Anatomy 6/8/10 1/2008 - Outline the anatomical relations of the cervical trachea relevant to performing a percutaneous tracheostomy.

Percutaneous Tracheostomy Anatomy - cylindrical tube - projects onto the spine - C6 -> T5 - moving downwards it courses slightly backwards - first 6 tracheal rings are extrathoracic - length = 10-15cm in adults - blood supply = inferior thyroid artery & veins and bronchial arteries - nerves = vagus and recurrent laryngeal (pain and secretomotor) + sympathetics (blood flow and smooth muscles) SUPERIORLY - cricotracheal membrane -> circoid cartilage INFERIORLY - terminates at the bifurcation of the bronchi ANTERIORLY (superficial -> deep) - skin - superficial fascia + anterior jugular veins connected by a vein that runs superficially across the lower neck - muscles (sternothyreoideus and sternohyoideus) - isthmus of the thyroid gland (2-4th tracheal rings) + - inferior thyroid veins - deep pretracheal fascia POSTERIORLY - oesophagus - recurrent laryngeal nerves LATERALLY - right and left lobes of the thyroid - inferior thyroid arteries POSTEROLATERALLY - carotid sheath (common carotid, jugular vein, vagus nerve) - recurrent laryngeal nerves (lies in groove between trachea and oesophagus)

Jeremy Fernando (2011)

Jeremy Fernando (2011)

1/2005 - Outline the anatomical structures relevant to the insertion of a femoral venous catheter Femoral Vein Anatomy 6/8/10 SP Notes continuation of the popliteal vein lies in the intermediate compartment of the femoral sheath accompanies the femoral artery in the femoral triangle at the inguinal ligament it becomes the external iliac vein

FEMORAL TRIANGLE superior: inguinal ligament medial border: adductor longus lateral border: sartorius apex: sartorius crossing the adductor longus muscle roof: skin subcutaneous tissue, the cribriform fascia and the fascia lata floor: adductor longus, adductor brevis, pectineus and iliopsoas muscles

LANDMARKS anterior superior iliac spine (ASIS) pubic ramus inguinal ligament femoral sheath medially -> laterally (vein, artery, nerve)

INSERTION POINT - 1cm below inguinal ligament - 1cm medial to femoral arterial pulsation STRUCTURES NEEDLE PASSES THROUGH (superficial -> deep) - skin - subcutaneous tissue - fascia (encloses the femoral vessels) - femoral vein - medial: medial compartment of femoral sheath (femoral canal lymph vessels, nodes and fatty tissue) - lateral: fibrous septum separating intermediate compartment and lateral compartment (containing femoral artery) and further lateral = femoral nerve - posterior: posterior fascia and pectineus

Jeremy Fernando (2011)

Jeremy Fernando (2011)

2/2005 - Describe the anatomy of the tracheobronchial tree, as seen down a bronchoscope inserted via an endotracheal tube Bronchoscopic Anatomy 6/8/10 See: Sabines Notes, My diagram, Bronchoscopy photos ETT - via adaptor - clear plastic with markings on ETT - Murphys eye TRACHEA mucous membranes anterior and lateral walls: cartilaginous U shaped rings connected by connective tissue posterior wall: muscle (trachealis, par membranaceus) length: 10-15c in adults (cricoid -> bifurcation) diameter: 19-22mm

CARINA - cartilaginous ring that runs anterior-posteriorly between to main bronchi - lumen narrows slightly as it progresses towards the carina

RIGHT MAIN BRONCHUS - more vertical orientation than left - bronchus intermedius directly ahead - 1-2cm in is the RIGHT UPPER LOBE BRONCHUS @ 0300 RIGHT UPPER LOBE BRONCHUS - trifurcation: APICAL, ANTERIOR AND POSTERIOR SEGMENTS - this is the only place that has 3 orifices - 1/250 people have their RIGHT UPPER LOBE BRONCHUS coming directory off CARINA RIGHT BRONCHUS INTERMEDIUS

Jeremy Fernando (2011)

- come back into RIGHT MAIN BRONCHUS - identify the RIGHT MIDDLE and LOWER LOBE BRONCHI

