Procedural anatomy Flashcards
Internal jugular vein originates?
Jugular bulb (confluence of the inferior petrosal sinus and sigmoid sinus)
* exits the skull via the jugular foramen
How does the IJ descned in the neck? Relationship to the carotid?
- Descending laterally to the internal carotid and later common carotid in the carotid sheath
- To ICA
◦ At C2 - IJV posterior to ICA
◦ At C3 posterolateral
◦ From C4 anterolateral (common carotid) at the apex of sedilots triangle between he two heads ot the SCM
Where does the IJ terminate
- Terminates behind the sternal end of the clavicle where it joins the subclavian vein to form the brachiocephalic vein - the inferior end dilates to from the inferior bulb of the IJV which has a bicuspid valve permitting blood flow toward the heart
How is the path of the left and right IJ slightly different?
- Right IJ follows a direct course inferiorly to the SVC
- The left IJ courses to the right after it joins the subclavian vein to become the brachiocephalic vein which courses inferiorly as it joins the SVC
Tributaries to the IJ vein (4 primary)
- inferior petrosal sinus - enters superior bulb of the IJV after leaving the jugular foramen
- Facial vein - empties at the level of the hyoid, may receive the superior thyroid, lingual or sublingual veins
- Lingual veins - at the origin of the lingual artery
- Pharyngeal veins - from venous plexus of the pharyngeal wall emptying at the angle of the mandible
- Superior and middle thyroid veins
- The occipital vein may drain into the IJV
Anterior borders of the IJ vein
- Anteriorly - SCM, fascia, platysma, fascia, skin
Posterior borders of the IJ vein
- Posterior - lateral mass of C1 (transverse process), scalene muscles, cervical plexus, sympathetic chain, phrenic nerve, vertebral vein, 1st part o subclavian artery, and lung pleura (thoracic duct on left)
Medial borders of IJ vein
- Medially by internal carotid, thyroid, trachea, oesophageal
Lateral borders of the IJ vein
- Lateral - fascia, skin, SCM
Name 4 major relationships of the IJ vein and describe their relative passage
- To ICA
◦ At C2 - IJV posterior to ICA
◦ At C3 posterolateral
◦ From C4 anterolateral (common carotid) at the apex of sedilots triangle between he two heads ot the SCM - Vagus nerve - posteriorly in the carotid sheath between the carotid and the IJV; 9th to 12th cranial nerves above common carotid artery and vagus
- Cervical sympathetic plexus and phrenic nerve posterior to carotid sheath behind the ICA in the prevertebral layer of the deep cervical fascia
- Deep cervical lymph nodes close to vein
- External jugular crosses the sternomastoid belly of the SCM running posteriorly and more superficial to the IJV - later perforating the deep fascia to drain into the subclavian vein
- PLeura rises above the clavicle and is close to the vein at its termination
- Thoracic duct passes inferior and lateral to the confluence of the L IJV and SCV (as it joins on the superior margin of the subclavian vein near the jugular-subclavian junction) and may be injured during LEFT IJV cannulation - the right lymphatic duct can also be injuries during R cannulation but due to its smaller size this is less common
What is the triangle used to ascertain surface anatomy of the IJ vein
- Sedillots Triangle formed from 2 heads of SCM (sternal heat medially, clavicular heat laterally) and clavicle superior border of medial third - enter at the middle of the triangle
What is Sedillots triangle? Describe its makeup
- Sedillots Triangle formed from 2 heads of SCM (sternal heat medially, clavicular heat laterally) and clavicle superior border of medial third - enter at the middle of the triangle
If you use Sedillots triangle for insertion of an IJ describe the surface anatomy for insertion
- Sedillots Triangle formed from 2 heads of SCM (sternal heat medially, clavicular heat laterally) and clavicle superior border of medial third - enter at the middle of the triangle
- Palpate the artery and entry site is lateral to this at approximately C6
- Aim caudally, 30 degree angle to frontal plane parallel to sagital plane and towards ipsilateral nipple
Descibe the USS characteristics of the IJ
Ultrasound - deep to SCM thin walled, non pulsatility and compressible. Either halfway between clavicle and mastoid, or 1/3 of the way up from the clavicle (i.e. slightly lower). Too low and risk of pneumothorax increased but increased separation from carotid, too high and in beard, difficult to dress neatly, carotid closer.
