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5 Cards in this Set
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Why is it important to assess for distention of the right Internal Jugular vein (IJ) ?
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Its importance lies in the fact that the IJ is in straight-line communication with the right atrium. The IJ can therefore function as a manometer, with distention indicating elevation of Central Venous Pressure (CVP). This in turn is an important marker of intravascular volume status and related cardiac function. The focus here is on simply determining whether or not Jugular Venous Distention (JVD) is present.
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What's the IJ pathway?
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The right IJ runs between the two heads (sternal and clavicular) of the sternocleidomastoid muscle (SCM) and up in front of the ear. This muscle can be identified by asking the patient to turn their head to the left and into your hand while you provide resistance to the movement. The two heads form the sides of a small triangle, with the clavicle making up the bottom edge. You should be able to feel a shallow defect formed by the borders of these landmarks. Note, you are trying to identify impulses originating from the IJ and transmitted to the overlying skin in this area. You can't actually see the IJ.
Take your time. Look at the area in question for several minutes while the patient's head is turned to the left. The carotid artery is adjacent to the IJ, lying just medial to it. If you are unsure whether a pulsation is caused by the carotid or the IJ, place your hand on the patient's radial artery and use this as a reference. The carotid impulse coincides with the palpated radial artery pulsation and is characterized by a single upstroke timed with systole. |
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What's a trick if you can't find the IJ pathway at first?
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If you are still uncertain, apply gentle pressure to the right upper quadrant of the abdomen for 5 to 10 seconds. This elicits Hepato-Jugular Reflux which, in pathologic states, will cause blood that has pooled in the liver to flow in a retrograde fashion and fill out the IJ, making the transmitted pulsations more apparent. Make sure that you are looking in the right area when you push as the best time to detect any change in the height of this column of blood is immediately after you apply hepatic pressure.
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What is the Angle of Louis and why do you care?
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The angle is the site of the joint which connects the manubrium with the rest of the sternum. First identify the supra-sternal notch, a concavity at the top of the manubrium. Then walk your fingers downward until you detect a subtle change in the angle of the bone, which is approximately 4 to 5 cm below the notch. This is roughly at the level of the 2nd intercostal space. The vertical distance from the top of the column to this angle is added to 5cm, the rough vertical distance from the angle to the right atrium with the patient lying at a 45 degree angle. The sum is an estimate of the CVP. However, if you can simply determine with some accuracy whether JVD is present or not, you will be way ahead of the game! Normal is 7-9 cm.
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What is a thrill?
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a vibratory sensation produced by turbulent blood flow that is usually secondary to valvular abnormalities
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