Date post: | 03-Jun-2018 |
Category: |
Documents |
Upload: | drbartakke |
View: | 240 times |
Download: | 1 times |
of 38
8/12/2019 Anatomy for FRCA
1/38
ANATOMY FOR FRCA
1. Describe the anatomy of the larynx.
2. What is the innervation of the larynx
3. From where does the larynx derive its blood supply.
4. With damage to the nerves of the larynx what is the position of the cords with a unilateral complete palsy.
!. Describe the procedure for insertion of a percutaneous tracheostomy
8/12/2019 Anatomy for FRCA
2/38
Functions 1. "rotects respiratory tree2. allows speech
3. allows swallowing
4. allows coughing# straining
$xtends % root of tongue to cricoid ring.
&artilages ' paired ( arytenoids
&orniculate
&uneiform
3 unpaired $piglottis
)hyroid
&ricoid
*igaments of larynx
4 extrinsic ( thyrohyoid+ hyoepiglottic
+ cricothyroid
+ cricotracheal
8/12/2019 Anatomy for FRCA
3/38
,uscles of the larynx
$xtrinsic ( -) outside
-+ternothyroid /depresses larynx0 arises sternum to thyroid
+nferior constrictor /arises posterior border0)+ thyrohyoid /elevates larynx0
ntrinsic ( & "*))
&+ cricothyroid )ilts cricoid increases ocal cord tension
"+osterior cricoarytenoid bducts cords
*+ateral cricoarytenoid dducts cords
+ryepiglottic &onstricts cords
)+ransverse arytenoids From arytenoids to arytenoids constricts)+hyroarytenoid "ulls arytenoids forward *5 $ ) 6$*7 &6D-
8lood supply
8$ glottis ( superior laryngeal artery from external carotid
8$*W glottis ( inferior laryngeal branch of inferior thyroid from subclavian
nnervation
6$&966$) *65:$* ( sensation 8$*W glottis
( ** intrinsic muscles $7&$") cricothyroid
( close to inferior pole of thyroid and left side has intra+thoracic path therefore at ris;from lung tumours# aneurysm# oesophageal tumours. Damage causes
paralysed midline cord if unilateral if bilateral causes severe stridor anddyspnoea.
-uperior laryngeal ( sensation 8$ glottis close to superior thyroid vessels can be damaged at surgery
resulting hoarseness if unilateral % opposite often ta;es over in time.( cricothyroid
*ymphatics mainly to deep cervical chain.
8/12/2019 Anatomy for FRCA
4/38
iew of the laryngx at laryngoscopy
ppropriate anatomy for percutaneous tracheostomy insertion
8/12/2019 Anatomy for FRCA
5/38
1. Describe the landmar;s of the respiratory tree with respect to the relevant vertebral body.
2.
8/12/2019 Anatomy for FRCA
6/38
8lood supply inferior thyroid artery and veins
erves recurrent laryngeal and -- from cervical chain*ymphatic deep cervical pre ? para tracheal nodes
8ronchial tree 23 bifurcations 1' onward are transitional and respiratory
*$F) bronchus passes 9D$6 aortic arch in F6) of oesophagus@thoracic duct and descending aorta then below and
behind left pulmonary artery.6ight main bronchus is shorter wider and more vertical passes 9D$6 the aAygous and is above and behind the right
pulmonary artery.
*ayers ,ucosal % ciliated and goblets cells /reduced numbers in smaller bronchioles0
8asement menmrane %-ubmucous % elastic fibres
,uscular % unstriped withstand respiratory pressures relative thic;ness increases as bronchi get smaller
ct as sphinters at terminal bronchioles /entry point into alveolar sacs0
&artilage % rings replaced by plates in intrapulmonary area become less complete
"leura 8oundaries % upper 4cm above clavical
+ behind sternum at level 2ndrib
+ >thrib midclavicular line 1=thrid mid+axillary line and 12thrib posteriorly
isceral + no sensory innervation
*ung
8/12/2019 Anatomy for FRCA
7/38
&entral tendinuos portion and muscular periphery slightly higher on right.
6elations + &entral ( trefoil tendon contiguous with fibrous pericardium,uscle ( tips last ' costal margins xiphoid posterior surface.
