Estimate the Jugular Venous Pressure

To assess the pressure in the right side of the heart, it is necessary to establish a reference level. The standard reference is the manubriosternal angle. At any degree of elevation, this position is used to measure the pressure in the internal jugular system. The examiner must first determine the height of the venous distention by noting the top of the wave forms in the internal jugular venous pulsations. An imaginary horizontal line is then drawn from this height to the sternal angle. The examiner should then measure the distance from the sternal angle to this imaginary line. The angle of elevation of the head of the bed is also estimated. It might be stated, ''At 45° elevation, the jugular pulse is 7 cm above the sternal angle.'' At 45°, the upper limit of normal is 4 to 5 cm above the sternal angle;if the patient is at 30°, the upper limit of normal is 6 cm. When the height of the venous column is equal to or lower than the sternal angle in the supine position, venous pressure is usually normal.

There is tremendous inaccuracy in attempting to determine the pressure in the right atrium by the jugular manometer, as just indicated. It has been demonstrated numerous times that the sensitivity and specificity of this test are low, and thus it is inaccurate in

Table 14-6 Differentiation of Jugular and Carotid Pulses

Feature Internal Jugular Pulse Carotid Pulse

Table 14-6 Differentiation of Jugular and Carotid Pulses

Feature Internal Jugular Pulse Carotid Pulse

Palpation

Not palpable

Palpable

Waveforms

Multiform: two or three components

Single

Quality

Soft, undulating

Vigorous

Pressure*

Wave forms obliterated

No effect

Inspiration

Decreased height of wave forms

No effect

Sitting up

Decreased height of wave forms

No effect

Valsalva maneuver

Increased height of wave forms

No effect

*Light pressure on the vessel above the sternal end of clavicle.

*Light pressure on the vessel above the sternal end of clavicle.

predicting elevated pressures. The only accurate statement is that right atrial pressure is high when there is neck vein distention up to the jaw margin while the patient is seated at 90°. In this situation, the right atrial pressure usually exceeds 15 mm Hg. In Figure 14-26, the neck veins are distended to the angle of the jaw while the patient is seated upright. His right atrial pressure was 21 mm Hg.

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