Internal Medicine: Venous Anatomy
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Questions and Answers

What is the primary indication for peripheral venous line placement?

  • To facilitate intubation
  • To monitor blood pressure
  • For administration of fluids, medications, blood products, and/or nutritional support (correct)
  • To perform ECG interpretation

    • Where is the 'Clerk’s vein' located?

  • Medial aspect of the wrist near the anatomic snuffbox
  • Lateral aspect of the wrist near the anatomic snuffbox (correct)
  • Great saphenous vein
  • Dorsal metatarsal veins

    • Which of the following veins drains to the great saphenous vein?

  • Medial aspect of the wrist near the anatomic snuffbox
  • Cephalic vein
  • Dorsal metatarsal veins (correct)
  • Small saphenous vein

    • What is the page number for the content on ECG interpretation?

    <p>2</p> Signup and view all the answers

    What is the purpose of inserting a nasogastric tube?

    <p>Not specified in the content</p> Signup and view all the answers

    Where is the dorsal venous arch located in relation to the great saphenous vein?

    <p>Medially</p> Signup and view all the answers

    What is the term for the prominent vein tributary of the cephalic vein?

    <p>Clerk's vein</p> Signup and view all the answers

    What is the page number for the content on central venous line placement?

    <p>2</p> Signup and view all the answers

    What is the purpose of applying traction to the skin using the nondominant hand?

    <p>To stabilize the vein during the procedure</p> Signup and view all the answers

    What is the angle of insertion of the needle into the target vein?

    <p>45 degree angle</p> Signup and view all the answers

    What is the purpose of infiltrating the skin with 1% Lidocaine around the insertion site?

    <p>To reduce the discomfort associated with the procedure</p> Signup and view all the answers

    What is the purpose of using a guidewire in the central line kit?

    <p>To guide the cannula through the vein</p> Signup and view all the answers

    What is the purpose of placing the patient in the Trendelenburg position?

    <p>To reduce the risk of air embolism</p> Signup and view all the answers

    What is the purpose of using an ultrasound or landmarks to locate the target vein?

    <p>To ensure accurate and safe placement of the cannula</p> Signup and view all the answers

    What is the purpose of applying pressure proximal to the insertion site as the needle is retracted?

    <p>To reduce the bleeding associated with the procedure</p> Signup and view all the answers

    What is the first step in preparing for venous access insertion?

    <p>Prepare all necessary materials and equipment.</p> Signup and view all the answers

    What is the purpose of using a 18-gauge introducer needle?

    <p>To create a tract for the cannula to follow</p> Signup and view all the answers

    What is the primary reason for choosing the non-dominant upper extremity for venous access?

    <p>It is less prone to extravasation and dislodgement.</p> Signup and view all the answers

    What is a relative contraindication for venous access insertion?

    <p>Local infections or burns on the intended site of insertion.</p> Signup and view all the answers

    What type of vein is ideal for venous access insertion?

    <p>Nonbranched vein.</p> Signup and view all the answers

    What should be done when locating the target vein for venous access insertion?

    <p>Start distally and look for straight, nonbranched veins.</p> Signup and view all the answers

    What is the purpose of using a tourniquet during venous access insertion?

    <p>To constrict the vein and facilitate insertion.</p> Signup and view all the answers

    What should be done immediately after inserting the IV cannula?

    <p>Remove the tourniquet and apply pressure to the site.</p> Signup and view all the answers

    What is the purpose of using saline flush during venous access insertion?

    <p>To test the patency of the vein.</p> Signup and view all the answers

    What is the primary reason why the femoral vein is usually avoided as a site for catheter insertion?

    <p>It has a higher risk of catheter-related deep vein thrombosis</p> Signup and view all the answers

    What is the purpose of flushing the catheter with sterile saline?

    <p>To remove any air bubbles or debris</p> Signup and view all the answers

    Which of the following is NOT a type of limb lead in ECG placement?

    <p>Unipolar limb leads</p> Signup and view all the answers

    What is the location of the V1 chest lead in ECG placement?

    <p>4th ICS, right parasternal border</p> Signup and view all the answers

    What is the last step in the steps for intrajugular catheter insertion?