3 arcuate ligaments % ,edia* % psoas *ateral Buadratum lumborum median % arch between crura
&rura ( *eft from 1stand 2ndlumber vertebral bodies
6ight from 1stto 3rdlumber vertebral bodies
Foramina % 3 maor openings in the diaphragm
1 )> ( inferior vena cava /sometimes right phrenic nerve0
2 )1= ( oesophagus agi *$F) gastric artery and vein3 )12 ( aorta thoracic duct and aygous vein.
,otor supply ( phrenic /&3+!0
-ensory % phrenic to central tendinous portion
*ower thoracic to muscular areas.
8/12/2019 Anatomy for FRCA
8/38
1. Describe the coronary circulation
2.
8/12/2019 Anatomy for FRCA
9/38
*eft ( left atrial appendage and left ventricle
nterior ( mainle right ventricle
nferior ( right and left ventricles onto diaphragm"osterior ( left atrium
4 chambers 6ight atrium ( receives de+oxygenated blood from vena cava flows through tri+cuspid into right ventricle.
- node is situated in upper part lies near base of tricuspid valve
6ight ventricle % pumps blood into pulmonary artery through the pulmonary valve /tricuspid in structure0ormally relatively thin walled as pulmonary circulation is low pressure system
*eft atrium % oxygenated blood from lungs via 4 pulmonary veins blood passes through mitral/2 leaflet0 valve into
*eft ventricle.
*eft ventricle % thic; walled pumps blood through three leafleted aortic valve /left#right and posterior leaflet0-mall sinuses above leaflets give rise to coronary vessels.
&onducting system - node ( near opening -& in 6 atrium initiates impulse in direct contact with atrial tissue and wave of conduction passes
across both atria.
node % receives impulse from - node. o direct contact with - or contractile tissue allows delay in conduction so atriaand ventricles do not contract simultaneously.
8undle of
8/12/2019 Anatomy for FRCA
10/38
scending % gives off the two coronarys
rch gives off % brachiocephalic that becomes right common carotid and right subclavian
+ left common carotid+ left subclavian
+ thyroidea ima /sometimes0
Descending + )4 to diaphragmatic opening at )12
+ visceral branches to pericardium# bronchial# oesophageal# mediastinal and phrenic
+ somatic branches to posterior intercostals# lateral cutaneous and mammarybdominal + paired lumbar
+ paired visceral ( inferior phrenic# suprarenal# renal# gonadal
+ 9npaired midline arteries ( celiac to foregut
( superior mesenteric to midgut
( inferior mesenteric to hindgut
,aor vessels of the nec;
8/12/2019 Anatomy for FRCA
11/38
6ight common carotid + branch of brachiocephalic ascends in carotid sheath and divides at level &4 into internal and external
*eft common carotid % direct branch from aortic arch
nternal carotid % main blood supply to intracranial structures enters s;ull through carotid canal 1= branches within the s;ull
ncluding anterior#middle cerebral# ophthalmic# posterior communicating Forms part of circle of willis.
$xternal carotid % main blood supply to head and nec; ' branches superior thyroid# ascending pharyngeal# facial# occipital# posterior
auricular before bifurcating within the parotid as the superficial temporal and maxillary.
,aor veins of head and nec;
$xternal ugular drains scalp# face drains into subclavian
nternal ugular runs from ugular foramen runs in carotid sheath to oin subclavian drains cranial vault
1. Describe with the aid of a diagram the blood supply to the brain.
8/12/2019 Anatomy for FRCA
12/38
2. Draw a cross section of the spinal cord.
3. What is peculiar about the blood supply of the spinal cord and at which area is it particularly at ris;.
4. *ist the structures through which your needle will pass whilst performing a neuroaxial bloc;.
!. Where is &-F form and describe its circulation throughout the &-.
)
8/12/2019 Anatomy for FRCA
13/38
rterial supply paired ( carotids and vertebral / which forms the basilar0
enous drainage dural sinuses to the internal ugular
&ircle of willis
-pinal cord
4!cm long cylindrical with flattening in lumbar region. extends as extension of medulla oblongata to lumbar region where it becomes
the conus medullaris. )hin thread extends to attach to coccyx as the filum terminale.
31 paired spinal nerve roots / > cervical 12 thoracic ! lumbar ! sacral and 1 coccygeal0
&auda eBuina % elongation of lumbar and sacral nerve roots prior to them leaving the intervertebral foramina.
