Investigation and evaluation of arterial pulses, blood pressure, and jugular venous pressure

Transcription

1 Investigation and evaluation of arterial pulses, blood pressure, and jugular venous pressure Dr. András Tislér October 2013.

2 Objectives To understand the principles of Assessing vital signs Examination of the peripheral arterial system Pulse Blood pressure Examination of jugular veins

3 Follow up 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 DIAGNOSIS

4 Vital signs Heart rate / blood pressure Temperature Respiratory rate / 0 2 saturation Level of consciousness

5 Evaluating the peripheral pulse Palpable? (equal?) Heart rate? Regular? (rythm) Amplitude? contour? compressible? Variability? Beat-to-beat With respiration

6 Assessment of heart rate Rate Regularity / rhythm Amplitude / contour Variation Beat-to-beat With respiration

7 Heart rate regularity assessment

8 Irregular rhythms

9 Pressure Pressure Arterial system Stiff system Elastic system Mean pressure Mean pressure Systole Diastole Systole Diastole

10 Pulse pressure wave reflects from the periphery, augmenting central pressure

11 Propagation and reflecion of the pulse wave

12 Central pulse pressure: incident (primary) + reflected wave amplitude

13 Brachial and aorta pressure cirve in a young heathy (compliant arteries) and an elderly individual (with stiff arteries) young elderly

14 Abnormalities of the arterial pulse wave contour

15 Examanation of the peripheral arterial system Palpable: Radial Dorsalis pedis/tibial posterior Popliteal Femoral Bruit Abdominal Femoral Carotid

16 Examanation of the peripheral arterial system Inspection Paleness Cyanosis Oedema Ulcers Emboli Palpation: Pulse Temperature Ausculatation Bruit

17 Acute arterial insufficiency in the limb: Embolus, thrombosis 5 P-s Pain Pallor (pale) Pulselessness Poikilothermia (coldness) Paresthesia

18 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

19 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

20 Pulse pressure Arterial blood pressure systolic Mean blood pressure diastolic

21 Systolic blood pressure increases towards the periphery: amplification

22 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

23 Stephen Hales, 1714

24 Samuel von Bash ( ) Der Shygmomanometer, Berlin 1887

25 Riva-Rocci sphagmomanometer

26 Blood pressure measurement: devices Mercury sphygmomanometer Aneroid sphygmomanometer Automated (oscillometric) devices

27 Blood pressure measurement: cuff size 80% Undercuffing : too small bladder leads to overestimation of true BP

28 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

29 Blood pressure measurement: normal values

30 Objectives To understand the principles of Assessing vital signs Examination of the peripheral arterial system Pulse Blood pressure Examination of jugular veins

31 Examination of the internal (external) jugular vein

32 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

33 Examination of the internal (external) jugular vein

34 Examination of the internal (external) jugular vein

35 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.

36 Objectives To understand the principles of Assessing vital signs Examination of the peripheral arterial system Pulse Blood pressure Examination of jugular veins