Veinity Fair: Evaluating jugular venous distension

Paramedics are a strange breed. What fascinates us often escapes the interest of others. Proof of our weirdness can be found in our interactions with other people. We can discuss abdominal eviscerations over a plate of spaghetti, and fantasize about the day we'll cut a hole in someone's throat or stick a huge needle in their chest – and never find it odd. And when other people meet someone new, they may be attracted to a warm smile or beautiful eyes. Paramedics and ER nurses, on the other hand, are only thinking one thing: "Heeyyyyy, nice veins!"

Come on, admit it. How many of us, when meeting someone new, have barely registered their name because we're hopelessly distracted by God's gift of great vasculature? I know I have. Hey, don't judge me. I told you I was weird (and not alone ... vein oggling is a top off-duty habit of EMS providers).

JuGULAR VENOUS DISTENSION To properly evaluate jugular venous distension, the patient must be placed at a 45 degree angle,or slightly less. Visualization of the jugular veins is best done at an oblique angle, so sit beside the patient and elevate the head of the cot into a semi-Fowler's position. Look along the sternocleidomastoid muscle for where the jugular vein runs perpendicularly across its surface.

ugular venous distension roughly correlates to central venous pressure, and one can often calculate a central venous pressure from observing the degree of JVD. Normal CVP in a healthy person is 10 cm H2O, and causes JVD to the level of the clavicles. For every centimeter of JVD above the clavicles, CVP is elevated 1 cm H2O. Thus, a patient with JVD four centimeters above the clavicles would have a roughly estimated CVP of 14 cm H2O.

Aside from being a neat piece of cool medical trivia you can impress your friends and colleagues with, clinical evaluation (as opposed to formal, invasive measurement, rarely available to us outside the critical care transport environment) of elevated CVP is an important diagnostic indicator of a number of disease states, most notably right ventricular infarction and obstructive shock.

Kussmaul's Sign is the observation of JVD that rises with inspiration. Normally, jugular venous pressure does just the opposite during inspiration, due to the fall in intrathoracic pressure. If your patient's jugular veins appear to fill rather than empty during inspiration, that's a pretty solid indication of impaired right ventricular filling. One of the conditions that can cause such impairment is right ventricular infarction.

If your patient with epigastric or chest pain exhibits Kussmaul's Sign, orthostatic weakness or syncope, and 12-lead findings indicative of inferior wall MI, take the time to do a right-sided EKG (or just look for ST elevation in V4R) to rule out RVI. Those patients are notoriously sensitive to even small decreases in preload, so use nitrates with due caution. Obstructive shock, such as that induced by cardiac tamponade or tension pneumothorax, can be a life-threatening event, and evaluation of JVD may yield important diagnostic clues. In cardiac tamponade, jugular venous distension is one corner of Beck's Triad, which consists of the presence of JVD, muffled heart sounds, and narrowed pulse pressure.

Jugular venous distension, narrowed pulse pressure, and unilaterally decreased or absent breath sounds often indicate a tension pneumothorax. This is also a diagnostic triad, although since I cannot find a specific claim to it, I'm going to call it "Kelly's Shameless Ripoff of Beck's Triad." I hope the following tidbits about jugular venous distension prove helpful to you in clinical practice, and remember, the next time someone catches you ogling his/her veins, you're not weird.

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