$D- % usually between *1 ? *2 /neonate lower border of *3 vertebral body0
-tructure
6oughly circular in cross section. Flattened " aspect.
)wo indentations 1 anterior median fissure
2 posterior median sulcus / forms a septum further down0
&entral canal from 4thventricle continues throughout % enlarges at conus medularis
:rey matter
8/12/2019 Anatomy for FRCA
14/38
ascular supply
rterial nterior /single0 from vertebral arteries 2#3rds of supply
"osterior % paired from cerebellar arteries branches from nearby arteries.
6adicular arteries % branch to both anterior and posterior arteries artery of adam;iewicAG
enous series of venous plexuses which drain into aAygous# vertebral# lumbar and lumbrosacral veins.
8/12/2019 Anatomy for FRCA
15/38
,eninges 3 contiguous layers protect and support
rranged epidural space % dura % subdural space % arachnoid mater % subarachnoid space % pia mater applied to neural tissue.
$xtradural space /epidural0 separate dura from periosteuim triangular in cross section.
$xtends foramen magnum to sacral hiatus. sideways within spinal foramina.Depth 3+!cm from s;in surface extends 1mm cervical to 'mm lumbar
&ontents fat lymphatics arteries veins/valveless batsons plexus % communication of pelvic to cerebral veins0
Dura dense fibrous double layer % outer attaches to foramen magnum ? &2+3 extends to *!+-3.&overs filum terminale to attach at coccygeal periosteum
ttached anteriorly to posterior longitudinal ligament latteraly to foramina posterior surface is not attached.
-ubdural space potential space
rachnoid mater thin delicate
-ubarachnoid space contains &-F
"ia ,ater ascular connective tissue that closely envelopes neural tissuenterior )hic;end as linea splendensG
*ateral strands that attach to dura ( ligamentum denticulatum
"osterior incomplete attachment to dura by posterior subarachnoid septum
nferior to coccyx
&-F 1!=ml in total 2!ml in subarachnoid space
"roduced choroids plexus of lateral# 3rdand 4thventricles passes lateral C foramina of monro C 3rdvent C 4thvent C spinal cord via
Foramina of lush;a /lateral0 and magendie /medial0
bsorbed arachnoid villi in cerebral venous sinuses some in lymphatics.
"ressure gravity dependent '+1=ch when lying and 2=+4=cm in lumbar region when sitting.
&omposition osmo 2>= sp 1==! p< H.4 gluc 1+4 a 14=+1!= bicarb 2!+3=
cervical 12 thoracic ! lumbar ! sacral and 1 coccygeal0,ixed motor and sensory formed from fusion of anterior /ventral0 motor and posterior /dorsal0 nerve roots/ has ganglion0.
$xit via intervertebral foramina sheathed in meninges.
8ranches -mall meningeal branch to supply vertebral bodyDorsal and ventral rami
6ami communicantes ( branch to sympathetic chain
8/12/2019 Anatomy for FRCA
16/38
Dorsal posterior rami generally smaller divides medial and lateral branches. :$$6**5 dermatomal
$xcept 1stcervical ( dorsal ramus is totally ,)6 supplies suboccipital region
2ndcervical ( lerge medial branch /occipital nerve0 and smaller lateral branch
&occygeal % very small doesnIt divide and supplys s;in over coccyx.
entral anterior primary rami generally larger supply limbs and anterior# lateral torso-ome combine to form plexuses % cervical brachial lumbosacral
)
8/12/2019 Anatomy for FRCA
17/38
3. -uperficial branches + sensory to nec;
scending + lesser occipital &2
+ greater auricular &2?3Descending + supraclavicular nerves &3+4
)ransverse + anterior cutaneous nerve of nec; &2+3
4. Deep branches + motor to nec; ( anterior vertebral and contribution to scalenus medius
levator scalpulae sternomastoid and trapeAius
8rachial plexus
Formed ventral rami of &! %) 1 / can be contribution from &4 and )20
6oots ! pass between scalenus medius and anterior
)run;s 9pper &! ? ' J
,iddle &H J pass over first rib at lateral border divides
*ower &> ? )1 J
Divisions anterior and posterior occurs behind the clavicle
&ords dependent upon position around axillary artery
*ateral anterior divisions of upper and middle trun;s,edial anterior division of lower trun;
"osterior posterior divisions of all three trun;s
-urrounded by fibrous sheath from origin at scalene up to the axilla.
