D. Heart and blood vessels Chapter V Thorax D. Heart and blood vessels Blood Vessel by Dr. Zhuo-ren Lu

1. Inspection (1) Venous blood pressure l   When the venous pressure is elevated, an engorged external jugular vein can be seen above the lower one third of the distance between super clavicle and the angle of the jaw with patient sitting erect, and above the lower two third of the distance between super clavicle and the angle of the jaw at supine position. l   It often indicates the elevated pressure in the right atrium and is an important sign of congestive heart failure, pericardial constriction, and pericardial effusion.

(2) The visible pulsation in the neck veins It indicates the regurgitation of tricuspid valve and the visible pulsation of carotid artery occurs in aortic regurgitation. The level of visible pulsation in the neck veins descends on normal inspiration and rises on expiration. The pulsation of jugular vein looks diffuse, but the point of carotid artery pulse is limited. It requires much greater pressure to eliminate the carotid artery pulse with a distinct pulse feeling. 

(3) Hepatojugular reflux Compression of the right upper abdominal quadrant for 30 to 45 seconds will result in more prominent distension of external jugular vein. l  It usually is an important sign of right ventricular failure or pericardial effusion or constriction, because blood is being transmitted from the liver to the superior vena cave without returning back to right atrium more. It is usually used to distinguish hepotohemia from hepatitis, hepotoma, hepatocirrhosis.

(4) Capillary pulsation Check capillary pulsation by pressing on nails or lips with a clear glass and looking at the change of color from pink to white. Capillary pulsation occurs in aortic regurgitation and other abnormalities associated with wide pulse pressure.

2. Palpation (1) Examiner place fingers over the radial artery and can feel the strong artery pulsating. It is still a bounding pulse when elevating the patient’s arm over his head. It is called as water-hammer pulse and often occurs in aortic regurgitation and other abnormalities associated with wide pulse pressure. (2) Pulsus paradoxus (paradoxical pulse) is an important sign of cardiac tamponade with tense pericardial effusion and less frequently with chronic constrictive pericarditis. The term refers to weakening of the pulse during deep inspiration.

(3) Pulsus alternans is characterized by a regularly alternating pulse, in which every other beat is weaker than the preceding beat. It is valuable indication of left ventricular failure. (4) Check the symmetry of pulses. Thrombosis or embolism involving one subclavian, axillary, or brachial artery usually results in an absent radial pulse on the affected side. Thus one must palpate over both sides of the radial, brachial, dorsalis pedis, popliteal, femoral arteries pulse simultaneously.

3. Auscultation (1) Auscultate both sides of carotid bruit. (2) Put the bell head on the femoral artery or brachial artery to auscultate for a pistal-shot sound like “Ta-Ta” and over the femoral artery to hear the to and fro bruit called Duroziez sign. Both of the sounds are associated with increased pulse pressure.

4. Arterial blood pressure (1) Measure blood pressure (Bp) on right arm. l    The point in which Bp is to be measured should be at the level of the heart. l   Place cuff in correct location 23cm above the elbow joint and make one finger admitted under the cuff. l    The mercury column on the manometer should be properly calibrated with the pointer at “0” before the cuff is inflated. l    The stethoscope is placed firmly over the brachial artery.

l    The examiner inflated the cuff slowly but steadily until the brachial artery pulse disappears and 2030mmHg higher. Deflate the cuff slowly at the rate of about 2mmHg/min. l    The number where the examiner hears the first pulse is the systolic pressure. The number where the pulse sound disappears is the diastolic pressure. If the difference between weakening of the sound and its disappearance is 20mmHg or greater, these two numbers should be recorded. l    One minute later, the same procedure may be followed for a second measurement of Bp. The lowest pressure is recorded as the patient’s Bp.

(2) Under the normal circumstances there is little or no significant difference in Bp (510mmHg) in the two upper extremities. The systemic pressure is slightly higher, 2040mmHg in the lower extremities by placing the cuff around the lower third of the thigh and the stethoscope over the popliteal artery than in the upper. It is important to mearsur Bp in the low extremities when the femoral and popliteal pulses are either weak or absent and in order to rule out coarctation of the aorta.

Definitions and classification of blood pressure levels (mmHg) by WHO/ISH 1999 Category Systolic Diastolic Optimal < 120 < 80 Normal <130 < 85 High normal 130-139 85-89 Grade 1 hypertension (mild) 140-159 90-99 Subgroup: borderline 140-149 90-94 Grade 2 hypertension(moderate) 160-179 100-109 Grade 3 hypertension (severe) 180  110 Isolated systolic hypertension  140 < 90 subgroup:borderline 140-149 < 90

l   Some serious causes of low Bp include acute myocardial infarction, hemorrhage, and shock. l    Increased pulse pressure happens frequently in hyperthyroidism, aortic valve regurgitation, etc. l    In elderly persons the most common cause for an elevated SP and normal DP is aortic atherosclerosis or arteriosclerosis.  The decreased pulse pressure may be resulted from pericardial effusion, constrictive pericarditis, aortic stenosis, mitral stenosis, and heart failure.