RIGHT MIDDLE BRONCHUS - seen at 1200 - D shape - MEDIAL and LATERAL SEGMENTS RIGHT LOWER LOBE - APICAL SEGMENT @ 0600 - four basal segments (MEDIAL, LATERAL, ANTERIOR and POSTERIOR) -> withdraw back into trachea LEFT MAIN BRONCHUS - lies more horizontal than RIGHT MAIN BRONCHUS - it is longer and divides into LEFT UPPER and LEFT LOWER LOBE BRONCHI LEFT UPPER LOBE BRONCHUS - divides into SUPERIOR and LINGULAR DIVISION @ 0900 - SUPERIOR: gives rise to APICOPOSTERIOR and ANTERIOR segments - LINGULA: gives rise to the SUPERIOR and INFERIOR segments LEFT LOWER LOBE BRONCHUS - APICAL SEGMENT @ 0600 - 3 BASAL SEGMENTS (LATERAL, ANTERIOR and POSTERIOR)

Jeremy Fernando (2011)

2/1997 - Briefly outline the gross anatomy observed when doing a general bronchoscopy in an endotracheally intubated patient? Sketches may help to illustrate Bronchoscopic Anatomy 6/8/10 See: Sabines Notes, My diagram, Bronchoscopy photos ETT - via adaptor - clear plastic with markings on ETT - Murphys eye TRACHEA mucous membranes anterior and lateral walls: cartilaginous U shaped rings connected by connective tissue posterior wall: muscle (trachealis, par membranaceus) length: 10-15c in adults (cricoid -> bifurcation) diameter: 19-22mm

CARINA - cartilaginous ring that runs anterior-posteriorly between to main bronchi - lumen narrows slightly as it progresses towards the carina

RIGHT MAIN BRONCHUS - more vertical orientation than left - bronchus intermedius directly ahead - 1-2cm in is the RIGHT UPPER LOBE BRONCHUS @ 0300 RIGHT UPPER LOBE BRONCHUS - trifurcation: APICAL, ANTERIOR AND POSTERIOR SEGMENTS - this is the only place that has 3 orifices - 1/250 people have their RIGHT UPPER LOBE BRONCHUS coming directory off CARINA

Jeremy Fernando (2011)

RIGHT BRONCHUS INTERMEDIUS - come back into RIGHT MAIN BRONCHUS - identify the RIGHT MIDDLE and LOWER LOBE BRONCHI

RIGHT MIDDLE BRONCHUS - seen at 1200 - D shape - MEDIAL and LATERAL SEGMENTS RIGHT LOWER LOBE - APICAL SEGMENT @ 0600 - four basal segments (MEDIAL, LATERAL, ANTERIOR and POSTERIOR) -> withdraw back into trachea LEFT MAIN BRONCHUS - lies more horizontal than RIGHT MAIN BRONCHUS - it is longer and divides into LEFT UPPER and LEFT LOWER LOBE BRONCHI LEFT UPPER LOBE BRONCHUS - divides into SUPERIOR and LINGULAR DIVISION @ 0900 - SUPERIOR: gives rise to APICOPOSTERIOR and ANTERIOR segments - LINGULA: gives rise to the SUPERIOR and INFERIOR segments LEFT LOWER LOBE BRONCHUS - APICAL SEGMENT @ 0600 - 3 BASAL SEGMENTS (LATERAL, ANTERIOR and POSTERIOR)

Jeremy Fernando (2011)

1/1996 - Outline the functions of the vagus nerve Vagus Nerve Functions 6/8/10 SP Notes - Xth cranial nerves - paired nerves - neurotransmitters = Ach and Noradrenaline - pre and postganglionic neurons - provides 75% of all the parasympathetic nerve fibers (heart, lungs, oesophagus, stomach, small intestine, proximal half of colon, liver, gall bladder, pancreas, kidneys, upper ureters) BRANCHIAL MOTOR -> voluntary control over swallowing - striated muscles of pharynx - striated muscles of larynx (except stylopharyngeus and tensor veli palatini) - palatoglossus muscle of the tongue SECRETOMOTOR - efferent fibres which innervate the smooth muscle and glands -> pharynx, larynx, thoracic and abdominal viscera down to the splenic flexure. - parasympathetic tone -> increase gland secretion and smooth muscle contraction (rest and digest)

Cardiovascular
- heart: right vagus -> SA node, left vagus -> AV node, atrial muscle innervated by vagal efferentes (slow HR, decrease contractility and dilate coronaries) - arterial pressure -> slight decrease (requires strong stimulation) - supply to blood vessels in salivary, GI glands and erectile tissue -> vasodilation

Respiratory
- bronchoconstriction and increased secretions - pulmonary vasodilation

Gastrointestinal
increased peristalsis increased secretions (gastric, pancreatic, lacrimal) relax sphincters hepatic glycogen synthesis gall bladder contraction