8/12/2019 Anatomy for FRCA
18/38
8/12/2019 Anatomy for FRCA
19/38
,aor nerves
1. median nerve superficial flexors abductor#flexor pollicis brevis opponens pollicis flexor pollicis longus and pronator.
2. 6adial nerve axillary deltoid and s;in over posteromedial upper arm
9pper arm triceps brachioradialis extensor carpi radialisForearm elbow oint wrist intercarpel oints ** extensor muscle of forearm /except carpi longus0
Dorsum of lateral 2+3 fingers
3. 9lnar nerve sensory ulnar half of palm and hand elbow oint flexi carpi ulnaris
8/12/2019 Anatomy for FRCA
20/38
8/12/2019 Anatomy for FRCA
21/38
Femoral nerve *2+4 formed within the psoas descends between psoas and iliacus entering the thigh lateral to the femoral artery.
-plits within the femoral triangle to anterior and posterior branches.
,uscles ( anterior branch to sartorius
( posterior branch to Buadriceps femoris
-ensory ( anterior % cutaneous and medial cutaneous nerve of thigh
( posterior % terminal saphenous
-aphenous nerve *6:$-) 86&< F F$,6* $6$Descends between sartorius and gracilis passing down medial border of tibia to end within the foot.
8/12/2019 Anatomy for FRCA
22/38
-acrococcygeal plexus wide variation exists
-acral plexus *4+! ? -1+4&occygeal -4?! and the coccygeal nerve
*4 ? ! forms lumbrosacral trun; at medial border of psoas
)ravels over pelvic brim to oin -1
entral rami -1+4 and -! and coccygeal oin the trun; within the pelvis.
8ranches 1. -uperior gluteal *4+! and -1
2. inferior gluteal *! -1?2
3. posterior cutaneous femoral nerve -1+34. "erforating cutaneoud -2?3
!. "udendal -2+4
'. -ciatic -2+4
&occygeal portion is small and forms anococcygeal nerve /-4?! and coccygeal/-;in over coccyx.
-ciatic nerve
*4+! and -1+3 passes through greater sciatic foramen % deep to gluteus maximus running posterior to acetabulum.6oute "oint midway between greater trochanter and ishial tuberosity it runs directly on the Buadriceps femoris passing
between two heads of biceps femoris.
)erminates as common peroneal and tibial nerves.
-upplys ,uscle semitendinous#membranous bicep femoris and part of adductor magnus ? Buads
-ensory hip and ;nee oint and s;in anterior thigh medial lower leg and foot.
)ibial nerve arises lower third thigh"asses through popliteal fossa leaving between heads gastrocnemius to run on posterior tibial border
$nters foot deep to flexor retinaculum
8ranches ,uscles popliteus gastrocnemius soleus plantaris plantars of foot
8/12/2019 Anatomy for FRCA
23/38
&ommon peroneal 6uns lateral part popliteal fossa wraps around head of fibula then divides
Deep anterior to tibia at an;le ,ucles ( extensors-ensory ( 1st? 2ndweb spaces
-uperficial % lateral surface of tibia and becomes anterior over an;le
-ensory % lower outer aspect of leg and dosrsum of foot.
Other nerves of note
1. ntercostal nerves derived ventral rami of )1+11
$merge intervertebral foramina and for a short distance lie between pleura and inner muscle layer.
)hen "ass posterior and below the intercostals arteries to run between the innermost and inner intercostals muscles.
Follows subcostal groove
8ranches &ollateral arises angle of rib and supplies underlying muscle*at cutaneous arises mid axillary line and supplys overlying s;in sensation
nt cutaneous arises anterior chest to supply s;in overlying.
typical forms )1 no cutaneous branches forms part of brachial plexus)2 *at cutaneous branch forms intercostobrachial and supplys s;in of upper arm.
)H+11 o abdominal branches
8/12/2019 Anatomy for FRCA
24/38
Autonomic nervous system
)ypically myelinated which emerge from &- synapse and then secondary 9,5$*)$D fibres pass on to end organs.
-- ganglia close to central nervous system cell bodies in lateral horn of spinal cord.
