cardiology pulse characters and JVP examination

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