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Jugular venous pulse is the oscillating top of the the distended proximal portion of the internal jugular vein and represents volumetric changes that faithfully reflect the pressure cahnges in the right heart

Right atrial pressure during systole and right ventricular filling pressure during diastole

Window into the right heart, providing critical information regarding its hemodynamics.

AnatomyJV pressure measurementCauses of elevated JVPNormal wave patternAbnormal wave patternKussmaul s sign and hepatojugular refluxSpecific conditions

Jugular veins

Internal jugular veinExternal jugular vein

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Lateral to carotid artery & deep to sternomastoid muscle.External jugular is superficial to sternomastoid

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Examination of JVPRight IJV is usually assessed both for waveform and estimation of venous pressure

Transmitted pulsations to overlying skin between two heads of sternocleidomastoid

Right IJV Preferred :Why?Straight line course through innominate vein to the svc and right atrium Less likely extrinsic compression from other structures in neck

Why not EJVNo or less numbers of valves in IJV than EJV

It is preferable to examine the internal rather than external jugular veins since the internal jugular veins are in a direct line with the superior vena cava and right atrium whereas the external jugular veins are not in a direct line with the superior vena cava and connect with it after negotiating two almost 90 degree angles

Differences between IJV and Carotid pulsesSuperficial and lateral in the neck Better seen than felt Has two peaks and two troughs

Descents >obvious than crests

Digital compression abolishes venous pulse Jugular venous pressure falls during inspirationAbdominal compression elevates jugular pressure Deeper and medial in the neck

Better felt than seen

Has single upstroke only

Upstroke brisker and visible Digital compression has no effect

Do not change with respiration

Abdominal compression has no effect on carotid pulse

Estimation of Venous Pressure Measuring jugular venous pressure Hepatojugular reflux Examining the veins on the dorsum of the hand

Assessment of jugular venous pressure at bed side reflect mean right atrial pressure

Measurement of JV Pressure

Sternal angle or angle of Louis - reference point

Found approximately 5 cm above the center of the right atrium

Sternal angle RA Fixed relationship

Position of PatientPatient should lie comfortably and trunk is inclined by an angle Elevate chin and slightly rotate head to the left Neck and trunk should be in same line

When neck muscles are relaxed ,shine the light tangentially over the skin and see pulsations

Simultaneous palpation of the left carotid artery or apical impulse aids in timing of the venous pulsations in cardiac cycle .

Measurement of JVPTwo scale method is commonly used

Normally JV pressure does not exceed 3- 4 cm above the sternal angle

Since RA is approximately 5 cm below the sternal angle , the jugular venous pressure corresponds to 9 cm =7mmhg

Elevated JVP : JVP of >4 cm above sternal angle .

Elevated JVP Increased RVP and reduced compliance: Pulmonary stenosis Pulmonary hypertension Right ventricular failure RV infarctionRV inflow impedance: Tricuspid stenosis / atresia RA myxoma Constrictive pericarditis

Elevated JVP Circulatory overload : Renal failure Cirrhosis liver Excessive fluid administration

SVC obstruction

Kussmaul's signMean jugular venous pressure increases during inspirationConstrictive pericarditis Severe right heart failure RV infarction Restrictive cardiomyopathy Impaired RV compliance.

Abdominal -Jugular Reflux Hepatojugular reflux Rondot (1898)

Apply firm pressure to periumbilical region 15 secNormally JV pressure rises transiently to < 1cm while abdominal pressure is continued

If JV pressure remains elevated >1cm until abdominal pressure is continued: Positive AJR.

Abdominal compression forces venous blood into thorax.

A failing/dilated RV not able to receive venous return without rise in mean venous pressure.

Positive AJR

Incipient and or compensated RVF Tricuspid regurgitation COPD

Normal JVPNormal JVP reflects phasic pressure changes in RA during systole and RV during diastole Two visible positive waves ( a and v) and two negative troughs ( x and y)Two additional positive waves can be recorded C wave interrupts x descent and h wave

Normal JVPJVP dievaluasi tinggi dan karakternya.Tinggi JVP lebih dari 3 cm H2O merupakan tanda peningkatan tekanan atrium kanan. Normal berkisar 5+/- 2 cm H2O

Cara JVPMeminta pasien tidur terlentang sedemikian rupa sehingga kepala membentuk sudut 30 dan 450 dengan tempat tidur.Meminta pasien menggerakan kepala ke arah kiriMenekan vena jugularis pada bagian distal agar vena jelas melebarMenekan vena tersebut di bagian kranial setinggi sudut rahang sehingga aliran darah ke jantung berhentiMeminta pasien untuk inspirasi dalamMenetapkan titik pengosongan vena jugularis pada waktu inspirasi dalam dan diberi tanda dengan pensil alisMembuat sebuah bidang datar dengan penggaris melalui angulus Ludovici (insersi dua iga pada sternum) sejajar dengan lantaiMengukur jarak titik pengosongan vena jugularis dengan bidang datar tersebut dengan pengaris lain yang diletakan tegak lurus terhadap budang datar tadiMelaporkan hasil pengukuran tekanan vena, di atas titik pengosongan menjadi 5+A, di bawah titik pengosongan menjadi 5-A

Thank you

Right atrial pressure during systole and right ventricular filling pressure during diastole are producing pulsations and pressure waves in jugular veins .Evaluation of the jugular venous pulse offers a window into the right heart, providing critical information regarding its hemodynamics.

*Two jugular veins int and ext can be used 4 assessing jv pulse and pressure, though internal one is the preffered one*The internal jugular vein begins just medial to the mastoid process at the base of the skull. The internal jugular vein runs directly inferior from the mastoid process,. it joins the subclavian vein, to form r innominate which continue as superior vena cava and then into the right atrium.*The internal jugular vein is **Shows the vertical course of the ijv which psses inbetween the two heads of the st mastoid under the medial end of clavicle*Unlike ejv pulsations it is not possible to see ijv pulsations directly as it is deep. We actually see the transmitted pulsations to the overlying skin b/w the two heads of st mast.*Usually rijv s pref 4 jvp examination. RIJV is less likely affected by extrinsic compression from other structures in neck. Left inno compresssed by arch f aorta and presence of left svc can falsely elevate the jvp on left side. So in conditions with increased symp tone ejv pulsations less visible. Left IJV drains into left innominate vein, which is not in straight line from RA

**Venous pressure can be roughly assessed *Sternal angle or angle of Louis is a surface anatomical mark reference point used for JVP measurementDistance between sternal angle and center of right atrium remains relatively constant regardless of position of the thorax

In an adult with anatomically normal chestthe sternal angle is found to be 5 cm above the centre of ra in siiting supine or varios reclining angle inbetween. Since tha angle of louis has a fixed relationship with the centre of ra this landmark is used for measuresment os jvp.**Or at an angle which permits best view of the upperlevel of the venouspulsations

Iclination is required as level go below mandible in high jvp or below clavi in low pr. So start with 45 then tilt pt appropriately up or down . In patients with low jugular pressure , a lesser (