$xtends )1 % *2
&ervical ganglia usually 3
)horacic usually 12
*umbar usually 4
-acral usually 4
8 1. -tellate ganglia &H+)1 close relationship with sympathetic chain"osition % between transverse process of &H and 1strib about 3cm above sternoclavicular oint
8loc; head full extension needle right angles to s;in hit transverse process about 3cm inect
Why painful arms &6"- post herpetic."roduces
8/12/2019 Anatomy for FRCA
25/38
Parasympathetic nervous system
&ranial nerves 7 and 7
Function pupilaary constriction salivation lacrimation cardiac inhibitory bronchoconstriction and stimulates intestinal motor activity.
-acral formed ventral rami of -2+4
Function rectal and bladder motor function genital vasodilatation.
$dinger westphal nucleus
Where opiates cause miosiscts via occulomotor nerve.
Vertebral column
)ypical vertebra anterior body and posterior nural arch lumbar are largest bodies separated by fibous disc
rch connected to body by two strong pedicles.
"edicles have inferior and superior articulation facets which articulate via synovial oints.ural arch completed posteriorly by two bony lamina oining at spinous process.
)ransverse process provides additional attachment area for muscles.
&ostal processes well developed in the thoracic region.
tlas no true body ring of bone supports weight of s;ull and articulates with occipital condyles and inferior facets with axis.
lso % has rounded facet on anterior arch to articulate with odontoid peg.
-;ull roc;s bac; and forward on atlas.
8/12/2019 Anatomy for FRCA
26/38
xis allows head to rotate odontoid attached to occipital bone by apical ligaments
*aminae strong and transverse processes are short.
&H vertebrae prominens
*argest cervical occasional cervical rib is seen.
)horacic vertebrae has articulations for the ribs
-pinous processes generally slender long and downward pointing.
8/12/2019 Anatomy for FRCA
27/38
*umbar vertebrae largest lac; costal facets bodies large and ;idney shaped pedicles short and strong superior and inferior articulating facets
are vertical
*! % body is wedge shaped.
-acrum fusion of ! sacral vertebrae central axis of pelvis
rticulates above ( *!
-ides ( innominates at sacroiliac oints8elow ( coccyx
s concave anteriorly and wedge shaped.
Foramina 4 pairs
&anal contains cauda eBuine
Filum treminale-pinal meninges&occygeal#sacral nerves
$pidural fat and veins
8/12/2019 Anatomy for FRCA
28/38
-acral hiatus failure of fusion of 4th!thsacral laminae
&overed by sacrococcygeal ligament
&audal anaesthetic given by finding eBualteral triangle from posterior superior iliac spines and sacral hiatus
ertebral ligaments 1. ntervertebral iscs % 2!E of vertebral height outer annulus fibrosus inner annulus pulposus surfaces of vertebral bodieslined with hyaline cartlage ti allow adhesion to discs.
2. nterior longitudinal ligament % runs anterior surface of vertebral bodies and discs &2 % sacrum
3. "osterior ligament % attached disc and vertebral bodies.
4. *igamentum flava % thic; elastic vertical ligaments connecting adacent laminae.
!. nterspinous ligaments shafts of spinous processes.'. -upraspinous % tough fibrous connects tips of spinous processes.
H. ligamentum nuchae superior extension of supraspinous ligament % from &H to occiput.
8/12/2019 Anatomy for FRCA
29/38
)he s;ull
Fossa 1. "osterior % largest and deepest anterior borders are sphenoid temporal "osterior laterally by occipital bones..)ransverse sinuses create the deep grooves running laterally the occipital prominence lies centrally extending to
the attachment of the falx cerebelli.
&ontains % medulla pons cerebellum 8$*W tentorium cerebelli and occipital lobes above
Foramina 1. internal acoustic ( facial# vestibulococchlear nerves and labarynthine vessels
2. ugular ( glossopharyngeal vagus and accessory nerves ugular vein
3.
