Investigation and evaluation of arterial pulses,

blood pressure, and jugular venous pressure

Dr. András Tislér

October 2013.

Objectives

To understand the principles of…

• Assessing vital signs

• Examination of the peripheral arterial system

– Pulse

– Blood pressure

• Examination of jugular veins

Evaluation and management of the medical patient

• Reason for admission

• History of present illness/current complaints/ review of the systems

• Past medical / social / family history

• Mediactions/allergies

• Physical examination

• Laboratory tests

• Other investigations

• Differential diagnosis

• Confirmatory tests

• Therapy

• Follow up

DIAGNOSIS

Vital signs

• Heart rate / blood pressure

• Temperature

• Respiratory rate / 02 saturation

• Level of consciousness

Evaluating the peripheral pulse

• Palpable? (equal?)

• Heart rate?

• Regular? (rythm)

• Amplitude? contour? compressible?

• Variability?

– Beat-to-beat

– With respiration

Assessment of heart rate

• Rate

• Regularity / rhythm

• Amplitude / contour

• Variation

– Beat-to-beat

– With respiration

Heart rate regularity assessment

Irregular rhythms

Arterial system

Stiff system Elastic system

Pre

ssu

re

Systole Diastole

Mean

pressure

Pre

ssu

re

Systole Diastole

Mean

pressure

Pulse pressure wave reflects from the

periphery, augmenting central pressure

Propagation and reflecion of the pulse wave

Central pulse pressure:

incident (primary) + reflected wave amplitude

Brachial and aorta pressure cirve in a young heathy

(compliant arteries) and an elderly individual (with

stiff arteries)

elderlyyoung

Abnormalities of the arterial pulse wave contour

Examanation of the peripheral arterial system

• Palpable:

– Radial

– Dorsalis pedis/tibial posterior

– Popliteal

– Femoral

• Bruit

– Abdominal

– Femoral

– Carotid

Examanation of the peripheral arterial system

• Inspection

– Paleness

– Cyanosis

– Oedema

– Ulcers

– Emboli

• Palpation:

– Pulse

– Temperature

• Ausculatation

– Bruit

Acute arterial insufficiency in the limb:

Embolus, thrombosis

• „ 5 P-s”

– Pain

– Pallor (pale)

– Pulselessness

– Poikilothermia (coldness)

– Paresthesia

Chronic arterial insufficiency of the lower limb:

• Complain

– Intermittent claudication

• Physical examination

– Limb pale/cyanotic, colder

– Non palpable TP/DP arteries

– Muscle - skin atrophy

– Dependent rubor

– Ulcers

– Gangrene

Blood pressure measurement

• Factors influencing blood pressure

BP= volume x peripheral resistance

– Stroke volume

– Heart rate

– Distensibility of the large arteries

– Peripheral vascular resistance

– Viscosity of the blood

Arterial blood pressure

systolic

Pu

lse

pre

ssu

reMean blood pressure

diastolic

Systolic blood pressure increases towards the periphery:

amplification

Arterial blood pressure

• Systolic pressure

– Increases from the heart towards the periphery (amplification)

• Diastolic pressure

– Remains unchanged toward the periphery

• Pulse pressure

– Difference between the systolic and diastolic pressure

– Increases towards the periphery

• Mean arterial pressure

– Area under the pressure curve

– ~ diastolic + 1/3 pulse pressure

Stephen Hales, 1714

Samuel von Bash (1837-1905)Der Shygmomanometer, Berlin 1887

Riva-Rocci sphagmomanometer

Blood pressure measurement: devices

• Mercury sphygmomanometer

• Aneroid sphygmomanometer

• Automated (oscillometric) devices

Blood pressure measurement: cuff size

• „Undercuffing”: too small bladder leads to

overestimation of true BP

80%

Blood pressure measurement: methods

• Quiet room

• After 5 minutes of rest

• More than 30 minutes after

meal/coffe/smoking

• Back supported, legs

uncrossed

• Arm supported at heart level

• Deflation rate: 2 mmHg/heart

beat

• Repeat measuremnts x2 or x3

Blood pressure measurement: normal values

Objectives

To understand the principles of…

• Assessing vital signs

• Examination of the peripheral arterial system

– Pulse

– Blood pressure

• Examination of jugular veins

Examination of the internal (external) jugular vein

Examination of the internal (external) jugular vein

• Used mostly to assess extracellular (intravascular) fluid

volume and heart failure

• Jugular vein distension is seen in

– Fluid overload

– tricuspid valve insufficiency

– heart failure (right venticule)

– SVC compression/thrombosis, e.g. mediastinal masses

• Hepato-jugular reflux to assess right ventricular function

– Pressure on the liver increases IJV (EJV) hight that

subsequently decreases

– If not may suggest fluid overload and/or right ventricular

failure

Examination of the internal (external) jugular vein

Examination of the internal (external) jugular vein

External jugular vein distention

Markedly distended right external jugular vein (EJV).

This is the result of elevated central venous pressure (CVP). In practice

the EJV is not as reliable in determining CVP as the internal jugular vein

due to the fact that it sometimes has valves and is not in a direct line with

the right atrium. Pressure on the liver, however, will have similar impact

on the appearance of the IJV as for the EJV. This is referred to as

hepatojugular reflux.

Objectives

To understand the principles of…

• Assessing vital signs

• Examination of the peripheral arterial system

– Pulse

– Blood pressure

• Examination of jugular veins