|Assessing Chest Pain
|Cardiogenic Pulmonary Oedema
Jugular Venous pressure
- Technique is to get the patient to lie back at 45 degrees to the horizontal with the head turned slightly to the left with the head on a pillow so the sternomastoid are relaxed.
- The lack of one-way valves between the internal jugular and Right atrium suggests it may be used as a manometer of right atrial pressure. Examination of the internal jugular vein can take some practice but can give some clues to right-sided filling pressures. It is located between the heads of the sternomastoid.
- Best seen at an angle with light glancing off. Very high levels seen from the end of the bed as the earlobes move with a pulse. Do not confuse with the more superficial external jugular vein which has valves and is a poor marker of right atrial pressure.
|Differentiating JVP and Carotid pulse
- Carotid is readily palpable. JVP isn't
- Carotid has one main waveform, JVP multiple
- Only the JVP varies with posture and respiration
- JVP pulsation can be occluded by pressure above
- Pressure on the abdomen can cause a temporary rise in JVP
Inspecting the Jugular venous pulse
- Measure the height by calculating the vertical height above the sternal notch which approximates to the right atrium.
- If the JVP is not pulsatile then consider SVC obstruction - other veins are often dilated on the chest wall and the face and conjunctiva suffused
- JVP usually falls on inspiration, if it rises consider pericardial tamponade or constrictive pericarditis
- 'a' wave : atrial systole - lost with AF. Increased with pulmonary hypertension/stenosis and RVH.
- 'c' wave : carotid artefact
- 'v' wave: atria fills while tricuspid valve shut
- 'x' descent : RAP falls during ventricular systole
- 'y' descent : Sharp y descent in constrictive pericarditis
Pathological JVP waveforms
- Cannon 'a' waves - Complete heart block or VT or frequent Ventricular ectopics where atria may contract against a closed Tricuspid valve.
- Pathological giant "V" wave which is different to "v" waves is a composite of both a and the v wave seen with right ventricular systole and Tricuspid regurgitation
Causes of a raised JVP
- Congestive cardiac failure (LHF+RHF)
- Right sided failure - Inferior MI
- Increase in Inspiration (Kussmaul's sign) - Constrictive pericarditis and tamponade
- Pulmonary embolism
- Cardiac tamponade
- Pericardial effusion
- Constrictive pericarditis
- IV Fluids and overhydration
- Superior venal caval obstruction (NON Pulsatile