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Anatomy for FRCA

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    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

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    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

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    ,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.

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    iew of the laryngx at laryngoscopy

    ppropriate anatomy for percutaneous tracheostomy insertion

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    1. Describe the landmar;s of the respiratory tree with respect to the relevant vertebral body.

    2.

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    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

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    &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.

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    1. Describe the coronary circulation

    2.

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    *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

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    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;

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    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.

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    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 &-.

    )

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    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

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    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.

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    ,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

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    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

    )

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    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.

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    ,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

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    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.

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    -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

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    &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

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    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

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    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.

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    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.

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    *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

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    -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.

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    )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.

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    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$

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    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

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    )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

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    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

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    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

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    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.

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    Antecubital fossa


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