8/12/2019 Anatomy for FRCA
30/38
8/12/2019 Anatomy for FRCA
31/38
8/12/2019 Anatomy for FRCA
32/38
Thoracic inlet
s roughly ;idney shaped
8ound nterior superior manubrium
"osterior anterior surface of first vertebral body
*aterally first rib and cartilages
*ung apex proects 3cm above clavical
grooved anteriorly by subclavian artery
posteriorly by stelleate ganglion superior intercostal artery and first thoracic ventral rami
1. scalenus muscles 3 of them ( anterior# medius and posterior
ntreior + originates from &3+' passes to scalene tubercule of first rib
+ lies 8$
8/12/2019 Anatomy for FRCA
33/38
2. First rib shortest flattest most curved.
natomy head with facet for body of )1ec; and tubercle for transverse process )1
)he intercostal space
1. ,uscles 1. $xternal intercostals ( 11 pairs outer most layer.
"asses % lower border upper t upper border of lower rib
8ecomes more tendenous towards chondral margins
2. nternal ( 11 pairs fibres run at right angles to external intercostals
$xtends % fron sternum to angle of rib becoming more tendinous.
3. nnermost ( largely incomplete. umerous slips of muscle continuous fascial sheet.
-eparated from pleura by endothoracic fascia
2.eurovascular bundle ( /top to bottom0
1. eins % anterior veins drain into musculophrenic or internal thoracic and posterior drains into hemi+aAygous.
2. rteries % nterior % )1+K ( from branches subclavain
+ "osterior % from thoracic aorta )3+11 and from superior intercostal artery for )1 nd )2.
)$ )1= and )11 only supplied by posterior intercostal artery.
3. erves entral rami )1+11
)H % )11 within internal and innermost layers+ continuing to supply abdominal wall as well.
6ami communicantes ( -- chain&ollateral ( to intercostal muscle and pleura
*ateral cutaneous ( lateral s;in wall and muscels
nterior cutaneous ( anterior wall and muscles
8/12/2019 Anatomy for FRCA
34/38
)he abdominal wall
$xtends xiphy sternum at )K to iliac crest# inguinal ligament and pubis symphysis inferiorly.
9mbilicus % dermatome )1= and *3 vertebral body.
1. ,uscles a0 abdominal rectus
6ectus sheath % contains muscle superior and inferior epigastric vessels terminal nerves of )H+)11.
b0 $xternal obliBue is outer most wall.
$xtends linea alba to pubis#iliac crest and rib insertionsFibres run down and medial
8/12/2019 Anatomy for FRCA
35/38
c0 nternal obliBue is inner to external obliBue
continuation of internal intercostals above.
Fibres run upwards and lateral
d0 )ransverse abdominis is innermost muscle with horiAontal fibres
8lood supply
,aority ( inferior epigastric from external iliac
-uperior epigastric from internal thoracic artery.
erve supply
entral rami )H to *1
8/12/2019 Anatomy for FRCA
36/38
Inuinal canal
$xtends deep inguinal ring /opening trabsversalis fascia0Down medially to superficial ring /external obliBue fascia opening0
nguinal ligament % extends from pubic tubercle to anterior superior iliac spine.
8oundaries nterior aponeurosis external obliBue"osterior common tendon of internal obliBue
Floor inguinal ligament
6oof fibres of transverses abdominis and internal obliBue.
&ontents ,*$ ilioinguinal nerve spermatic cord /vas deferens# testiculat artey# pampiniform plexus# genital branch ofgenitofemoral0
F$,*$ ilioinguinal nerve and round ligament
8/12/2019 Anatomy for FRCA
37/38
Paravertebral space
8oundaries anterior ( parietal pleura,edial ( vertebral body disc and vertebral foramen
bove and below ( head and nec; ofribs
-uperiorly ( transverse vertebral ligament
&ontents fat vessels and spinal nerve roots
8loc; indications ( rib fractures thoracic surgery breast surgery cholecystectomy
&an use catheter for prolonged analgesia
,ethod 1. "t sitting or lying on side operative side upper most.
2. full asepsis
3. spinous process of appropriate vertebra
4. 2.! cm lateral needle inserted perpendicular to s;in.!. dvance until hit transverse process 2+!cm
'. ngle needle cephalad and wal; off of upper surface. dvancing 1+2cm.
H. *oss of resistance or parasthesia along intercostals nerve.
>. nect !+1!ml of local anaesthetic high volumes may bloc; 3+! dermatomes.
&omplications 1. Failure
2. ntra+pleural inection
3. "neumothorax
4.
8/12/2019 Anatomy for FRCA
38/38
Antecubital fossa