IJlla. H::JIi.lt r:;.~hll{l:I~II,lly r.l~'L·S 10 in lenor m;lI))" Ornl"" (LAn! ~"r~' ~p't'.iOrhIJfl nl'lllhilds IV $cplUm MO~i\f\' ~.:~ry
R,):hl vcolnc/L' ~O;/ JPL'X ofli".HI A'''r,llIeh'',i
"'~:
;!I:d .ljI:'!
2 (irrJUlI\~ Llofl (flfO.llf)' P~ISCS 10 leli in AV!:roO'if Jnd l1IilI [dl ,Inum ilnd Icft \t'lIri(i~ Righi (Ofl)UI), J!W)'
~·.I ,!.'I;IH 1\' RI';llsin pos[criot Wtroo'~ 10 Ril:hl and Iclll'I;l1lJici.:s inti AI~\'llt)( IV b(,llld~I'~ (ll~:( anr~' Wpll\l(!liar lutf~(/ O(h,Jrt
...., :'lx·,,(lilit·.11i pOSltfillf Ihrrd of IlPiUOI WI(ln~Ij';trll\')' (,'r'l't\'x)
3 l,'(lnw);;ull CiiIUrtlJ1l~brJ.ldl Rrllol'ls IMI botdrrofhr.lfl l~ii \'l'11lriric IV "(all(hes
,".

~
,'Wnod,l; R,~If1 """:11.11)' rJ~\\'S 10 ,'tV nodI AI' "OX
i.:. .~.(h.'~· :-('.:.r(\t~~'fl
4- rl,il1lioriV

Rllns in pomnor ~I ~ro"\t 10 ;~If'.\ Righi ,Irld He pOII<rior Ihi(d of ,'\llICnOr Ivbr.Jn(n ofltfl
CI?Oi:tti~( ~,
o(hcJn !VltpWf11 ~O"Ofl.1')· ,111/~'

.:rtn),

AV, J:n(lVtfllri(,ular; IV, illlelwIHlieul,l!'; LAD, Ide .lmenOf dmrndinr, airel)'; SA, "intl<llri~ 1.

72!/,

 -i:F'1(

Interior of Rt. Ventricle

Ri. Atri urn & Locations of Conducting System Nodes

AOIi" . (llllfllonilIY lrunk

SllJltHlor v{!n~ r~ l vn

Superior 'iella cava fli!JIII ;]uriclO II ;;7'1~ '

-"'--~--- COIlUS :Jrtoriosus

Sinllatrial node
_-,-_ _''.. SCP'"' rnpill"ry ",,,sr:lt

". , '\ Inlcrvclltriculilf seplum

LimlJus fossa (l'mlis '~~!-.Jgl'ir!
SCIlla' cusp ---~
Fossa ovalis --L 1I::;;:;;t
Postorlor cusp --I~
VIII'.'e of inferior ll----"-'J.-- Scp'omarginol
lralJoCtrJn
vella cava Chordae IClufineae

Inferior vena cava ~?;;;'~~ F-·!'

Opening of right
Atrioventricular noelc atrioventricular valve
coronary sinus Tr:tI)f!ClJ!;ir. r.ntnCf1C

Valvular Heart Disease Conducting System of the Heart

" Disease of the valves of the heart

u Causes stenosis or insuffiency of valves

'" Stenosis is inability of valve to open fully

Interventricular Se ptum
" Insuffiency of valves causes regurgitation
Rt (AV) Bundle

" Both stenosis and regurgitation causes Lt. (AV) Bundle

turbulen ce. This produces vibration when
audible are called murmurs while felt is called
thrW
sy;
 ~,
II
Clinical Correlation X-ray of Chest (Ant Post View)
Conducting System of the Heart (Injury)
carl! be affected by: 151 rib
Claviclo

Corecola
Superior
pro=(;sG
von;) cava

'" Coronary artery disease (ischemia of) Ri9111111nQ --:- '~ "
Atcn of aOiln

Pu1monart'
cardiac muscle contraction is impaired tIIlory
LeI! ou;lele
AiS~ 1 ~or<lor
.' Blood vessels occlusion supplying SA of Ilearl I.al! bOlcer
01 hoorf (Ioh
friglll "ilium)
and AV node '.'cntridc }

Righi dOl11e Ape, o!.1lO0ol

..'. ~ . ';:: ~.:~' ~~: .. ~, }~I t4 i~ (1l-r.; t~ra 1~! (; t'"1 {:;s ca use of diaphragm
InfariocL\jft!p,r
heart block i.e. conduction is impaired. 01 hOOil

