Phenomena
❑ Elevated jugular venous pressure
❑ Low jugular venous pressure
❑ Kussmaul sign
❑ Giant a waves
❑ Cannon a waves
❑ Prominent v wave
❑ Flutter waves
❑ Precipitous x descent
❑ Prominent y descent
❑ Slow y descent
Tangential light and the patient at a 30 to 45 degree angle facilitate observation of the meniscus of the undulating internal jugular pulse. Uncertainty may be reduced by light pressure over the base of the neck, which will obliterate the jugular but not carotid pulse. The sternomanubrial angle is by convention 5 cm vertically above the mid-right atrium, and the jugular venous pressure (JVP) is measured vertically above this landmark.
The a wave is the dominant waveform, caused by right atrial contraction, preceding the carotid impulse. It is absent in atrial fibrillation. The c wave is simultaneous with the carotid pulse, caused by bulging of the tricuspid into the right atrium. It is not usually visible. The v wave occurs during systole until the tricuspid valve opens, and is due to passive increase in right ventricle pressure with filling in late systole and early diastole. The x descent is caused by right atrial relaxation and downward displacement of the tricuspid valve during ventricular systole. The y descent results from the opening of the tricuspid valve and rapid inflow of blood into the right ventricle.
Engorged veins over the thoracic outlet may be caused by retrosternal goiter or superior venal cava obstruction. Unilateral JVD may be due to supraclavicular occlusion caused by enlarged lymph nodes, thrombosis, or subclavian neoplasm.
Elevated jugular venous pressure Elevated JVP is associated with right heart failure, constrictive pericarditis, and tamponade. Acute left ventricular failure (as in acute myocardial infarction) may raise the pulmonary artery pressure without increasing the mean right atrial pressure. Pulmonary hypertension or tricuspid insufficiency may elevate JVP without left heart failure. Abdominojugular reflux (sustained elevation of the JVP with abdominal pressure) is due to the failing right ventricle’s inability to respond to augmented preload, and suggests right ventricular dysfunction. Cardiac tamponade should be suspected when there is an elevated JVP, pulsus paradoxus, a quiet precordium and absence of signs of pulmonary hypertension.
Low jugular venous pressure If the jugular veins are collapsed in the supine position, right atrial pressure is low, usually due to volume depletion or shock.
Kussmaul sign JVP paradoxically rises rather than collapses during inspiration. It occurs in constrictive pericarditis (40% of cases) but is uncommon in acute tamponade. It is also seen in .90% of patients with acute right ventricular infarction, and in massive pulmonary embolism.
Giant a waves The jugular pulse appears to be leaping, caused by the right atrium contracting against resistence, such as a noncompliant right ventricle (pulmonic stenosis, cor pulmonale, or restrictive cardiomyopathy), tricuspid stenosis, or a right ventricular mass (presenting with syncope). Tricuspid valvular disease may be associated with a mid-diastolic rumble at the LLSB which increases with inspiration, and an opening snap. Pulmonic stenosis is associated with a systolic ejection murmur, widely split S 2 with a loud P2, and a sustained left parasternal impulse.
Cannon a waves These waves are variable in height and appearance. They occur when the atrium contracts against a closed tricuspid valve. Irregular cannon a waves occur with atrioventricular dissociation (complete heart block or ventricular tachycardia) whereas regular cannon a waves can occur with junctional tachycardia, slow ventricular tachycardia, 2:1 atrioventricular block and bigeminy.
Prominent v wave The v wave may be as prominent as the a wave in atrial septal defect or tricuspid regurgitation, the latter with a steep y descent. Severe tricuspid regurgitation may cause earlobe or liver pulsation.
Flutter waves In atrial flutter, they appear as rapid low amplitude jugular waves.
Precipitous x descent It may occur in pericardial constriction and tamponade but not in right heart failure.
Prominent y descent Associated with an S3 or pericardial knock, it suggests constrictive pericarditis.
Slow y descent Due to delayed right atrial emptying, it is caused by tricuspid stenosis or right atrial myxoma.
Review other book chapters online related to Sandhoff Disease:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5 
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