Veins: Neck Veins

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To assess central venous pressure and right atrial hemodynamics.

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Veins: Neck Veins

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

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