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REVIEW OF ANATOMY
UNDERLYING PROCEDURES USED
IN EMERGENCY MEDICINE
ANATOMY OF THORACIC WALL AND THORACOSTOMY
Thoracostomy is the
insertion of a tube into the
pleural cavity.
Thoracostomy is
performed as a procedure
to drain fluid or blood
(hemothorax) or to remove
air (pneumothorax) from
the pleural cavity.
Knowledge of the anatomy
of the chest is necessary
for accurate tube
placement.
Thoracostomy
tube
STRUCTURE OF ANTERIOR THORACIC WALL: MOST
STRUCTURES ARE PALPABLE
Rib 1 not
palpable
Rib 2
Suprasternal notch
Manubrium
Sternal angle
Body of sternum
costal cartilage
Xiphoid process
Rib
7
The anterior thoracic wall is
formed by the ribs and sternum;
ribs 1-7 attach to the sternum via
costal cartilages; ribs 8-10 attach
to the costal cartilages above;
ribs 11-12 are floating (cannot be
palpated)
INTERCOSTAL MUSCLES AND COURSE OF INTERCOSTAL
NERVES, ARTERIES AND VEINS
Intercostal muscles
Intercostal vein,
artery, nerve
External
Intercostal
Muscle
Internal
and
Innermost
Intercostal
Muscles
Three layers of
intercostal
muscles are found
between the ribs
(External, Internal
and Innermost
Intercostal Muscles)
Intercostal veins,
arteries and nerves
course in the
intercostal spaces.
COURSE OF INTERCOSTAL NERVES, ARTERIES AND VEINS
The intercostal
nerves, arteries and
veins course
between the Internal
and Innermost
Intercostal muscles:
Order:
Superior to Inferior:
vein, artery, nerve =
VAN
The bundles are
found along the
inferior margins
of the ribs, often
forming a groove in
the rib.
SENSORY INNERVATION AND DAMAGE TO INTERCOSTAL NERVE
1. Dermatome (= area of skin innervated by
single spinal nerve) - in thorax dermatome map
looks like stripes.
OVERLAP OF
DERMATOMES
GREATEST ON
TRUNK
2. Overlap - there is some overlap between
adjacent dermatomes; overlap is greater on
trunk than on extremities
3. Clinical signs of damage to intercostal nerve
- damage (pressure) to a single spinal nerve or
single dorsal root can produce pain in the skin
of its dermatome.
(Note: because of overlap of dermatomes in
region of trunk, damage to a single intercostal
nerve often will not produce loss of sensation
(anesthesia); loss of sensation on skin of trunk
will occur if two or more adjacent nerves are
damaged.
ANATOMY OF THE LARYNX AND AIRWAY OBSTRUCTION
Obstruction of the
upper airway can
occur for a variety of
reasons,
including ingestion of
food, anaphylactic
shock and trauma.
This can often be life
threatening.
Cricothyrotomy and
tracheotomy establish
an opening of the
lower respiratory
system in the neck,
below the obstruction.
This requires
knowledge of the
anatomy of the larynx.
LARYNX: CARTILAGES
Larynx consists of cartilages
that are linked by membranes
and joints
Laryngeal
Prominence
Thyroid cartilage is shield
shaped and sits above Cricoid
Cartilage (ring shaped, cricoid
= signet ring)
Cricoid Cartilage is above
trachea
trachea
Laryngeal Prominence or
Notch = Adam’s Apple, more
prominent in males
LIGAMENTS OF LARYNX - link cartilages
and attach it to hyoid bone
Median
Thyrohyoid
Ligament
Median
Cricothyroid
Ligament
1. Thyrohyoid Membrane
links larynx to hyoid bone;
Median Thyrohyoid
Ligament - thickened midline
part
2. Cricothyroid Membrane
links thyroid to cricoid;
Median Cricothyroid
Ligament - thickened midline
part
3. Cricotracheal ligament
links Cricoid to first tracheal
cartilage
VI. LARYNX - ARTERIAL SUPPLY
Sup. Laryngeal A.
from Sup. Thyroid
artery
Inf. Laryngeal A.
from Inf. Thyroid
artery
OBSTRUCTION OF LARYNX: TRACHEOTOMY
open airway to lungs below obstructed larynx
Tracheotomy
- cut between
first and
second or
second and
third tracheal
cartilages
BLEEDING IS PROBLEM: MIDLINE THYROID VEINS
1) Sup. Thyroid vein
follows artery
2) Middle Thyroid
vein - to Int Jugular
3) Inf. Thyroid vein
Both sides join at
midline; drain to Left
Brachiocephalic Vein
CRICOTHYROTOMY - OPENING OF AIRWAY THROUGH
CRICOTHYROID MEMBRANE
Incision is made in
midline through
Cricothyroid
membrane at
Median Cricothyroid
Ligament
No major veins so
bleeding is minimal
Arteries and nerves
are unaffected as
they enter
larynx from lateral
and posterior sides.
ANATOMY OF VENOUS SYSTEM AND CATHETER
PLACEMENT
The placement of flexible tubes
into the circulatory system
(catheterization) is
now widely used in medicine in
treatment and diagnosis.
Central
venous
line
Central venous lines are
catheters placed into the venous
system close to the heart. They
can be used to rapidly and
reliably administer drugs to the
circulatory system and to the
heart itself. The can also provide
for sampling of blood when other
veins are small (infants)
Knowledge of anatomy of the
venous system is essential in
performing catheterization.