    <p>Observe for any untoward reactions</p> Signup and view all the answers

    What is the advantage of using the right subclavian vein as a site for catheter insertion?

    <p>It provides a more direct route to the right atrium</p> Signup and view all the answers

    What is the purpose of securing the catheter with suture and sterile dressing?

    <p>To prevent catheter displacement and infection</p> Signup and view all the answers

    What is the primary risk associated with using the right subclavian vein as a site for catheter insertion?

    <p>Pneumothorax and bleeding</p> Signup and view all the answers

    What is the normal heart rate range in beats per minute?

    <p>60-100bpm</p> Signup and view all the answers

    What is the location of the V3 electrode in a 12-lead ECG?

    <p>Between V2 and V4</p> Signup and view all the answers

    What is the characteristic of a P-wave in a Second degree AV block (Mobitz I)?

    <p>P-wave is usually buried in the QRS complex</p> Signup and view all the answers

    What is the characteristic of ventricular fibrillation on an ECG?

    <p>No identifiable P-wave, QRS complex, or T-wave</p> Signup and view all the answers

    What is the characteristic of a Second degree AV block (Mobitz II)?

    <p>R/S in V5 or V6</p> Signup and view all the answers

    What is the normal duration of the P-wave?

    <p>0.5s</p> Signup and view all the answers

    What is the characteristic of an incomplete QRS complex in ischemia or infarction?

    <p>QRS complex is incomplete</p> Signup and view all the answers

    What is the location of the V4 electrode in a 12-lead ECG?

    <p>5th ICS, left midclavicular line</p> Signup and view all the answers

    At what angle should the needle be directed when attempting to collect blood from the internal jugular vein?

    <p>Towards the ipsilateral nipple</p> Signup and view all the answers

    What should be done immediately after inserting the IV cannula?

    <p>Secure the cannula onto the skin</p> Signup and view all the answers

    What is the purpose of aspirating while advancing the needle towards the internal jugular vein?

    <p>To locate the vessel</p> Signup and view all the answers

    What is the purpose of attaching a saline flush to the IV cannula?

    <p>To ensure adequate flow</p> Signup and view all the answers

    What should be done to confirm the access is in the vessel?

    <p>Saline push or administer IV fluid</p> Signup and view all the answers

    What should be avoided during guidewire advancement?

    <p>Intracardiac advancement</p> Signup and view all the answers

    At what point should the tourniquet be removed?

    <p>After securing the cannula onto the skin</p> Signup and view all the answers

    What is the target location for the guidewire during central venous line placement?

    <p>The superior portion of the IVC</p> Signup and view all the answers

    What is the primary purpose of infiltrating the skin with 1% Lidocaine around the insertion site?

    <p>To reduce the pain associated with the procedure</p> Signup and view all the answers

    What is the purpose of using a 45-degree angle when inserting the needle into the target vein?

    <p>To facilitate the insertion of the needle</p> Signup and view all the answers

    What is the primary purpose of applying pressure proximal to the insertion site as the needle is retracted?

    <p>To control bleeding</p> Signup and view all the answers

    What is the purpose of using a guidewire in the central line kit?

    <p>To facilitate the insertion of the catheter</p> Signup and view all the answers

    Why is the patient placed in the Trendelenburg position?

    <p>To reduce the risk of air embolism</p> Signup and view all the answers

    What is the purpose of using an ultrasound or landmarks to locate the target vein?

    <p>To improve the accuracy of the insertion</p> Signup and view all the answers

    What is the purpose of using a 18-gauge introducer needle?

    <p>To facilitate the insertion of the catheter</p> Signup and view all the answers

    What is the primary purpose of applying traction to the skin using the nondominant hand?

    <p>To stabilize the vein</p> Signup and view all the answers

    What is the primary advantage of using the right subclavian vein as a site for catheter insertion?

    <p>Direct route to the right atrium</p> Signup and view all the answers

    What is the primary indication for avoiding the femoral vein as a site for catheter insertion?

    <p>Higher risk of catheter-related deep vein thrombosis</p> Signup and view all the answers

    What is the purpose of flushing the catheter with sterile saline after insertion?

