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Pleura Pericardium
Pleura Pericardium
Pleura Pericardium
PERICARDI
UM,
DR NWOSU C.I.A. MA,
MSc, MBBS, MD.
LEARNING OBJECTIVES
TO KNOW THAT :
The lungs and heart develop and invaginate into their respective
sacs which form functional coverings for them(visceral & parietal),
The potential spaces included between the layers of these sacs
may become real spaces in certain disease processes,
The cervical part of Parietal pleura extends into the root of neck
& is vulnerable there
Innervation & vasculature: The visceral part of the coverings of
the heart and lungs tend to be supplied along with the viscera, and
the parietal with the wall (pariety),
Pericardium and Pericardial sinuses are clinically useful spaces
between the great vessels : pericardial effusion and cardiac
tamponade,
Costomediastinal recess is clinically useful in relieving pericardial
effusion,
In stab injuries of the abdomen, and in surgeries of the
kidneys and spleen, the lungs may be injured,
Terminology/vocabulary
THORAC
IC
CAVITY
PLEURA
PLEURA is a serous membrane which is lined by
mesothelium (epithelium that covers all serous
membranes), and associated supporting connective tissue
There are 2 pleural sacs, one on each side of mediastinum,
Pleura is divided into two major types based on location;
parietal or wall pleura & visceral or organ pleura,
Each pleural sac is invaginated from the mediastinal side
by the lung,
Universal : In the same way, the heart, gut
tube/derivatives, testes and ovaries invaginate their
respective sacs,
There are 2 layers of pleura : VISCERAL (organ related) &
PARIETAL (wall related),
The Parietal pleura is described in 4 parts : cervical,
costal, mediastinal & diaphragmatic
Visceral pleura
heart
SURFACE MARKINGS OF
PLEURA
SL
Bare area of
the pericardial
sac
Anterior View
MAL
MCL
VL
A pleura is
A. Serous membrane
B. Mucous membrane
C. Superficial fascia
D. Deep fascia
A pleural recess is
A. Ventricles and chambers of the
lung
B. Spaces between serous and
fibrous layers
C. Spaces between parietal and
visceral layers
D. Spaces between viscus and
visceral layer
Normal
Pleural effusion
WHY POSTERIOR
THORACOCENTESIS IS NOT A
VIABLE OPTION
A STAB WOUND & IATROGENIC
INJURY
LUNG
D
K
s
THORACOCENTESIS
A thoracocentesis for pleural
effusion at the midaxillary line is
best performed in which
intercostal spaces?
A. Sixth and seventh
B. Seventh and eighth
C. Eighth and ninth
D. Ninth and tenth
PERICARDIUM
Pericardium is a
fibro serous sac
which encloses the
heart and the roots Branches of
aortic arch
of the great
vessels,
It is situated in the
middle
mediastinum,
There are two sacs Sternum
of pericardium:
- outer single-layered
fibrous
pericardium, &
- inner double
layered serous
pericardium.
Trachea
First rib
Left lung
Fibrous
pericardium
Thoracic
Diaphragm
Outer parietal layer is fused inseparably with fibrous pericardium, and the
inner visceral pericardium forms the epicardium of the heart,
The two layers are continuous at the root of the great vessels,
Between the parietal and visceral layers is the potential space known as the
pericardial cavity,; contains a thin film of fluid that allows movement of the
heart,
PERICARDIUM
Phrenic
nerve
Pericardia
l branch
Intercostal
nerve
INNERVATION
OF
PERICARDIUM
CLINICAL APPLICATION OF
PERICARDIAL SINUSES
TRANSVERS
E : ligation in
cardiac
surgery &
stoppage of
bleeding
OBLIQUE :
dead space
for LT atrium
APPLICATION ;
Surgery
Potential
space
CLINICAL APPLICATION OF
PERICARDIAL SINUSES
TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Cardiomegaly
PERICARDIOCENTESIS
CAUTION : Any patient who
comes in with shock and
penetrating chest injury has
cardiac involvement until
otherwise proven,
ACUTE/CHRONIC : can take only
100 ml to produce acute features,
but chronic type as in
hypothyroidism, can take as much
as 500 ml or more to produce
symptoms,
BECKS TRIAD : Cardiac
tamponade presents with a triad of
Hypotension, Jugular distension &
muffled heart sounds,
PERICARDIOCENTESIS :
infrasternal angle
PERICARDIOCENTES
IS
DRAINAGE
TEST ON DRAINAGE
Insertion of a needle for
pericardiocentesis is best
performed through which
route?
A. 5th right intercostal space
B. 5th left intercostal space
C. 6th right intercostal space
D. 6th left intercostal space
E. Left infrasternal angle
E. Right infrasternal angle
PNEUMOTHO
RAX
DEFINITION : presence of air in pleural space
TYPES :1. spontaneous, traumatic & tension
Spontaneous : occurs without antecedent
trauma
- primary :no underlying lung disease
- secondary : presence of underlying lung
disease
Traumatic : due to penetrating or nonpenetrating injury
Tension : a one-way valve that
maintains a positive pressure in the
pleural space high throughout the
respiratory cycle. Positive pleural
pressure is a medical emergency
because it is life-threatening,
PHYSICAL FINDINGS : hemithorax is
enlarged, and mediastinum is pushed
MANAGEMENT : insert a wide-bore needle
immediately in the 2nd ICS anteriorly, and
leave it there until a thoracotomy tube is
inserted.
PNEUMOTHORAX
In sucking
pneumothorax air
enters and leaves.
But in tension
pneumothorax air
enters but does not
leave. What will be the
fate of this patient?
PRACTICE QUESTIONS
A tumor seen in a radiograph at the level of sternal angle
would likely affect which structures in the thoracic cavity?
A tumor in posterior mediastinum may involve which
structures?
A tumor located just superior to the root of right lung is
likely to obstruct which vein?
Insertion of a needle for pericardiocentesis is best
performed through which route?
What is Pancost tumor, and what are its effects?
Where is pleural effusion located, and how do posture and
gravity affect it?
A Marfans patient with aneurysm of the arch of aorta is
likely to experience compression of which structure (s)?
A thoracocentesis for pleural effusion at the midaxillary
line is best performed in which intercostal spaces? Would
you drain a pneumothorax at same site?
Which structure transit the thoracic diaphragm through
the esophageal hiatus?
EMBRYOLOGIC ORIGIN OF
SEROUS MEMBRANES
SEROUS MEMBRANES :
serous pericardium, serous
pleura, serous peritoneum,
- parietal layer from
somatopleuric (somatic) part
of lateral plate mesoderm,
- visceral layer from the
splanchnopleuric (visceral)
part of lateral plate
mesoderm
FIBROUS PERICARDIUM:
from pleuropericardial
folds/membranes
LINES OF PLEURAL
REFLECTION
Vertebral line
RECESSES OF
PLEURA
THESE ARE RESERVE SPACES : for the expansion of the lungs during deep
inspiration,
COSTOMEDIASTINAL RECESS : Lies anteriorly behind the sternum /costal cartilages,
and between costal and mediastinal pleura,
COSTODIAPHRAGMATIC RECESS : Lies inferiorly between costal and diaphragmatic pleurae,
Bare area
Costal pleura
CLINICAL CORRELATES OF
PERICARDIUM
OTHERS
CARDIAC TAMPONADE