X-ray Chest: Cardiac shadow description

(cardiac silhouette

Ci<iVi(:II;S
'-"'-"'~1'~/
~ ' \ \---'-~".4"" .,J"
~.~.~ -,Ate/) ()[
Rigl'll ~'.~) :~../~/.~ Clorl[J
bracnio' -~, '--'I, ';( _-'' F'ulmOfHHy
c~phalic' .r; (__/---- trLlnk
F:ighl i 1/[;11"1 ,--.-.'~ \ t ..,..-"' Left
b-:JrdN ':I' ' ~.
S~Jpenor~ !\ ),--
.. - 1-
aunc l:
\ left
t oordo(
\'erl~ cava,/'"--i \_n..~ LefL J
RIUt .,' \ , \ 'I J
r
' 11",
• (1 trilJm ./ .~~_, ~1 'Jentnc 0
/ .,.... ~ 1:>:I(il·
Init;rior -- / .....-~\ ;~ti-cardifl!
1,- l,IE;n;~ caoora Diaphmgrn' \, (al

f/f

 I - ~~ Itlr-"

Superior Mediastinum Superior Mediastinum

Boundaries:
.. Superior: Thoracic aperture (thoracic inlet)
• Posterior: .Bodies of vertebrae (T 1 -T4 )
• Anterior: Manubrium of sternum
• Lateral: Mediastinal pleura (Rt. and Lt.)
• Inferior: Plane between sternal angle & T4-T5 Pericardium

• Part of the Thymus (lymphatic organ) will be

seen in prepubertal. Rest in Anterior part of
Inferior Mediastinum

Cross Section of Thorax

Contents
Contains structures that pass between
the neck and thorax and thorax and
upper limb. These structures include:

• Great vessels and primary branches

• Trachea
~ Esophagus

G Tho racic duct (from abdomen)

'.:,';f~~tti1{~ M

 ~'V

Structures: Superior Mediastinum & Above

Arch of Aorta and branches Thoracic Inlet

~
'P9st.:
(hf;hi ~ Lilli comm0i1 ca.rolid (jficry
~IJ)C:~.' \' Ii'l ··
I nft .m@@I'

t
~!: : !.~ I y

Left subclavian (ulery

Ri{J~1 bmc1t '.
IlrachlocepbaUc

Ar~1l
.Arit;;
Superior veoar.;l\<iI-..;....;~_

Clinical Correlation Cross Section of the Thorax

Posterior

Identify the structure causing posterior

displacement of esophagus

1. Above T4
2. Below T4

See the Image in' previous slide

Anterior
.Tfl<>ra¢it::<te~et:?-':

@//a

 ~ I"

CT S(:an of Thoracic Cavity & Contents Cross Section: Arch of Aorta Branching Level

Cross Section: Above Arch of Aorta

Relationship of Great Vessels and Nerves
in the Superior Mediastinum
The superior ve na ca V<l (S VC )
forms at the infHiol" bo t'de:'
of 1,t costal cartila~e

* Note: Lt. recurrent laryngeal N.'passes lateral to ligamentum arteriosum

Phrenic N. passes anterior to the root of Rt. and It. lung - Vagus - posterior
ThoradcLevel?:
, - . ...'.
' .

~/()

 Clinical Correlation Branches of Arch of Aorta Ant. to Post.

' ..

pulmonary artery

Rt. Pulmonary A. ,. Pulmonary trunk

I'•... '
Clinical Correlation
Arch of aorta
.OBScQndlng aonil,
·"1; • . ' ' .

· . l~lfatirum
L~(l t;ornrllon carotid MOry
L~rt:pulmOOl:)iya~~rY
Lelt :subclavla,ntirIery
lelt ventricle'
,Posforlor cusp of .aorllc valvo
Transversa p~rlCaidral sll')US
flIght alT[um
. Rlgbt pUlrnOna,y3.rfary
R!ght pulmonalYveti1 .,
Rfghtsllbclavlall artery ,RT- ; ~,f-!~' RT . LT
Right ve.im'1cIQ
Superior vena·cava Pneumothorax and Mediastinum

Hi9

 -=--1 •

Posterior Mediastinum
Contents of Posterior Mediastinum
. .-. ~. :"
• Thoracic aorta
• Thoracic duct
• Posterior mediastinal lymph nodes
(tracheobronchial nodes)
• Azygos and hemiazygos veins
• Esophagus
• Esophagus plexus
• Thoracic Sympathetic trunks
... f~hv(;·t~~~!i~~,li~itljstea? · .

sup. vena caV(l

E
Course of Rt. And Lt. Vagus ::J
passes ant. to

...
c:
(/)
Vagus passes ·
Post to the root , .
tl1eo ·1 .
root of rt. lung

ca oflung
"0 ~sop,",agu~
CJ)
~
. '­
Rt. Bronchus · o
...
'­

..
CJ)
Larger Diameter (/)
Shorter o
More vertical a.
'+­
(Foreign Body) o
Sternal angle plane (T4-TS)
J!J
c:
Bifurcation of Trachea
Beginning and ending
.sc:
of Aorta o
Ending of pericardium u

sf?

