Lecture 4 Flashcards
Describe the Angle of Louis/Trans-Thoracic Plane TIV/TV?
Plane between TIV and TV. Manubrio-sternal angle at the front. Use it to find lots of things i..e jugular venous pressure and how much fluid a person has.
What will you find int he Trans-thoracic Plane?
The arch of aorta, the azygos vein arch (will drain into SVC), the trachea will also bifurcate into left and right main bronchi, ligamentum arteriosum (joins pulmonary trunk to aorta), the pulmonary trunk bifurcates into left and right pulmonary arteries, the thoracic duct has made its way to the left hand side of the oesophagus, and measure the jugular venous pressure (JVP).
Describe the great veins in the neck?
The SVC drains into the RA, the azygos vein drains into the SVC. The left and right brachiocephalic veins meet and join to become the SVC. The two veins that make up the brachiocephalic veins are the internal jugular vein (coming down from the neck) and the subclavian vein (coming underneath the clavicle) - the external jugular vein also drains into the subclavian vein. With the manubrium back in place, the veins are tucked in behind the manubrium. This is not the case in kids. The brachiocephalic veins are exposed above the manubrium, so you need to be careful.
What are the vessels used for central lines?
The internal jugular vein and the subclavian vein.
Describe the arteries?
Coming out of the LV is the arch of the aorta (everything coming off the arch of the aorta is part of the superior mediastinum). The arch will give off 3 vessels (one to the right and 2 to the left). The first branch is the brachiocephalic trunk. The second branch is the left common carotid artery 9which will head up into the neck). The third branch is the left subclavian artery. The thoracic aorta then starts to descend. The brachiocephalic trunk branches into 2 - right common carotid and right subclavian artery. The subclavian (both left and right) each will drop off a branch, which runs down anteriorly - internal thoracic arteries (run down each side of the sternum).
Describe the phrenic nerves?
The left vagus will come down and give off a branch near the arch of the aorta. It wraps around the aorta and heads back up (recurrent - left recurrent laryngeal nerve) - this nerve heads up to supply the larynx. The right recurrent laryngeal nerve wraps around the right subclavian. Anyone with a change of voice that lasts for a couple months, could mean damage to laryngeal nerve - this could indicate aneurysm to the aorta. The bulk of the vagus heads backwards and wraps itself around the oesophagus (forms a mesh and passes into the abdomen to provide parasympathetic supply). The right phrenic nerve is found posterior to the hilt of the lungs.
What is a central line?
A canula that you will put in and deliver whatever you have in it close to the heart as possible. You want it to be as close to the SVC as possible. Most of the time peripheral lines are fine (when things you don’t need in a hurry - i.e. not emergency situation).
Describe the pros using the internal jugular vein as a central line?
Relatively easy to find, it’s not covered with bone and quite reliable.
Describe the cons using the internal jugular vein as a central line?
Can get arterial injury (carotid artery - risk sending a clot up to the brain). Uncomfortable and not good for long term. Hard to do chest compressions (in terms of emergency situation) and intubation.
Describe the pros using the subclavian vein as a central line?
More comfortable for a patient and can often do it whilst doing an airway.
Describe the cons using the subclavian vein as a central line?
More often than not you can get an arterial injury, and you can’t compress it to stop it from bleeding. There is a risk of a pneumothorax, and more difficult to put in due to the angle of it. Need to worry about where the brachial plexus is sitting (brachial plexus injury).
Describe the pros using the external jugular vein as a central line?
Can see it easier (as it is more superficial - thus easier to find). Due to where it is positioned there is decreased risk of pneumothorax. Due to it being a smaller vein, the risk of bleeding is a lot less. Can even use it when there is a clotting problem.
Describe the cons using the external jugular vein as a central line?
It is difficult to thread (to get the line into the vein). It is uncomfortable.
Describe the pros using the femoral vein as a central line?
Can do CPR, intubation. Can find it really easily and get a big line in really fast and you can find it fast. More used for a vein that will be in for 24hours or so.
Describe the cons using the femoral vein as a central line?
This region is less sterile, so hard to keep the veins sterile. If the patient is conscious and awake - mobilisation is a problem. There is a clot risk using the femoral vein - pulmonary embolism.