    <p>To aspirate all ports</p> Signup and view all the answers

    What is the location of the V1 chest lead in ECG placement?

    <p>4th ICS, right parasternal border</p> Signup and view all the answers

    What is the purpose of securing the catheter with suture and sterile dressing?

    <p>To secure the catheter in place</p> Signup and view all the answers

    What is the primary risk associated with using the right subclavian vein as a site for catheter insertion?

    <p>Higher risk of pneumothorax</p> Signup and view all the answers

    What is the final step in the intrajugular catheter insertion process?

    <p>Confirm placement of the catheter tip with chest radiography</p> Signup and view all the answers

    What is the purpose of aspirating all ports with sterile saline during catheter insertion?

    <p>To flush out any air or debris</p> Signup and view all the answers

    What is the primary purpose of thoracentesis?

    <p>To drain fluid from the pleural space</p> Signup and view all the answers

    What is the primary indication for paracentesis?

    <p>Ascites due to liver cirrhosis</p> Signup and view all the answers

    What is the primary goal of intubation?

    <p>To establish a secure airway</p> Signup and view all the answers

    Which of the following is a contraindication for thoracentesis?

    <p>Coagulopathy</p> Signup and view all the answers

    What is the primary complication of paracentesis?

    <p>All of the above</p> Signup and view all the answers

    What is the primary indication for intubation in a patient with respiratory distress?

    <p>Severe respiratory acidosis</p> Signup and view all the answers

    What is the primary advantage of thoracentesis over other drainage methods?

    <p>It is a less invasive procedure</p> Signup and view all the answers

    What is the primary post-procedure care for patients who have undergone thoracentesis?

    <p>Monitor for bleeding and infection</p> Signup and view all the answers

    What is the primary indication for emergency venous access?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of making an incision around the guidewire?

    <p>To insert the dilator over the guidewire</p> Signup and view all the answers

    What is a relative contraindication for central venous access?

    <p>All of the above</p> Signup and view all the answers

    What is the preferred site for central venous access?

    <p>Right internal jugular vein</p> Signup and view all the answers

    What is the purpose of withdrawing the dilator while maintaining guidewire position?

    <p>To apply immediate pressure onto the exit site</p> Signup and view all the answers

    How far is the dilator advanced during central venous access?

    <p>Up to 3-4 cm</p> Signup and view all the answers

    What is the purpose of carefully removing the guidewire?

    <p>To prevent damage to the catheter or vessel</p> Signup and view all the answers

    What is the desired length of the central venous line catheter?

    <p>16-18 cm</p> Signup and view all the answers

    Study Notes

    Peripheral Venous Line Placement

    • Convenient and immediate access for IV administration of fluids, medications, blood products, and/or nutritional support
    • Indication: administration of fluids, medications, blood products, and/or nutritional support
    • No absolute contraindications, but relative contraindications include local infections and burns on the intended site of insertion, and arteriovenous fistula formation or deep vein thrombosis on the affected limb
    • Non-dominant upper extremity is usually used for convenience and less risk of extravasation/dislodgement

    Steps for Peripheral Venous Line Placement

    • Prepare all materials, including IV cannula, gloves, tourniquet, sterile cotton, medical adhesive tape/dressings, sharps disposal, and IV fluid/medications
    • Practice universal precaution, perform hand hygiene, and use gloves
    • Locate the target vein, ideally the most prominent, non-branched vein
    • Stabilize the vein by applying traction to the skin using the non-dominant hand
    • Hold the cannula, with the needle pointing proximally to the target vein, and insert at a 45-degree angle
    • Advance the needle slowly until a flashback of blood appears in the chamber
    • Slightly decrease the angle and carefully advance through the vein, following the contour, until the bushing is on the insertion site
    • Apply pressure proximal to the insertion as the needle is carefully retracted with the dominant hand

    Central Venous Line Placement

    • Used for patients who require long-term access for IV administration, monitoring, and/or blood draws
    • Sites include the subclavian vein, internal jugular vein, and femoral vein
    • Subclavian vein provides a direct route to the right atrium but has a higher risk for pneumothorax and bleeding
    • Femoral vein is used for patients who have a high risk of bleeding but is usually avoided due to increased risk of catheter-related deep vein thrombosis unless the other sites are unavailable

