Pdx Cardiac 2

Front 1

What is Central Venous Pressure a measure of?

Back 1

It is the mean right atrial pressure. This pressure is equal to the filling pressure of the right ventricle when the tricuspid valve is open.

Front 2

Normal CVP for adults

Back 2

4-7cm H20

Front 3

How can you estimate the Central Venous Pressure apart from putting in a central line?

Back 3

Physical exam of Jugular Venous Pressure

Front 4

How do you measure JVP?

Back 4

1. Put the patient at an angle so that you can see where the pulse ends on the RIGHT INTERNAL JUGULAR vein
2. Measure with a ruler out over the sternal angle, measure with a ruler how many cm it is above the sternal angle, then add 5cm

Front 5

How can you tell if the JVP is abnormally elevated?

Back 5

If, when you measure, it is more than 3cm above (vertically) from the sternal angle. This means it is total 8cm above if lying down, or 11 cm, above mid atrium if sitting up.

Front 6

What is another reference point besides the sternal angle?

Back 6

Measure from the clavicle. Mid Right Atrium is 10-11cm below clavicle so find the top of the jugular pulse and add 10.

Front 7

Where is the internal jugular vein located?

Back 7

Deep to the SCM, so venous filling must be inferred from the surface movements of the SCM.

Front 8

What are some causes of elevated JVP?

Back 8

1. RA can't empty (tricuspid stenosis)
2. RV can't empty (RV failure or pulmonic valve stenosis)
3. RV can't relax (RV hypertrophy)

Front 9

What does it mean when you hav an elevated JVP and you also have ascites or edema?

Back 9

Heart failure (due to increased RAP) or pulmonary disease.

Front 10

What happens when you have a normal JVP and also have ascites or edema?

Back 10

Chronic liver disease, lymph obstruction, abdominal malignancy.

Front 11

What are your two objectives during neck vein examination?

Back 11

1. Getting the CVP (from the JVP)
2. observing the waveforms of the venous pulse

Front 12

Which vein should you use to observe the waveforms of the venous pulse?

Back 12

RIGHT INTERNAL JUGULAR! ALLDAYERRDAY!

Front 13

What will you see when you observe the waveforms?

Back 13

-2 out deflections (a + v)
-2 in deflections (x + y)
-c wave is too small to visualize

Front 14

What is the "a" wave produced from?

Back 14

Atrial contraction: pressure forces blood into the ventricles and to the neck (through the SVC)
-LARGEST wave
-follows the Pwave of the ECG right before the 1st heart sound = Presystolic

Front 15

What produces the "c" wave?

Back 15

Bulging of the tricuspid valve into the RA during Ventricular contraction.
-Starts at the end of the 1st heart sound.

Front 16

X' Descent

Back 16

Composed of RA relaxation (early x descent) and pulling of tricuspid valves into the ventricle (late x descent) during Ejection
-Ends right before 2nd heart sound
=Systolic Collapse of venous pulse (coincides with carotid pulse)

Front 17

V wave

Back 17

Caused by the build-up of venous return in the right atrium when tricuspid is closed during relaxation.
-Prior to 2nd heart sound

Front 18

Y descent

Back 18

Caused by drop in RA pressure that happens when the Tricuspid opens during the filling phase.
-starts after 2nd heart sound
=Diastolic Collapse of venous pulse

Front 19

Why do "giant" a waves occur?

Back 19

Increased resistance to right atrial emptying will produced a giant a wave.
1. atrial contraction preceds ventricular contraction
2. obstruction to right atrial or ventricular emptying

Front 20

Under what physical circumstances do "giant" a waves occur?

Back 20

1. tricuspid stenosis (blood goes to neck instead of veins)
2. right ventricular hypertrophy (ventr. doesn't relax to accept blood)
3. pulmonary hypertension
4. pulmonic stenosis

Front 21

Absent 'a' wave

Back 21

Completely no atrial contraction.
Caused by atrial fibrillation.

Front 22

Intermittent cannon 'a' waves:

Back 22

These type of waves develope when RA contraction is synchronous with RV contraction.
The tricuspid is closed, so full force of contraction is directed upward into the jugular veins.
Cannon waves are SYSTOLIC (a waves are DYSTOLIC in timing)

Front 23

Cannon "a" waves and Regular arterial pulse:

Back 23

= atrioentricular dissociation due to 3rd degree heart block.
Ventricular contractions are regular in timing and don't depend on atrial depol to carry on.

Front 24

Cannon "a" wave and Irregular pulse:

Back 24

=Premature ventricular contractions.
When these contractions coincide with atrial contractions, then cannon waves will be generated.