Central approach to the blind IJ insertion technique?
- Central - apex of triangle formed by each muscle belly of the SCM and the clavicle, insert 1cm above apex of head of SCM and clavicle advancing 60cm to skin aiming towards ipsilateral nipple (45 degrees off a coronal plane, needel advaned in a sagital plane) with aspiration of blood at 3cm
Anatomical variations of the IJ vein
Anatomical variations
* Variation in its relationship to the carotid artery - further lateral, or medially overlying the carotid artery anteriorly
* Partial or complete duplication
* Stenosis or occlusion
* Intraluminal membranes, webs or inverted valves
* Congenital aneurysm
* Absent IJV
Describe the path of the external jugular vein
- Crosses SCM sternomastoid belly running posteriorly and more superficial to the IJV later eprforating the deep fascia to drain into the subclavian vein
Origin of the subclavian vein
a direct continuation of the axiliary vein beginning at the lateral border of the first rib as the vein passes deep to the clavicle
Course of the subclavian vein
- The subclavian vein travels medially superficially and superior to the first rib forming a slight groove, posterior to clavicle
- Arches up, medially then down to its termination
- Turns infero-medially entering thoracic inlet into the mediastinum passing anteiro the scalenus anterior
Landmarks on surface anatomy of the subclavian vein
◦ Clavicle
◦ Two muscle bellies of SCM
◦ Suprasternal notch
◦ Deltopectoral groove
◦ Manubrosternal junction
Describe the infraclavicular approach to a subclavian line?
◦ Insert the needle a 1-2cm inferior and lateral to (Deltoid tuberosity of clavicle) junction of medial third of clavicle, 2-3cm inferior to deltopectoral groove aiming towards suprasternal notch (non dominant index finger stays in the supraclavicular notch) and keep neelde parallel to floor
‣ Needle should pass under the junction o the medial 1/3 and lateral 2/3 of the clavicle and directed at index finger/supra sternal notch or just superior
What critical safety aspects to blind insertion of a subclavian line do you need to be aware of? 2 things to never do
- Never angle posteriorly - artery or lung
* Never angle inferior - lung
* Puncture reasonable distance from the clavicle else you’ll never get under it - the more medial you come the more it opposes the pleura
Layers of insertion for a subclavian line
‣ Skin
‣ Subcutaneous fat
‣ Clavicular head of pectoralis major
‣ Clavipectoral fascia enclosing subclavius
‣ Subclavian vein
‣ Further insertion would penetrate scalenus anterior –> subclavian artery/brchial trunk plexus –> pleura
How does the subclavian vein relate to the artery?
◦ Runs together with artery deep to vein throughout course - superior and posterior
◦ Subclavian artery is separated from subclavian vein by scalenus anterior - artery posterior to same
How does the subclavian vein relate to the brachiocephalic plexus
◦ Subclavian artery associated with trunks of brachial plexus posterior to scalenus anterior muscle
◦ Superior and posterior to medial portion of subclavian artery
Subclaivan vs thoracic duct relations
◦ Drains into the subclavian vein ner the junction with the internal jugular vein
Give 4 critical structures you need to be mindful of in surrounding anatomy when isnertion a subclavian line
- Subclavian artery
◦ Runs together with artery deep to vein throughout course - superior and posterior
◦ Subclavian artery is separated from subclavian vein by scalenus anterior - artery posterior to same - Brachiocephalic plexus
◦ Subclavian artery associated with trunks of brachial plexus posterior to scalenus anterior muscle - Thoracic duct
◦ Drains into the subclavian vein ner the junction with the internal jugular vein - Lung - deep and inferior to medial subclavian vein - the dome of the left often extends above the level of the first rib
- Brachial plexus
◦ Superior and posterior to medial portion of subclavian artery
What are the superior relations to the subclavian vein
- superior relations - midpoint of clavicle, superior and posterior subclavian artery, thoracic duct medially, phrenic nerve, lower tunk of brachial pleux laterally
What are the inferior relations to the subclavian vein
Lung and first rib
Anterior relations to the subclavian vein
skin, external jugular, posterior border of clavicle, subclavius muscle
Medial relations to the subclavian vein
- Medial relations - fascia, trachea, brachiocephalic artery, vagal trunk, thoracic duct, oesophagus medial and posterior
Lateral relations to the subclavian vein
Inferior trunk of the brachial plexus
Posterior relations to the subclavian vein
first rib, anterior scalene, phrenic nerve, pleura/apex of lung superiorly, and first intercostal space inferiorly, internal mammary artery
Termination of the subclavian vein occurs where? Left to right differences
- Terminates posterior to the sternoclavicular joint at the medial border of scalenus anterior where it joins the IJV to form the brachiocephalic vein
- LEFT brachiocephalic vein continues inferomedialy crossing the midline before joining the contralateral brachiocephalic vein at the 1st costal cartilage to become the SVC
- Left subclavian - Arcs through the innomninate vein tot he SVC in a gentle curve
- Right subclavian - Sharper angle into the SVC as it joins the IJV
Femoral vein outline - origin, termination, course
Femoral vein is a direct continuation of the popliteal vein and takes a superficial course at the femoral triangle before passing beneath the inguinal ligament to become the external iliac vein
Femoral triangle is otherwise known as?