 ~/..,.

Note:
E Abs € nc~ Vert
:::J
c:: Of Bronchus
....
CJ)
/"?&."'¥.~
..

C'tI
I \

"0
Q.)
:E
r~r,•\ ~

'­
Mediastinal Lt. Lung ~
o Pleura 1
'L:
....
o
Q.)
CJ)

a...
:·, · tt}
", . .
. · ~l".l
/1

~
'­
o
'­
Q.)
0.
:::J vein
en ~L~teral VleviJ Structural relationsh~p in the inferior mediastinum

Postero-Iateral Mediastinum (Rt.) Postero-Iateral Mediastinum (Lt.)

Rami commUJ\icanies.....;

". ' .. :

no,,'O
~1::\+-.l"ICrCOs,al v~Jn. artery, ns....e
~phr.nlo rieNe Ant.. to hilum mal~ bronchus

-I!I/ ' 0:•. . , ., . ' ~'~Puimona'Y ligamnnl Ttiorncie aona and "ollie plo.us
__ Sympalhollc.ganollor.l ,',,{] ,ru n~

G/en1.' sprancnnlc """'. ~'H~

iI,· ·.. ~f.11
III . Inloriorvei\acava

tIIJ-i-r. ' AAI iJ,( splnnchl1ic [lcr'Jo

clq

 Esophagus

Descending Aorta
1 Anterio-Posterior View of Post. Mediastinum

2b Azygos Vein ~c::....,.

Intercostal Artery la

,- Paravertebral Ganglion
Rami
Communicantes

RIGHT

_ Transverse section of a thoracic vertebra and its ribs (viewed inferiorly,

as in a CT scan) illustrating relationships of various nearby structures to these bones
and to one another. Origin and contents of intercostal space Post. intercostal' ~rlt~'~i~~,

Arterial Supply - Intercostal Spaces Anterior

CO"tocol\lical tf\Jnk }

Superior

, , Intercostal
;
'>
I1lnhl
(".1,1:::::::1\'-1,1'1
, - 1st rib

{ W:Uly
":. "
lIunl

~" ".I'''I'-I ... e.q",,'fJ I

1
D

~Supa;l lol' phroJ1ic

l
": , ~'- '.J . , '_<;.~' ~ . ,' ~_' " .o. ;:. ;.'t :' ~ · ,--- : : ; i&Z\.~:~I., \: . ~t.':'- ~ ' :c.."":' . , -. -. . ,~ ':,'1_.,

' Int~~p:a(~ith()ia,
. . . .."
di:¢ {~rtetY '& -An'a stomosis Of Branches
~ ' .' "

~/1

 .pY , ­

Venous Drainage - Intercostal Spaces Anterior

LiJ't ':MIO"'i1<a~e
'I
I

P~~~ripr .
1

Right itt-twtu·j:'nate _ ._ _'

A:::Ala08 ~ei1t
.~.
\Joins Post to SVC CD
·E:!cm,;aZ1/9O$ Vel:,.
. -Mft ~1J.pra,.e-M:J.t
-iUlJilP
.... ~~./ . .L e / t r m t a l . , . ·1, . .. ·· ..•.
~~-- - Left internal. SpermallO .J\nte.rt9r: .

H
.~J- Left comm.on iliac
. ~-E:""e"l!.al .1iac
·-JlYl>OfJ=trio Thoracic Duct

Clinical Correlation
Clinical Correlation
Collateral Venous Routes to the Heart

Obstruction of inferior vena cava (IVC)

The azygos and hemiazygos veins offer
r-, alternate means of drainage when Ive is
Obstructed
iI',;
i \ \
Obstruction of superior vena cava (SVC)
I"
: .s.'v
. I
'. ,
When obstruction of SVC occurs superior to its
joining the azygos vein then blood will return
to the right atrium through IVC and azygos
system of veins (knowledge of SVC formation)
--~. --~---

?/1

 ..,-, ,...­

.:Ass.
. :, "
'Hemiazygos
. ;. , .
.Ass. Hemiazygo s

·~ ~~$ia~ygO¥'. . Hemiazygos

. ~;~ql11b~r Veins
:' -'::- ' . ,"

Clinical Correlation
Clinical Correlation
Horner's Syndrome: Sympathetic Ganglia
affected

Clinical features on same side

• Ptosis: drooping upper eyelid

• Miosis: constricted pupil

• Enophthalmos the impression that the eye is

sunken

<> Anhidrosis decreased sweating

er/J