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Pulse and JVP examination.pptx

  1. Pulse and JVP examination Done by: Mays Najjar Supervised by: Dr. Bajes Amir 12/09/2022 12/09/2022 1
  2. Outlines: Pulse definition. General assessment of arterial pulse. How to palpate? Where to palpate? Radio-radial delay. Pulse rate. •Causes of bradycardia. •Causes of tachycardia. Pulse rhythm. Pulse volume. •Hypokinetic and hyperkinetic pulse. JVP definition. IJV VS EJV. Examination of JVP. JVP waves and descents and their abnormalities. JVP VS carotid pulse. Hepatojugular reflux. Resources. 12/09/2022 2
  3. Pulse: • Pulse is defined as a pressure distension wave produced by the contraction of the left ventricle against a partially filled aorta which is transmitted to peripheries and is felt on a peripheral artery against a bony prominence. 12/09/2022 3
  4. General assessment of the pulse: Palpate the artery wall with the tips of the index and middle fingers. The tips are very sensitive. Some recommend avoiding palpation with the thumb (misinterpreting your own radial pulse pulsating in examiner's thumb). 1 Do not press too hard for fear of obliterating the pulse. 2 Establish whether the wall feels soft and pliable or hard and sclerotic. 3 Identify the qualities or characteristics of the pulse by asking: • What is the pulse rate? • What is the pulse rhythm? • What is the character of the pulse? 4 12/09/2022 4
  5. General assessment of arterial pulse: Why? Where and how? Which and what order? To assess rate and rhythm. Simultaneously with femoral to detect delay. Not good for pulse character. •Radial side of wrist. •With tips of index and middle fingers. Radial artery • To assess pulse character. • To confirm rhythm. •Medial border of humerus at elbow medial to biceps tendon. •Either with thumb of examiner's right hand or index and middle of left hand. Brachial artery • Best for pulse character and, to some extent, left ventricular function. • To detect carotid stenosis. • At resuscitation (CPR). • Press examiner's left thumb against patient's larynx. • Press back to feel carotid artery against precervical muscles. • Alternatively, from behind, curling fingers around side of neck. Carotid artery 12/09/2022 5
  6. How to palpate? Carotid Pulse Brachial Pulse Radial pulse Gently place the tips of your fingers between the larynx and the anterior border of the sternocleidomastoid muscle and feel the pulse . -It is advisable to auscultate for carotid bruit prior to palpation, to prevent possible dislodgement of the atherosclerotic plaque (if present). Use your index and middle fingers in the antecubital fossa just medial to the biceps tendon. Assess the character and volume. • Place the pads of your index and middle fingers over the right radial artery. • Count the pulse rate over 15 seconds; multiply by 4 to obtain the beats per minute (bpm). • The radial pulse is felt using 3 fingers. The distal finger is to prevent the backflow, proximal finger is to stabilize artery on the bone and middle finger is used to feel and count the pulse (3-finger method). 12/09/2022 6
  7. Where to palpate: 12/09/2022 7
  8. palpation of Common Femoral Artery: • Put your finger Just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis (the mid inguinal point). It is immediately lateral to the femoral vein and medial to the femoral nerve. 12/09/2022 8
  9. Palpation of other arteries: 12/09/2022 9
  10. 12/09/2022 10
  11. Radio-Radial Delay 12/09/2022 11 -Proceed to palpate both radial pulses simultaneously to detect any inequality in timing. -Causes include: • Presubclavian coarctation. • Thoracic inlet syndrome: Cervical rib. • Takayasu’s disease. • Aortic arch aneurysm.
  12. Radio-Femoral Delay 12/09/2022 12 • If the femoral pulse is appreciated at the same time as the radial pulse, the patient is said to have radio-femoral delay. This is a sign of coarctation of aorta. This can rarely be seen with aortoarteritis.
