Distinguishing the internal jugular vein pulsations from the carotid artery

Jugular Vein No pulsations palpable. Pulsations obliterated by pressure above the clavicle. Level of pulse wave decreased on inspiration; increased on expiration. Usually two pulsations per systole (x and y descents). Prominent descents. Pulsations sometimes more prominent with abdominal pressure.

Carotid Artery Palpable pulsations. Pulsations not obliterated by pressure above the clavicle. No effects of respiration on pulse. One pulsation per systole. escents not prominent. No effect of abdominal pressure on pulsations.

!he "u#ular venous pressure ($%P) provides an indirect measure of central venous pressure. !he internal "u#ular vein connects to the ri#ht atrium without any intervenin# valves & thus actin# as a column for the blood in the ri#ht atrium. !he $%P consists of certain waveforms and abnormalities of these can help dia#nose certain conditions. Unfortunately' detection of these abnormalities and even the $%P itself' can be difficult and has also been superseded by other dia#nostic methods. (ow to examine the $%P)'*'+ Use the ri#ht internal "u#ular vein (,$%) Patient should be at a -./ an#le (ead turned sli#htly to the left ,f possible have a tan#ential li#ht source that shines obli0uely from the left Locate the surface mar1in#s of the ,$% & runs from medial end of clavicle to the ear lobe under medial aspect of the sternocleidomastoid Locate the $%P & loo1 for the double waveform pulsation (palpatin# the contralateral carotid pulse will help) 2easure the level of the $%P by measurin# the vertical distance between the sternal an#le and the top of the $%P. 2easure the hei#ht & usually less than +cm.

!he sternal angle or 3an#le of Louis3 is the an#le formed by the "unction of the manubrium and the body of the sternum4)5 (the manubriosternal junction) in the form of

a secondary cartila#inous "oint (symphysis). !his is also called the manubriosternal "oint or 6n#le of Louis. !he sternal an#le is a palpable clinical landmar1.

,t mar1s the approximate level of the *nd pair of costal cartila#es and the level of the intervertebral disc between !- and !.. ,t also mar1s approximately the be#innin# and end of the aortic arch' and the bifurcation of the trachea into the left and ri#ht main bronchi. !he an#le is approximately )-7 de#rees

Traube's (semilunar) space is an anatomic re#ion of some clinical importance. ,t3s a crescent&shaped space' encompassed by the lower ed#e of the left lun#' the anterior border of the spleen' the left costal mar#in and the inferior mar#in of the left lobe of the liver. !hus' its surface mar1in#s are respectively the left sixth rib' the left midaxillary line' and the left costal mar#in.

Patient positioning [edit 1nees flexed expose from nipples to pubis !pleen location [edit posterior to the midaxillary line (26L)' between 8 to ))th ribs' si9e of palm Peripheral signs of hypersplenism [edit pallor brusin#

oval ulcers s1in infections petechiae

!tigmata of diseases associated "ith splenomegaly [edit hepatome#aly lymphadenopathy (:LL' lymphoma' ;<%)

"aundice (hemolytic anemia) macro#lossia (amyloidosis)

!tatic [edit =1in

o

sur#ical scars

discoloration

:ontour
o o o o

distended obese umbilical herniation bul#in# flan1s

#ith Deep $nspiration [edit =ymmetry & durin# several deep inspirations o note that the spleen enlar#es toward the >L? Percussion [edit Traube%s !pace [edit @th ,:=' lower costal mar#in' 26L tympanic due to the #astric bubble & in splenome#aly' stomach is displaced and re#ion sounds dull (not a specific test)

Aalse PositivesB full stomach' pleural effusion and pneumonia

Castell%s sign [edit lowest intercostal space' L 66L as1 the patient inhale and exhale slowly and deeply

splenome#aly C resonant on expiration but dull on inspiration

Palpation [edit ). Dith ri#ht hand be#innin# in >L?' pull the L ribca#e forward (#ive slac1 for the > hand to feel under the costal mar#in)' palpate superficially toward the LU?

assess effect of deep inspiration o describeB firmEsoft' nodularEsmooth' tenderness

*. &oo'ing (aneuver

stand on patientFs left and try hoo1in# hands under left costal mar#in

Auscultation [edit ). all - ?U6 >6N!= for bowel sounds *. Ariction rub (inflammation' tumor' infarction)

