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Clinical Summary

Central venous (right atrial) pressure is reflected by distention of the internal or external jugular veins. Distention greater than 4 cm above the sternal angle of Louis with the head of the bed elevated 30 to 60 degrees is abnormal. The presence of crackles, murmurs, rubs, percussed hyperresonance, or crepitus may help disclose the etiology.

The abdominojugular test, previously known as hepatojugular reflux, is performed by looking for JVD when placing pressure on the right upper quadrant. It is a marker for right ventricle dysfunction, constrictive pericarditis, cardiac tamponade, and tricuspid regurgitation.

Causes of JVD include right ventricular failure, left ventricular failure, biventricular failure, parenchymal lung disease, pulmonary hypertension, pulmonic stenosis, restrictive pericarditis, pericardial tamponade, SVC syndrome, pulmonary embolus, valvular disease, tension pneumothorax, increased circulating blood volume, and atrial myxoma. Temporary venous engorgement may result from Valsalva maneuver, positive-pressure ventilation, and Trendelenburg position.

Management and Disposition

Initial ED management focuses on determining the cause of the JVD as treatment varies depending on the cause. Preload reduction may help in cases of congestive heart failure. Tension pneumothorax requires a finger or needle thoracostomy and a chest tube. Pericardial tamponade requires a pericardiocentesis. Pulmonary embolism in unstable patients require thrombolytics or embolectomy. SVCS requires radiation therapy.

Pearls

  1. Right-sided myocardial infarction may produce JVD with clear lung fields.

  2. JVD may be absent in the presence of the above-listed causes if hypovolemia is present.

FIGURE 7.49

Jugulovenous Distention. An engorged external jugular vein is noted as it crosses the sternocleidomastoid muscle into the posterior triangle of the neck and disappears beneath the clavicle to join the brachiocephalic vein and the superior vena cava. This patient has severe congestive heart failure. (Photo contributor: Lawrence B. Stack, MD.)

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Video 07-06: Jugulovenous Pulsations

This patient with congestive heart failure, who is sitting at 45 degrees upright, demonstrates jugulovenous distension and pulsations.

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