Large veins of the neck
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VENOUS CANNULATION © 2004 The Medicine Publishing Company Ltd 4 ANAESTHESIA AND INTENSIVE CARE MEDICINE The skin of the neck is thin and its surface anatomical markings quite prominent (Figure 1). The key landmark is sternocleido- mastoid (SCM) a broad bulging muscle that bisects the neck diagonally and can be brought into prominence by turning the head to one side. SCM arises by two heads; a tendinous head from the manubrium and a broader muscular head from the medial part of the clavicle. The internal jugular vein passes deep to the gap between the sternal and clavicular heads. These two heads unite as they pass superolaterally to attach to the mastoid process of the temporal bone. The jugular notch of the manubrium is easily palpated between the medial ends of the clavicles. The trapezius is posterior and forms the sloping ridge of the neck. The superior bony landmarks of the neck are the inferior margin of the mandible, the mastoid process and the external occipital protruberance of the occiput. Its inferior landmarks are the superior borders of the clavicle and the manubrium. The triangles of the neck SCM divides the neck diagonally into anterior and posterior triangles (Figure 2). The posterior triangle is bounded by SCM anteriorly, trapezius posteriorly and by the middle third of the clavicle inferiorly. It contains the external jugular vein, which descends vertically across SCM to drain into the subclavian vein, which lies in the inferior part of the triangle. The anterior tri- angle is bounded by the SCM posteriorly, the midline of the neck anteriorly and by the inferior border of the mandible superiorly; its most prominent vascular contents are the common carotid artery and, lateral to it, the internal jugular vein. The major veins of the neck The external jugular vein drains most of the ipsilateral scalp and face. Though not a ‘large vein’ it provides a visible guide to both the internal jugular and subclavian veins (see below). It begins at the angle of the mandible, formed by the union of the posterior auricular and a branch of the retromandibular vein and descends to cross over SCM. In the inferior part of the posterior triangle, where the posterior border of SCM meets the medial third of the clavicle, it pierces the investing layer of cervical fascia to terminate in the subclavian vein. The subclavian vein, the continuation of the axillary vein, lies in the root of the neck. It begins at the lateral border of the first rib and ends medial to scalenus anterior, where it unites with the internal jugular vein, behind the medial end of the clavicle forming the brachiocephalic vein. Its only tributary is the exter- nal jugular vein. Throughout its short course it lies anterior and parallel to the subclavian artery, separated from it by scalenus anterior (Figure 3). The internal jugular vein drains blood from the intracranial region and the head and neck. It arises at the jugular foramen, on the base of the skull, as a continuation of the sigmoid venous sinus, passes downwards through the neck and behind the medial end of the clavicle, and is joined by the subclavian vein to form the brachiocephalic vein. The vein has a dilatation at each end, the superior and inferior jugular venous bulbs and a fairly constant pair of valves just above the lower bulb. The internal jugular vein lies within the carotid sheath with the vagus nerve behind and the internal or common carotid arteries medially. The deep cervical lymph nodes lie around it. At the base of the skull it lies lateral to the last four cranial nerves. Posteriorly it lies on the sympathetic chain, prevertebral fascia and muscles, Large veins of the neck John Craven John Craven was formerly Consultant Surgeon at York District Hospital, York, UK. He trained in Manchester, Uganda and Cardiff. He is past chairman of the primary examiners of the Royal College of Surgeons of England. 1 Surface anatomy of the neck: a trapezius, b thyroid notch, c laryngeal prominence, d clavicular head of sternocleidomastoid, e sternal head of sternocleidomastoid, f supraclavicular fossa, g jugular notch. 2 The triangles of the neck Posterior triangle External jugular vein Internal jugular vein Trapezius Mandible Anterior triangle Sternocleidomastoid Clavicle a b c d e g f
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Transcript of Large veins of the neck
VENOUS CANNULATION
© 2004 The Medicine Publishing Company Ltd4ANAESTHESIA AND INTENSIVE CARE MEDICINE
The skin of the neck is thin and its surface anatomical markings quite prominent (Figure 1). The key landmark is sternocleido-mastoid (SCM) a broad bulging muscle that bisects the neck diagonally and can be brought into prominence by turning the head to one side. SCM arises by two heads; a tendinous head from the manubrium and a broader muscular head from the medial part of the clavicle. The internal jugular vein passes deep to the gap between the sternal and clavicular heads. These two heads unite as they pass superolaterally to attach to the mastoid process of the temporal bone. The jugular notch of the manubrium is easily palpated between the medial ends of the clavicles. The trapezius is posterior and forms the sloping ridge of the neck. The superior bony landmarks of the neck are the inferior margin of the mandible, the mastoid process and the external occipital protruberance of the occiput. Its inferior landmarks are the superior borders of the clavicle and the manubrium.
The triangles of the neck SCM divides the neck diagonally into anterior and posterior triangles (Figure 2). The posterior triangle is bounded by SCManteriorly, trapezius posteriorly and by the middle third of the clavicle inferiorly. It contains the external jugular vein, which descends vertically across SCM to drain into the subclavian vein, which lies in the inferior part of the triangle. The anterior tri-angle is bounded by the SCM posteriorly, the midline of the neckanteriorly and by the inferior border of the mandible superiorly; its most prominent vascular contents are the common carotid artery and, lateral to it, the internal jugular vein.
