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Veins: Neck Veins

Veins: Neck Veins




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To assess central venous pressure and right atrial hemodynamics.



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    Veins: Neck Veins Veins: Neck Veins Presentation Transcript

    • Veins: Neck Veins To assess central venous pressure and right atrial hemodynamics.
    • Method Of Exam
      • Inspect for internal jugular vein pulsations in the neck, in supine position and with neck and trunk raised to approximate angle of 45o.
      • Internal jugular vein pulsation are visible at the root of the neck between clavicular and sternal heads of sternoclidomastoid muscle.
      • Internal jugular vein corresponds to a line drawn from this point to infra auricular region.
      • Inspection with simultaneous palpation of the carotid and/or auscultation of the heart will assist in identification and timing of the waves. Inspect the vein from different angles.
      • Apply light tangentially and observe for venous pulsations in the shadow of neck on the pillow.
      • At 0o jugular veins should be filled.
      • An impulse visible just prior to S1 or the upstroke of the carotid is the "a-wave".
      • This will be followed by a x-descent . The 'c' wave is usually not visible.
      • The 'v' wave occurs after the start of the carotid upstroke and during ventricular systole (which is atrial diastole). When the tricuspid valve opens there is a brisk descent (y-descent).
      • Observe the venous pressure changes with respiration.
      • There is normally a drop in intrathoracic pressure with inspiration.
      • This decrease is also reflected on the intracardiac pressures.
      • Therefore, an increase in the pressure difference between the SVC/IVC and the RA increases cardiac filling.
      • Normal:  
      • Neck veins are not visible at 45 o inclination.
      • Neck veins should be visible in supine position. 
      • JVP should decrease with inspiration.
    • Abnormal Finding
      • Neck vein distension at 45 o inclination is abnormal and is indicative of increased central venous pressure.
      • Describe the level to where the pulsations are seen in relationship to the angle of Louis. Note the effect of inspiration .
      • Apply gentle pressure to right upper quadrant and note its effect on neck veins ( hepatojugular reflux ).
      • If neck vein distension is present identify a, c and v waves and describe their amplitude .
      • Distended pulsatile neck veins ( CHF, Tricuspid insufficiency)
      • Hepatojugular reflux : Right ventricular non-compliance to increased filling
      • Distended non- pulsatile neck veins : ( SVC syndrome , cardiac tamponade, Constrictive pericarditis). These patients usually have prominent descents.
      • Quick Y descent and X descent: (Constrictive pericarditis)
      • Distended veins during expiration only : (COPD, Asthma)
      • Prominent "a" wave : "a" waves are due to atrial contraction and when abnormally prominent indicate atrial contraction into a noncompliant right ventricle or through a stenotic or closed tricuspid valve. In complete heart block and with premature ventricular contraction there is loss of a-v synchrony. When the atrial and ventricular contractions coincide a prominent wave is seen. This is called cannon a-wave. A noncompliant right ventricle can be hypertrophied (secondary to pulmonary hypertension) or "stiff" due to scar (ischemia/infarct) or infiltrative disease (amyloid).
      • JVP which increase with inspiration indicate restricted filling of the right sided chambers (Kussmaul's signs).
      • Absent "a" waves : (Atrial fibrillation).
      • "v" waves are most commonly due to an insufficient tricuspid valve with the ventricular systolic pressure reflected in the atrium during atrial filling (diastole).
      • Prominent "v" wave : (Tricuspid regurgitation).
      • Cannon wave : (Heart block, Premature ventricular contraction).
    • Knowledge Base
      • Anatomy of neck veins
      • Internal jugular vein
        • Deep behind sternoclidomastoid muscle
        • From the angle between sternal and clavicular head of sternomastoid to angle of neck
      • External jugular vein
      • Clinical methods for estimation of central venous pressure.
      • Physiology of a, c, v waves.
      • a: atrial contracion
      • v: venous filling
      • x descent: atrial relaxation
      • y descent venous emtying
      • c: not easily visible
      • Effect of respiration and pleural negative pressure on atrial filling.
      • Increased intrathoracic negative pressure facilitates venous return and filling of atrium
      • Hence neck veins decrease in height during inspiration
      • Conditions causing venous distension and prominent a or c or v waves.
      • Anatomical relationship to neck muscles and carotid artery.
      • Hepatojugular reflux.
      • Resources : Bates, A Guide to Physical Exam .
      • “ Nurses Informations”
      • http://nursesinformations.blogspot.com