Scarpa’s triangle
Superior part of the triangle
Base - inguinal ligament from pubic tubercle medially to ASIS laterally
Medial part of femoral triangel
Medial border of adductor LONGUS
Lateral part of femoral triangle
Sartorius
Apex of femoral triangle made up of
Sartorius crosing adductor longus
Floor of femoral triangle
Ilipsoas lateral, pectineus medially
Roof of the femoral triangle
skin —> subcut tissue —> superficial fascia —> deep fascia
Contents of the femoral triangle
NAVEL) nerve, artery, vein,empty space, lymph node
Describe the make up of the femoral triangle
Femoral triangle (Scarpa’s triangle)
* Superior (base of triangle)
◦ Inguinal ligament - running from the pubic tubercle medially to ASIS laterally
* Medial - medial border of adductor Longus
* Lateral - Sartorial muscle
* Apex - sartorius crossing adducotr longus
* Floor - iliopsoas (lateral), pectineus (medial)
* Roof - skin —> subcut tissue —> superficial fascia —> deep fascia
Femoral sheath is what? Created by what fascial layer? What is in it?
Contents of femoral triangle (NAVEL) nerve, artery, vein,empty space, lymph node
* Femoral nerve
* Femoral sheath - conical fascial sheath continuous with transversalis fascia of the abdomen and formed from fusion and invagination of psoas and transversalis fascia
◦ Femoral artery - lateral - it passes under the inguinal ligament at the midpoint between the ASIS and pubic tubercle
◦ Femoral vein - medial
Where does the femoral artery pass relative to the inguinal ligament
Contents of femoral triangle (NAVEL) nerve, artery, vein,empty space, lymph node
* Femoral nerve
* Femoral sheath - conical fascial sheath continuous with transversalis fascia of the abdomen and formed from fusion and invagination of psoas and transversalis fascia
◦ Femoral artery - lateral - it passes under the inguinal ligament at the midpoint between the ASIS and pubic tubercle
◦ Femoral vein - medial
Origin of the femoral vein
- Originates - continuation of the popliteal vein as it passes through the adductor opening
Where does the femoral vein travel in the thigh
- Lies in the intermediate compartment of the femoral sheath
- ◦ In distal adductor canal - vein posterolateral to superficial femoral artery
◦ Proximally in the canal - vein posterior to artery - Terminates at the inguinal ligament as the external iliac vein
Where does the femoral vein terminate
- Lies in the intermediate compartment of the femoral sheath
- Terminates at the inguinal ligament as the external iliac vein
4 major tributaries into the femoral vein
◦ Numerous muscular tributeries
◦ Profunda femoral vein joins the fmeoral vein posteriorly 4-12cm distal to inguinal ligament
◦ Greater saphenous vein enters anteriorly or anteromedially 1-3cm distal to the inguinal ligament draining at the saphenofemoral junction in the femoral triangle
‣ Pierces saphenous hiatus of the deep fascia of the thigh before draining
‣ 99% veinous valve 1-2mm distal to saphenofemoral junction
◦ Lateral and medial circumflex femoral veins
What is the most important vein in reference to the femoral vein when inserting a femoral line
Greater saphenous
◦ Numerous muscular tributeries ◦ Profunda femoral vein joins the fmeoral vein posteriorly 4-12cm distal to inguinal ligament ◦ Greater saphenous vein enters anteriorly or anteromedially 1-3cm distal to the inguinal ligament draining at the saphenofemoral junction in the femoral triangle ‣ Pierces saphenous hiatus of the deep fascia of the thigh before draining ‣ 99% veinous valve 1-2mm distal to saphenofemoral junction ◦ Lateral and medial circumflex femoral veins
Structures that a needle must pass through to gain entry inot the femoral vein
- skin
- subcutaneous tissue
- fascia (encloses the femoral vessels)
- femoral vein
Femoral artery is a continuation of which artery? At which level