OVERVIEW OF VENOUS RETURN TO THE HEART
Right
Brachiocephalic
vein
Superior Vena
Cava
Right
Atrium
Left
Brachiocephalic
vein
All venous blood returns
to the heart by entering
the Right Atrium
Inferior Vena Cava drains
venous blood from below
the diaphragm
Superior Vena Cava drains
venous blood from the
head, upper extremities and
thorax
Superior Vena Cava is
formed from the Right and
Left Brachiocephalic
Veins
Inferior Vena
Cava
VESSELS DRAINING TO SUPERIOR VENA CAVA
Right
Subclavian
vein
Right
Brachiocephalic
vein
Internal Jugular
Veins
The BRACHIOCEPHALIC
VEINS are symmetrical
Left
(unlike the arteries from
Subclavian the Aorta)
vein
Left
Brachiocephalic
vein
Each brachiocephalic
vein forms at the junction
of the Internal
Jugular and Subclavian
veins at the base of the
neck
Superior Vena
Cava
Right
Brachiocephalic
vein
Left
Brachiocephalic
vein
INTERNAL JUGULAR VEIN - VENOUS DRAINAGE OF BRAIN
AND DEEP STRUCTURES OF HEAD
Superior
Sagittal Sinus
Cavernous
Sinus
Common
Facial
Vein
INTERNAL
JUGULAR
VEIN
INTERNAL JUGULAR
VEIN - drains venous
sinuses of brain
- also veins of face
and deep structures
of head
- Int. Jug. Vein forms
at Jugular foramen of
skull
- Drains to
Brachiocephalic vein
PATTERN OF VENOUS DRAINAGE OF FACE AND HEAD: SUPERFICIAL VEINS
Post.
Auricular
Sup. Temp.
PATTERN OF VENOUS DRAINAGE
1. Superficial Temporal & Maxillary
veins form Retromandibular Vein (RM)
Max
RM
2. Retromandibular Vein Divides into
Ant. (AD) and Post. (PD) divisions
AD
EXTERNAL JUGULAR VEIN
Common
facial
3. Post. Division (PD) joins Post.
Auricular V. to form External Jugular V.;
drains to Subclavian V.
PD
Facial
4. Ant. Division (AD) joins Facial V. to
form Common Facial V.; drains to Int.
jugular V.
Anterior
jugular
Vein
External
Jugular
Vein
ANTERIOR JUGULAR VEIN
5. Ant. Jugular V. forms from veins
below mandible; drains to Ext. Jugular
vein above clavicle
LOCATION OF STRUCTURES IN NECK
MAJOR LANDMARK:
STERNO-CLEIDOMASTOID
MUSCLE
0rigin - Two heads
1) Manubrium of sternum
2) Clavicle- medial 1/3
(cleido- means clavicle)
STERNOCLEIDOMASTOID
Insertion - Mastoid
process of temporal bone
Action - bilateral - Flex
head; unilateral Rotate
head, face is directed to
opposite side
Innervation - CN XI
(Accessory n.)
STERNOCLEIDOMASTOID
Action on one side - rotate head, face
is directed to opposite side
LOCATION OF VEINS IN NECK: INTERNAL JUGULAR VEIN
INTERNAL
JUGULAR
VEIN
INTERNAL JUGULAR
VEIN - courses in
Carotid Sheath DEEP
TO STERNOCLEIDOMASTOID MUSCLE
STERNOCLEIDOMASTOID MUSCLE CUT
STERNOCLEIDOMASTOID
MUSCLE
INTERNAL
JUGULAR
VEIN
Carotid
sheath
contains
Internal and
Common
Carotid
Arteries,
Internal
Jugular Vein,
Vagus Nerve
COURSE OF VEINS IN NECK: EXTERNAL AND ANTERIOR
JUGULAR VEINS
ANTERIOR JUGULAR VEINS
External Jugular Vein courses on surface of
Sternocleidomastoid
muscle; drains to
Subclavian Vein
EXTERNAL
JUGULAR
VEIN
Anterior Jugular Veins course superficially in
EXTERNAL anterior neck; drains to
JUGULAR
External Jugular Vein
VEIN
SUBCLAVIAN
VEIN
LOCATION OF VEINS: DEEP BRACHIAL VEINS
AXILLARY
VEIN
clavicle
cut
DEEP BRACHIAL VEINS two large veins parallel
BRACHIAL ARTERY
in arm; also called Venae
comitantes
(accompanying veins)
DEEP BRACHIAL VEINS
drain to AXILLARY VEIN
DEEP BRACHIAL
VEINS
SUBCLAVIAN VEIN
AXILLARY VEIN becomes
SUBCLAVIAN VEIN (at
lateral border of rib 1)
LOCATION OF VEINS: SUBCLAVIAN VEIN
SUBCLAVIAN VEIN parallels
SUBCLAVIAN
ARTERY;
clavicle
both SUBCLAVIAN
ARTERY AND VEIN
are named for their
course DEEP TO CLAVICLE
SUBCLAVIAN
ARTERY
SUBCLAVIAN VEIN
SURFACE RELATIONSHIPS OF INTERNAL JUGULAR AND
SUBCLAVIAN VEINS
INTERNAL JUGULAR VEIN
1- Courses deep to
Sternocleidomastoid muscle
INTERNAL
JUGULAR
VEIN
2- Vein is accessible through
Sternal and Clavicular heads
of Sternocleidomastoid
SUBCLAVIAN VEIN - Courses
posterior to clavicle, anterior
to Rib 1. Accessible by
needle placed
3- Superior to clavicle
4- Inferior to clavicle.
SUBCLAVIAN VEIN