The major veins of the neckThe external jugular vein drains most of the ipsilateral scalp and face. Though not a ‘large vein’ it provides a visible guide to both the internal jugular and subclavian veins (see below). It begins at the angle of the mandible, formed by the union of the posterior auricular and a branch of the retromandibular vein and descends to cross over SCM. In the inferior part of the posterior triangle, where the posterior border of SCM meets the medial third of the clavicle, it pierces the investing layer of cervical fascia to terminate in the subclavian vein.
The subclavian vein, the continuation of the axillary vein, lies in the root of the neck. It begins at the lateral border of the first rib and ends medial to scalenus anterior, where it unites with the internal jugular vein, behind the medial end of the clavicle forming the brachiocephalic vein. Its only tributary is the exter-nal jugular vein. Throughout its short course it lies anterior and parallel to the subclavian artery, separated from it by scalenus anterior (Figure 3).
The internal jugular vein drains blood from the intracranial region and the head and neck. It arises at the jugular foramen, on the base of the skull, as a continuation of the sigmoid venous sinus, passes downwards through the neck and behind the medial end of the clavicle, and is joined by the subclavian vein to form the brachiocephalic vein. The vein has a dilatation at each end, the superior and inferior jugular venous bulbs and a fairly constant pair of valves just above the lower bulb. The internal jugular vein lies within the carotid sheath with the vagus nerve behind and the internal or common carotid arteries medially. The deep cervical lymph nodes lie around it. At the base of the skull it lies lateral to the last four cranial nerves. Posteriorly it lies on the sympathetic chain, prevertebral fascia and muscles,
Large veins of the neck John Craven
John Craven was formerly Consultant Surgeon at York District Hospital,
York, UK. He trained in Manchester, Uganda and Cardiff. He is past
chairman of the primary examiners of the Royal College of Surgeons of
England.
1 Surface anatomy of the neck: a trapezius, b thyroid notch, c laryngeal
prominence, d clavicular head of sternocleidomastoid, e sternal head of
sternocleidomastoid, f supraclavicular fossa, g jugular notch.
2
The triangles of the neck
Posterior triangle
External jugular veinInternal jugular vein
Trapezius
Mandible
Anterior triangle
Sternocleidomastoid
Clavicle
a
b
c
deg
f
Craven-neck.indd 4 17/12/03, 10:04:38
VENOUS CANNULATION
© 2004 The Medicine Publishing Company Ltd5ANAESTHESIA AND INTENSIVE CARE MEDICINE
Cannulation of the subclavian and internal jugular veins
Cannulation of the subclavian vein is best achieved by an infraclavicular approach. a The needle is inserted below the midpoint of the clavicle and aimed toward the sternal notch (x). b The danger of pneumothorax is minimized by keeping the needle horizontal as it is being advanced. Cannulation of the internal jugular is achieved on a supine patient by insertion of the needle at the apex of the triangle formed by the clavicular and sternal heads of sternomastoid (y) and guiding it towards the ipsilateral nipple
a
by
x
the phrenic nerve and, inferiorly, the subclavian artery. It iscrossed laterally by the accessory nerve passing downwards and laterally, then by the posterior belly of digastric and the omo-hyoid muscles. Further laterally, from above downwards, are the styloid process and its muscles, the SCM and the medial end of the clavicle. Its tributaries are the pharyngeal plexus, facial vein, lingual vein and the superior and inferior thyroid veins. On the left side the thoracic duct may enter the vein and on the right the right lymph duct (Figure 4).
Intravenous cannulationThe proximity to the surface and the constancy of their surface
Termination of the thoracic and right lymphatic ducts
Jugular trunk
Subclavian trunk
Right internal jugular vein
Right lymphatic duct
Right brachiocephalic vein
Right subclavian vein
Bronchomediastinal trunk
Left internal jugular vein
Thoracic duct
Subclavian trunk
Left subclavian vein
Left brachiocephalic vein
Bronchomediastinal trunk
Superior vena cava
anatomy allows percutaneous access to the large veins in this region.The subclavian vein is often catheterized for intravenous feeding, monitoring of the central venous pressure, rapid fluid replace-ment or long-term chemotherapy (Figure 5). Most techniques forcannulating the internal jugular vein depend on identifying thesternal and clavicular heads of SCM. The patient is positioned slightly head down. The internal jugular vein is cannulated at themidpoint between the mastoid process and the sternum (at the same level as the cricoid cartilage). The vein is identified byballotment or just lateral to the pulsation of the carotid artery.The angle of needle insertion is 10° caudad (to reduce the riskof pneumothorax) and 10° lateral, aiming for the ipsilateralnipple (Figure 6).
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5
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The subclavian vein
Dome of pleura Scalenus arterior
Trachea
Brachial plexus
Subclavian artery
Subclavian vein
Cannulating the internal jugular vein
Needledirection
Craven-neck.indd 5 17/12/03, 10:04:47
