Jugular venous distention resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Jugular venous distension (JVD), or an elevated jugular venous pressure (JVP), is considered a useful physical finding for assessing ventricular filling pressures and central venous pressure (CVP). JVD is defined as an estimated JVP ≥10 cm H2O.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Acute heart failure
• Massive pulmonary emboli
• Right ventricular myocardial infarction
• Cardiac Tamponade
• Tension Pneumothorax

Common Causes

• Congestive heart failure
• Cor pulmonale
• Fluid overload

Diagnosis

Shown below is an algorithm summarizing the diagnosis of jugular venous distension according to the ACC and ESC guidelines.

Jugular Venous Distension

With pulmonary edema

Without pulmonary edema

Congestive heart failure

Increased right atrial pressure

Venous obstruction

Increased intrathoracic pressure

❑ Restriction of right atrial and right ventricular filling: ❑ Cor pulmonale (Massive pulmonary emboli, COPD) ❑ Pulmonary Hypertension ❑ Constrictive pericarditis ❑ Cardiac Tamponade ❑RV Failure: ❑ Cardiomyopathy ❑ RV myocardial infarction ❑ Fluid overload due to renal diseases ❑ Tricuspid valve incompetence ❑ Tricuspid valve stenosis or obstruction

❑ Superior vena cava obstrcution

❑ Positive pressure ventilation ❑ A large pleural effusion ❑Tension Pneumothorax

Treatment

• The management of jugular venous distension should be directed towards the underlying causes.
• Treatment of congestive heart failure usually includes diuretics (for symptom relief), beta blockers, angiotensin converting enzyme inhibitors (ACE-I) /aldosterone receptor blockers (ARB).
  • For a complete guide on the treatment of congestive heart failure, click here.
    
• Treatment of right ventricular myocardial infarction includes reperfusion, maintenance of right ventricular preload, decreasing right ventricular afterload, restoring cardiac rate/rhythm and atrioventricular synchrony, and inotropic support.
  • For a complete guide on the treatment of right ventricular myocardial infarction, click here.
    
• Treatment of massive pulmonary embolism usually includes fibrinolytic therapy.
  • For a complete guide on the treatment of pulmonary embolism, click here.
    
• Treatment of pericardial tamponade usually includes pericardiocentesis.
  • For a complete guide on the treatment of cardiac tamponade, click here.
    
• Treatment of tension pneumothorax includes immediate needle decompression followed by chest tube insertion.
  • For a complete guide on the treatment of tension pnemuothorax, click here.
    

Do's

• If the JVP does not seem elevated when the patient is supine, a provocative test, i.e., abdominojugular test, should be performed.

Don'ts

• JVD only provides clues to the presence of an elevated central venous pressure (CVP). Clinicians should avoid making decisions about the degrees of CVP elevation based on the JVP measurement.

References

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