originates as a continuation of the external iliac artery at the level of the inguinal ligament
Describe the path of the femoral artery
◦ Enters femoral triangle deep to the midpoint of the inguinal canal - midway point between ASIS and pubic tubercle, lateral to vein
◦ Passes through the triangle exiting at the apex, entering Adductor Canal (Hunter’s Canal)
◦ Exits adductor canal by passing through adductor hiatus in adductor magnus at the level fo the junciton between middle and lower third of the thigh to become popliteal artery
Major branches of the femoral artery (4)
◦ Profunda femoris - artery to tight, from lateral aspect of femoral artery 2-5cm below inguinal ligament
◦ Superficial epigastric
◦ Superficial ilial circumflex
◦ Superficial and deep external pudendal
Medial and lateral relationships of the femoral vein
◦ Medial - femoral vein
◦ Lateral - femoral nerve, lumboinguinal nerve
Superior, posterior and anterior relationships for the femoral vein
◦ Superior - inguinal ligamnet
◦ Posterior - pectineus, psoas, posterior part of femoral sheath
◦ Anterior - skin, superficial fascia lata, lymph nodes, anterior part of femoral sheath
Landmark based femoral insertion
- Inguinal ligament and midpoint of femoral pulse (usually at midpoint of inguinal ligament) and femoral vein 1 - 1.5cm medial to same and 1cm inferior to inguinal ligament
- Ensure veinous puncture inferior to inguinal ligament
What are the boundaries of the antecubital fossa
- Medial
- Lateral
- Superior
- Inferior
- Floor
- Superficial
- Medial – lateral border of pronator teres from the medial epicondyle
- Lateral – medial border of brachioradialis from the lateral supraepicondylar ridge of the humerus
- Superior – an imaginary horizontal line connecting the medial and lateral humeral epicondyles
- Inferior – the apex is directed inferiorly and is formed by the meeting point of the medial and lateral boundaries
- Deep (floor) – brachialis (proximal) and supinator (distal) muscles
- Superficial (roof) – skin, superficial fascia (containing the medial cubital vein, lateral and medial cutaneous nerves of the forearm, deep fascia (reinforced by the bicipital aponeurosis)
Medial antecubital fossa
- Medial – lateral border of pronator teres from the medial epicondyle
- Lateral – medial border of brachioradialis from the lateral supraepicondylar ridge of the humerus
- Superior – an imaginary horizontal line connecting the medial and lateral humeral epicondyles
- Inferior – the apex is directed inferiorly and is formed by the meeting point of the medial and lateral boundaries
- Deep (floor) – brachialis (proximal) and supinator (distal) muscles
- Superficial (roof) – skin, superficial fascia (containing the medial cubital vein, lateral and medial cutaneous nerves of the forearm, deep fascia (reinforced by the bicipital aponeurosis)
Lateral antecubital fossa
- Medial – lateral border of pronator teres from the medial epicondyle
- Lateral – medial border of brachioradialis from the lateral supraepicondylar ridge of the humerus
- Superior – an imaginary horizontal line connecting the medial and lateral humeral epicondyles
- Inferior – the apex is directed inferiorly and is formed by the meeting point of the medial and lateral boundaries
- Deep (floor) – brachialis (proximal) and supinator (distal) muscles
- Superficial (roof) – skin, superficial fascia (containing the medial cubital vein, lateral and medial cutaneous nerves of the forearm, deep fascia (reinforced by the bicipital aponeurosis)
Draw a cross sectional description of the spinal cord and nerve roots
Draw a lateral/sagitall cross section of LP insertion
Draw an underwater seal drain set up
Draw a face on view of the inbtubation view and label
Sagital diagram of anatomy relevant to intubation