  13. Pulse Rate A normal pulse rate after a period of rest is between 60 and 80 beats per minute (bpm). It is faster in children. However, if tachycardia is defined as a pulse rate in excess of 100 bpm and bradycardia is less than 60 bpm then between 60 and 100 bpm must be seen as normal. An irregular pulse or a slow pulse should be measured over a longer time. As a guide, it is unwise to measure a regular rate for less than 20 seconds (30 seconds being preferable) and an irregular pulse should not be measured over less than 30 seconds, preferably a full minute. 12/09/2022 13
  14. Causes of bradycardia 12/09/2022 14 Could be physiological causes, like in athletes and in sleep. Problems with the sinoatrial (SA) node, sometimes called the heart’s natural pacemaker Problems in the conduction pathways of the heart that don’t allow electrical impulses to pass properly from the atria to the ventricles Metabolic problems such as hypothyroidism (low thyroid hormone) Damage to the heart from heart disease or heart attack Certain heart medications that can cause bradycardia as a side effect
  15. Causes of tachycardia: Physiological: • Infants, children, emotion, exertion, anxiety and pregnancy. Pathological: • Tachyarrhythmias: “Atrial fibrillation, Atrial flutter, Supraventricular tachycardia and Ventricular tachycardia cause tachycardia with arrhythmia”. • Fever , pain. • {An increase in heart rate of about 10 beats per minute for every 1° Celsius above normal} • High output states: Severe anemia, thyrotoxicosis, beriberi, Paget’s disease of the bone, cirrhosis of liver, AV fistula. • Drugs (e.g., atropine, nifedipine, salbutamol, terbutaline, nicotine, and caffeine). • Cardiac failure Cardiogenic shock. 12/09/2022 15
  16. Pulse Rhythm 12/09/2022 16 Rhythm is assessed by palpating the radial pulse. Sinus rhythm originates from the sinoatrial node and produces a regular rhythm. If irregular, it may be regularly irregular or Irregularly irregular or Regular.
  17. • Variable heart block or premature ventricular excitation will cause either an extra beat or a missed one. Premature ventricular contraction may cause a missed beat because the ventricle has not had time to fill adequately and so the stroke volume is low. The beat following a missed beat, whether due to premature excitation or failure of the ventricle to beat, may be rather stronger than the others, as the ventricle has filled more in the longer diastole. This irregularity will follow a regular pattern. • A much more random irregularity is a feature of AF. If the rate is fast in AF, it may be difficult to note if the irregularity is random or even if there is irregularity at all. It may be helpful to measure the rate at both the cardiac apex and the wrist and in AF there is usually a deficit at the radial pulse. This is usually done with two people timing simultaneously but it can be done alone, not timing but merely noting if the rates differ. The rate in AF and the rarer atrial flutter depends upon the degree of A-V block but it can be very fast. • It has been suggested that a way to distinguish between causes of irregularity is to get the patient to exercise to increase the pulse rate. In premature ventricular excitation it will reduce or disappear. In AF it will increase the irregularity or at least not reduce it. • Currently, most clinicians would use the ECG for a more reliable means of distinction. 12/09/2022 17
  18. Volume of the Pulse 12/09/2022 18 • Volume of the pulse is a measure of the pulse pressure. The pulse pressure is the difference between systolic and diastolic blood pressure. • Normal pulse pressure is 30–60 mm Hg.
  19. Hypokinetic and Hyperkinetic pulse causes: Hyperkinetic Hypokinetic Physiological: Fever, pregnancy, alcoholism, and exercise Pathological: 1. High output states: • Anemia, beriberi, hypercarbia, fever • Cirrhosis liver (hypoproteinemia) thyrotoxicosis, • Arterio-venous (AV) fistula • Paget’s disease of the bone 1. Cardiac causes (pulsus magnus): • Aortic regurgitation • Severe mitral regurgitation • Complete heart block • Patent ductus arteriosus (PDA) • Rupture of sinus of Valsalva and aortopulmonary window • Congestive cardiac failure • Hypovolemia • Shock • Mitral stenosis • Aortic stenosis (pulsus minimus) • Constrictive pericarditis 12/09/2022 19
  20. Character of pulse: • The character of a pulse refers to its strength and volume and can suggest various pathologies. The carotid pulse should be used when assessing the character of the pulse; palpation should show a smooth rapid upstroke and a more gradual downstroke with each pulse. 12/09/2022 20
  21. Pulse character abnormalities: 12/09/2022 21