Genitourinary
- detrusor contraction - trigone relaxation - penile erection
Jeremy Fernando (2011)

VISCERAL SENSORY - provides sensory information from larynx, oesophagus, trachea, abdominal and thoracic viscera - stretch receptors from the aortic arch and chemoreceptors to the aortic bodies GENERAL SENSORY pain, temperature and touch: skin of ear external auditory meatus external tympanic membrane larynx pharynx

Jeremy Fernando (2011)

2/1995 - Briefly describe your technique for ICC insertion in adult male with haemopneumothorax and multiple fractured ribs after MVA. What are the risks of insertion and how may they be prevented. Intercostal Drain Insertion 6/8/10 SP Notes PREPARATION exclude contraindications consent IV access (analgesia, resuscitation medications or products) monitoring (SpO2, ECG, BP) confirm affected side (clinically + CXR) position: supine with arm abducted and hand under head local anaesthesia: lignocaine with adrenaline = 7mg/kg

EQUIPMENT chlorhexidine drape scalpel forceps clamp 2.0 suture gauze dressing 32 Fr drain (blood) underwater seal drainage system (primed)

INSERTION full asepsis (G/G/H/M/C) landmarks = anterior to mid-axillary line, 5th IC space, nipple line (T4), palpate ribs and ICS 2-3cm transverse incision on top of rib blunt dissection down to pleura (just superior to rib -> avoid neurovascular structures) end point: pleural cavity (hiss or blood) sweep with finger insert clamped drain using curved forceps to guide in connect to UWSD check for drainage and respiratory swing suture sterile dressing

POST INSERTION - CXR - watch for complications: -> not draining (check for kinking) -> organ injury (lung, liver, spleen, heart, vessel) careful insertion -> blood loss careful observation -> surgical emphysema (small hole and good suturing) -> infection (sterile technique)
Jeremy Fernando (2011)

2/1995 - Describe the symptoms and signs of a complete 3rd nerve lesion. Explain the anatomical basis of these effects. IIIrd Cranial Nerve Lesion 6/8/10 SP Notes - oculomotor nerve - innervates: superior rectus, inferior rectus, medial rectus, inferior oblique, levator palpebrae, cillary muscle and iris sphincter SYMPTOMS/SIGNS - down and out because of antagonism of the trochlear nerve (superior oblique) and abducens nerve (lateral rectus) - ptosis weakness of levator palpebrae - diplopia + strabismus unable to maintain normal alignment when looking straight ahead - dilated, fixed pupil (anisocoria) + blurred vision parasympathetic fibres originate from the Edinger-Westphal subnucleus of IIIrd nerve complex ANATOMICAL BASIS (causes of IIIrd nerve dysfunction)

Nuclear Portion
- column shaped - either side of the midbrain tegmentum - infarction, haemorrhage, neoplasm, abscess

Fascicular Midbrain Portion

- courses ventrally
Jeremy Fernando (2011)

- passes through the red nucleus - emerges from the medial aspect of the cerebral peduncle - infarction, haemorrhage, neoplasm, abscess

Fascicular Subarachnoid Portion

- nerve runs in the subarachnoid space anterior to the midbrain and in close proximity to the posterior communicating artery - aneurysm, meningitis, meningeal infiltration, ophthalmoplegic migraine, compression from ipsilateral or mass effect (uncal herniation)

Fascicular Cavernous Sinus Portion

- the nerve runs through the lateral wall of the cavernous sinus - it enters the sinus just above the petroclinoid ligament and inferior to the interclinoid ligament - tumour, pituitary apoplexy/infarction, vascular (giant intracavernous aneurysm, carotid artery-cavernous sinus fistula, cavernous sinus thrombosis), ischaemia, inflammatory (TolosaHunt Syndrome)

Fascicular Orbital Portion

- it enters the orbit through the superior orbital fissure - it then branches into superior and inferior divisions - superior -> levator palpebrae and superior rectus - inferior -> innervates the rest - axons are mostly uncrossed with 2 exceptions (axons to levator palpebrae are from both sides, those for superior rectus come from the contralateral side) - inflammatory (orbital inflammatory pseudotumour), endocrine (thyroid orbitopathy), tumour (haemangioma, lymphoma)

Jeremy Fernando (2011)