+. systolic murmur over spleen & massive splenome#aly (dilated' tortuous splenic artery) )idney vs* !pleen [edit ). 1idney is <LO!!6<L;' spleen is NO! *. NO!:( ON 6N!;>,O> <O> ;> & palpable in spleen' not in 1idney +. spleen enlar#es dia#onally towards >L?' while the 1idney enlar#es inferiorly -. 1idney can be resonant to percussion (dEt overlyin# bowel)' spleen should be ULL .. UPP;> ; G; of spleen NO! palpable' upper ed#e of 1idney is @. =PL;N,: >U< on auscultation (have patient breath in and out) H. Dhen you are measurin# the hei#ht of anythin#' you need to have a reference point. ,n the case of the $%P' the reference point should be ta1en as the centre of the ri#ht atrium (>6). (owever' as this is not accessible' the manubriosternal an#le' also called the sternal an#le (=6)' is used as the reference point for measurin# the $%P. !he distance between the centre of the ri#ht atrium and the sternal an#le is .cm. This measurement does not vary significantly with the position of the patient. I. Dhen you measure the hei#ht of the distension of the $%P in the nec1' it is measured in centimetres as the vertical hei#ht above the sternal an#le. <y addin# .cm to the vertical hei#ht of the $%P above the sternal an#le' you are able to calculate the ri#ht atrial pressure (in cm of blood). 8. Dhen measurin# the $%P' it is important to remember that it is the vertical hei#ht which must be determined. Dhen a patient chan#es position (lyin# flat' -.de#rees or sittin#)' the position of the $%P chan#es in the nec1 but it actually does not chan#e its vertical hei#ht above the sternal an#le. 6 patient3s position is often chan#ed for ease of examination of the distended vein but it doesn3t chan#e the measured hei#ht above the sternal an#le. !his is beautifully demonstrated in the followin# animation. )7. #hat is a normal JVP+ !here is no consensus amon# textboo1s (or clinicians) as to the JnormalK hei#ht of the $%P. !he followin# is a list of the stated normal upper limits of the $%P above the sternal an#le' and the respective referenceB *cm ( acre and Lopelman)' *&+cm (Gray and !o#hill)' +cm (!alley and OF:onnor' 2cGee)' -cm (2cLeod' (utchison). (ence there is a#reement that M*cm is normal and N-cm is too hi#h but there is a borderline area between *&-cm. ,n these patients' it will be necessary to use other si#ns' e#. the presenceEabsence of an1le oedema' to interpret the $%P. )). ,n this dia#ram we have indicated a hei#ht of *cm above the sternal an#le as an example of normal $%P. !he $%P would be recorded as J*cm above the =6K or Ja total of HcmK (*cm above the =6 O .cm from the =6 to the >6). Observe the chan#es that would be seen at different an#les. )*. !he high JVP shown in this dia#ram is @cm above the sternal an#le. !he $%P would be recorded as J@cm above the =6K or Ja total of ))cmK. 6#ain' observe the chan#es that would be seen at different an#les.

)+. !he very high JVP shown in the dia#ram is ))cm above the sternal an#le. Observe that at -./' the top of the distension is not visible' but it can be seen at @7/ and 87/. !he $%P would be recorded as J))cm above the =6K or Ja total of )@cmK. ,t is possible for $%P measurements to be hi#her than this' e#. Jto the ear lobes when sittin# upri#htK. 2easure the vertical hei#ht in centimetres between the top of the sternal an#le and the top of the venous pulsation.

!here are two main veins in the nec1' drainin# into the heart & the internal and the external "u#ular vein. !he ,nternal $u#ular %ein enters the nec1 behind the ear' "ust behind the mastoid process' next to the an#le of the "aw. ,t is not superficial but runs deep to the main muscle in the nec1B the sternomastoid. ,t enters the chest between the two heads of the sternomastoid & between the attachments of the muscle at the sternum and the clavicle & at the sternoclavicular "oint. <ecause it runs deep' it can only be visualised when the nec1 muscles are relaxed (positionin# is importantP) and even then only a va#ue pulsation can be seen and not the outline of the vein. !he external "u#ular vein is the vein that is readily visible (you have all seen it in people who are an#ryP). ,tFs location ma1es it easier to use to assess the $%P than the internal "u#ular vein. (owever' it is prone to 1in1in# and #ettin# partly bloc1ed off under the clavicle. ,t would then be distended (but not pulsatin#) and #ive a falsely hi#h $%P measurement. Aor this reason' it has

traditionally been recommended to always measure the $%P by observin# the internal "u#ular vein' but the external "u#ular vein is still useful if you are aware of itFs limitations. ,n most cases' the external "u#ular vein will be consistent with the internal "u#ular vein. Loo1in# at the sli#ht pulsation which is visible in the ,nternal $u#ular %ein #ives us information about the function of the ri#ht side of the heart. !his is because there are no valves between the ,nternal $u#ular %ein (,$%) and the >i#ht 6trium and the ri#ht ,$% runs in an almost strai#ht line to the ri#ht atrium. !herefore the pressure in the ri#ht atrium is reflected in the ,$% with the hei#ht of the distension of the vein actually bein# e0ual to the pressure in the ri#ht atrium & we call this the $u#ular %enous Pressure. (pIH 2acleod3s) 6t the point at which the ,$% is distended' a sli#ht flic1erin# exists & this venous waveform is called the $u#ular %enous Pulsation and this also provides us with more information about ri#ht atrial function. (!alley and O3:onnor p-*&-+)