    Steps for Central Venous Line Placement (Intrajugular)

    • Prepare materials, including sterile gloves, drapes, gown, mask, antiseptic solution, sterile saline flush, and local anesthetic
    • Locate the target vein using an ultrasound or landmarks between the clavicular and sternal heads of the sternocleidomastoid muscle at the base of the neck
    • Infiltrate the skin with 1% Lidocaine around the insertion site
    • Insert the introducer needle at a 45-degree angle
    • Secure the catheter with suture and sterile dressing over the site
    • Observe for any untoward reactions, and then confirm placement of the catheter tip with chest radiography

    ECG Interpretation

    • ECG placement involves limb leads and chest leads
    • Limb leads include standard limb leads (I, II, III) and augmented limb leads (aVR, aVL, aVF)
    • Chest leads include V1-V6, with V1 located at the 4th ICS, right parasternal border, and V2 located at the 4th ICS, left parasternal border
    • How to read an ECG:
      • Heart rate (HR): normal (60-100bpm), tachycardic (>100bpm), bradycardic (<60bpm)
      • Second degree AV block (Mobitz I): progressive prolongation of PR interval then sudden beat drop (P-wave not followed by QRS complex)
      • Second degree AV block (Mobitz II): R/S in V5 or V6
      • Intervals: P-wave (0.5V), QRS complex (0.12s), and PR interval (0.12-0.2s)
      • Ischemia/infarction: incomplete QRS complex

    Peripheral Venous Line Placement

    • Convenient and immediate access for IV administration of fluids, medications, blood products, and/or nutritional support
    • Indications: administration of fluids, medications, blood products, and/or nutritional support
    • Stabilize vein by applying traction to skin using your nondominant hand
    • Use anesthetic - Lidocaine 1%, Scalpel – blade II, Central line kit, Fr 6 to 8 catheter and dilator, Guidewire, Syringes, Needles 18- and 22- gauge, and polypropylene suture 4-0

    Central Venous Line Placement

    • Steps:
      • Prepare materials (Sterile gloves, drapes, gown, mask, antiseptic solution, sterile saline flush, Local anesthetic)
      • Place patient in Trendelenburg position, head facing the contralateral side of insertion site
      • Locate target vein using an ultrasound or the landmarks: between the clavicular and sternal heads of the sternocleidomastoid (SCM) muscle at the base of the neck
      • Observe strict aseptic technique (proper handwashing, gowning, draping, sterile preparation of access site)
      • Infiltrate the skin with 1% Lidocaine around the insertion site
      • Insert 18-gauge introducer needle at a 45-degree angle
      • Remove the introducer needle while still holding the guidewire in place
      • Make an incision around the guidewire enough to insert the dilator over the guidewire
      • Advance the dilator up to ~3-4cm (for Right IJV) while still securing the position of the guidewire
      • Withdraw the dilator while maintaining guidewire position then apply immediate pressure onto the exit site
      • Advance the central venous line catheter over the guidewire until desired length is achieved (~16-18cm for Right IJV)
      • Carefully remove the guidewire
    • Indications: hemodynamic monitoring of critically ill patients, hemodialysis- and plasmapharesis-requiring patients, long-term access for parenteral nutrition
    • Contraindications: no absolute contraindications, relative contraindications include distorted local anatomy, local infection on intended site, severe coagulopathy and bleeding disorders, thrombosed veins or proximal vascular injury
    • Potential sites: Internal jugular vein (Right IJV is often the preferred site), Subclavian Vein, Femoral vein

    ECG Interpretation

    • ECG placement: Limb leads (Standard limb leads: I, II, III, Augmented limb leads: aVR, aVL, aVF), Chest leads (V1 – 4th ICS, right parasternal border)
    • How to read?: Discard the needle properly, Remove the tourniquet, Secure the cannula onto the skin using medical adhesive tape/dressing, Observe for any untoward reactions, and then confirm placement of catheter tip with chest radiography

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