2/1994 - Describe or illustrate the anatomical relationships of the left subclavian vein. Left Subclavian Vein Anatomy 6/8/10 SP Notes - in an adult: 3-4cm in length an 1-2cm in diameter - formed from the axillary veins at the lateral border of the first rib - joins the brachiocephalic vein to become the superior vena cava ANATOMICAL RELATIONSHIPS - superior: clavicle - inferior: pleura - posterior: anterior scalene muscle + subclavian artery - anterior: medial thirst of clavicle (immobilized by small attachments to the rib and clavicle) and subcutaneous tissue of the anterior chest wall - lateral: anterior aspect of the deltoid shoulder muscle - medial: internal jugular and brachiocephalic vein (this take place at the medial border of the anterior scalene muscle and behind the sternoclavicular joint) - the large thoracic duct on the left and small lymphatic duct on the right enter the superior margin of the subclavian vein near the IJ junction

Jeremy Fernando (2011)

2/1993 - Briefly discuss the anatomical basis and interpretation of pupillary signs in a patient paralysed and ventilated following a head injury. List the pharmacological and metabolic factors that may alter signs Pupillary Signs in Head Injury 6/8/10 SP Notes Pupillary signs in the head injured patient are dependent on a number of factors including: integrity of the eyes and retina optic nerve oculomotor nerve trochlear nerve abducens nerve the respective nerve nuclei for above nerves also the structures surrounding the above nerves and nuclei

Puplliary Signs
EQUAL AND REACTIVE TO LIGHT normal integrity of the above structures MIOSIS interruption of the sympathetic innervation or irritation of the conjunctivae or cornea (foreign bodies) -> mediated by the constrictor muscle (preganglionics = oculomotor nerve -> ciliary ganglion -> post ganglionics to constrictor muscles releasing Ach) MYDRIASIS parasympathetic innervation originates in the Edinger-Westphal subnucleus of the IIrd nerve -> compressive lesions affect autonomic fibers as they are very superficial in the nerve trunk (sympathetic preganglionics from thoracic region -> superior cervical ganglia -> postganglionic neurons releasing noradrenaline -> dilator muscle in iris ANISOCORIA unilateral lesions along any of the above tracts IRREGULAR SHAPED PUPILS ophthalmological procedures OVAL PUPILS early compression of IIIrd nerve due to increased ICP ONE EYE DOWN AND OUT dysfunction of the IIIrd cranial nerve or nuclei

Pharmacological Factors
MIOSIS: opioids, alcohol, neuroleptics MYDRIASIS: anticholinergics, catecholamines, cocaine, amphetamines PUPIL REACTIVITY: opioids, propofol, metoclopramide, haloperidol, droperidol

Metabolic Factors
PaCO2: ACIDOSIS: DIABETES: giant cell arteritis, syphyllis, hypertension -> IIIrd nerve palsy without dilated pupil
Jeremy Fernando (2011)

1/1992 - Briefly discuss the anatomical basis and interpretation of pupillary signs in a patient paralysed and ventilated following a head injury. List the pharmacological and metabolic factors that may alter signs Pupillary Signs in Head Injury 6/8/10 SP Notes Pupillary signs in the head injured patient are dependent on a number of factors including: integrity of the eyes and retina optic nerve oculomotor nerve trochlear nerve abducens nerve the respective nerve nuclei for above nerves also the structures surrounding the above nerves and nuclei

Puplliary Signs
EQUAL AND REACTIVE TO LIGHT normal integrity of the above structures MIOSIS interruption of the sympathetic innervation or irritation of the conjunctivae or cornea (foreign bodies) -> mediated by the constrictor muscle (preganglionics = oculomotor nerve -> ciliary ganglion -> post ganglionics to constrictor muscles releasing Ach) MYDRIASIS parasympathetic innervation originates in the Edinger-Westphal subnucleus of the IIrd nerve -> compressive lesions affect autonomic fibers as they are very superficial in the nerve trunk (sympathetic preganglionics from thoracic region -> superior cervical ganglia -> postganglionic neurons releasing noradrenaline -> dilator muscle in iris ANISOCORIA unilateral lesions along any of the above tracts IRREGULAR SHAPED PUPILS ophthalmological procedures OVAL PUPILS early compression of IIIrd nerve due to increased ICP ONE EYE DOWN AND OUT dysfunction of the IIIrd cranial nerve or nuclei

Pharmacological Factors
MIOSIS: opioids, alcohol, neuroleptics MYDRIASIS: anticholinergics, catecholamines, cocaine, amphetamines PUPIL REACTIVITY: opioids, propofol, metoclopramide, haloperidol, droperidol

Metabolic Factors
PaCO2: ACIDOSIS: DIABETES: giant cell arteritis, syphyllis, hypertension -> IIIrd nerve palsy without dilated pupil

Jeremy Fernando (2011)