  22. Pulse deficit (Apex- pulse deficit) • pulse deficit (Apex-pulse deficit) :is the difference between the heart rate (counted by auscultation) and pulse rate when counted simultaneously for one full minute by two individuals. • Pulse deficit of more than 10/minute occurs in atrial fibrillation (AF) and less than 10/minute may be found with ventricular premature beats or slow/controlled AF 12/09/2022 22
  23. Pulse grading • Complete absence of pulse. 0: • Small or feeble reduced pulse. 1: • Palpable but diminished as compared to other side. 2: • Normal pulsation. 3: • Large or high volume (bounding pulse). 4: 12/09/2022 23
  24. Jugular Venous Pressure (JVP) • Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. The internal jugular vein connects to the right atrium without any intervening valves , thus acting as a column for the blood in the right atrium. The JVP consists of certain waveforms and abnormalities of these can help to diagnose certain conditions]. Unfortunately, detection of these abnormalities and even the JVP itself, can be difficult and has also been superseded by other diagnostic methods. 12/09/2022 24
  25. Internal VS external Jugular veins? 12/09/2022 25
  26. Examination of JVP 1. Patient comfortably lying-in semi reclined position (45° position). 2. The patient’s neck should be slightly turned towards the left side. 3. Shine a torch light onto the neck tangentially from the left side. 4. Observe for pulsation between two heads of sternocleidomastoid muscle. 5. Trace the pulsation and locate the upper level. 6. Take two scales. Place one scale at the upper level of the JVP, parallel to the ground. And place the second scale at the level of the sternal angle, perpendicular to the first scale. 7. Measure the vertical height on the second scale. 8. Express as (…) cm of water above sternal angle. Add 5 cm to this value to determine the right atrial pressure. • The normal JVP is less than 4 cm above the sternal angle; or is just visible above the clavicle in 45° position. • Normal CVP is <7 mm of Hg or 9 cm H2O. 12/09/2022 26
  27. Examination of JVP 12/09/2022 27
  28. JVP Waves and Descents: 1. Waves • "A" wave: atrial contraction (ABSENT in atrial fibrillation). • "C" wave: ventricular contraction (tricuspid bulges). YOU WON'T SEE THIS. • "V" wave: atrial venous filling (occurs at same of time of ventricular contraction). 1. Descents • "Y" descent: ventricular filling (tricuspid opens). • "X" descent: atrial relaxation. 12/09/2022 28
  29. JVP Waves and descent: • The a and v waves can be identified by timing the double waveform with the opposite carotid pulse. • The a wave will occur just before the pulse and the v wave occurs towards the end of the pulse. • Distinguishing the c wave, x and y descents is an almost impossible task. 12/09/2022 29
  30. Changes in JVP waveforms: a wave; • Absent  Atrial fibrillation. • Large a wave  tricuspid stenosis, Pulmonary hypertension, PE. V wave; • Diminished  hypovolemia. • Prominent  Tricuspid regurgitation, ASD,VSD, atrial fibrillation, Cor pulmonale. X wave; • Absent Tricuspid regurgitation. • Prominent  ASD, constrictive pericarditis, Tamponade . Y wave; • Slow descent  Tamponade , Tricuspid stenosis. • Rapid descent  constrictive pericarditis, severe tricuspid regurgitation. 12/09/2022 30
  31. How to differentiate a jugular venous pulse from the carotid pulse: The JV pulse is not palpable but seen while the carotid pulse isn’t seen but palpable . The JV pulse is obliterated by pressure while carotid pulse isn’t. The JV pulse is characterized by a double waveform while carotid pulse is one waveform. The JV pulse is variable with respiration - it decreases with inspiration while carotid pulse isn’t. The JV pulse is enhanced by the hepatojugular reflux while the carotid pulse isn’t. 12/09/2022 31
  32. Hepatojugular reflux (abdominojugular reflux sign): • This can help to confirm that the pulsation is caused by the JVP. • In the classic test for hepatojugular reflux, firm pressure is applied to the right upper quadrant using the palm of the hand. It has been realised that pressure anywhere over the abdomen will produce the same result (abdominojugular reflux sign). Pressure over the peri-umbilical region is the usual method and may be more appropriate in patients with a tender liver. • A transient increase in the JVP will be seen in normal patients. • There may be a delayed recovery back to baseline which is more marked in right ventricular failure. 12/09/2022 32
  33. Resources: • ANUDEEP, B. O. L. O. O. R. A. R. C. H. I. T. H. P. A. D. A. K. A. N. T. I. (2019). Insiders guide to clinical medicine. JAYPEE Brothers MEDICAL P. 12/09/2022 33
  34. Thank you! 12/09/2022 34