pulmonary embolisms & JVD

[zzyzx]

Why is JVD not a common sign in a patient with a massive pulmonary embolism considering that such a a patient would be suffering from an acute failure of his right ventricle?

[AZCEP]

It is not necessarily a right ventricular failure. It will depend on where the embolus seats as to what the presentation will be.

[Hitej05]

If the embolism occurs superior to what is visible of the jugular veins than of course the veins will not be distended. However, I'm sure the statistics are against the formation of an embolism superior the jugular veins. Can anyone verify this?

[logos]

You could reasonably expect JVD in someone with a large PE causing right sided heart failure. However, I would expect that a OE that large would quickly result in death secondary to hypoxia.

[ERDoc]

If the embolism occurs superior to what is visible of the jugular veins than of course the veins will not be distended. However, I'm sure the statistics are against the formation of an embolism superior the jugular veins. Can anyone verify this?

If the embolism occurs superior to the visible portion of the jugular, then it is not a PE. Most PEs are small and occur in the periphery of the lung. You can get a massive saddle embolus (embolism that blocks where the pulmonary artery branches into the left and right arteries) that will cause significant hemodynamic compromise. Most smaller PEs will only cause right heart strain and not full failure, so you would not expect to see JVD.

[zzyzx]

From what I've read, death from a massive PE is not due to hypoxia but from cardiovascular collapse. I've looked into this with several sources, including a book that I'm reading now called "Egan's Fundamentals of Respiratory Care." To quote from the book: "Death from massive pulmonary embolism is the result of cardiovascular collapse rather than respiratory failure...Pulmonary hypertension occurs when 50% of the pulmonary vascular bed has been occluded. To maintain the same flow at a higher pressure, the right ventricle must work harder. The final result is an increase in the right ventricular work, causing the right ventricle to become dilated and ischemic...the right ventricle fails with consequent hemodynamic collapse."

So this is why I'm thinking that you ought to see JVD intially. I don't however see this listed as a common sign in the other sources that I've looked at. In an Emedicine online article that I read, it makes no mention of JVD. [Common signs are dyspnea (60% of cases), chest pain (20%), rales (50%), fever (40%), cyanosis (20%) ].

I can see how eventually you could get failure of both the right and left ventricles, but wouldn't you at first see signs of right-ventricular failure?

There are two other things that I'm wondering about. Why do so many patients with a pulmonary embolism present with rales? Is it due to the subsequent failure of the left ventricle? What causes wheezing in a PE? Is it due to fluid in the lungs, or some other mechanism?

[captainstandup]

JVD is, in my opinion, a virtually useless sign (unless distension is clearly present) considering the variability of the human form. The degree of obesity prevalent in the US makes it very challenging to accurately assess jugular vein tone.

We have always been taught; and taught to students the mantra of ACLS, ITLS, PHTLS the varying value of "flat, distended, or normal" jugular veins. Given the difficulty of accurately assessing jugular vein tone accompanied by the myriad of other assessment factors that must be combined in making a solid field diagnosis, I feel precious scene time could be more effectively used in other areas of assessment.

As I eluded to in the first paragraph of this post, I now simply teach students that the presence of JVD is potentially significant but it's absence is meaningless.

OK Dust, I'm sure you, ridryder or spenac are "takin me to the woodshed" on this one. I'm ready, I think er perhaps not...................

[AnthonyM83]

Isn't that the case with most signs/symptoms...alone they're insignificant...it's the combination of many and overall impression that help you make a dx?

[Dustdevil]

OK Dust, I'm sure you, ridryder or spenac are "takin me to the woodshed" on this one. I'm ready, I think er perhaps not...................

Nah, I'm with ya. Although, I'm almost afraid to say so, because Rid is way out of my league on this kind of discussion, and may well prove us both to be idiots, lol. But it takes a lot more than just a quick visualisation to properly assess JVD. That being the case, I don't consider it to be worth significant attention in the field. I agree that, if it is bulging out at you, and you don't even have to really look for it, then it is probably significant, but only so long as there are other signs. If you have a patient presenting with nothing but nausea and vomiting, and they have visible JVD, that's probably not a significant sign. But in the presence of dyspnoea and chest pain, it does become significant.

One symptom does not a disease make. But, conversely, the absence of one symptom should not give you any real sense of confidence either.

As for why JVD does not rate higher up there in statistical correlation, I would venture to guess that is because the patient is usually so haemodynamically compromised by the time they get to that point, that the circulation simply will no longer support distension. Remember, if the right heart is gradually failing, then output from the left heart is gradually decreasing too. Without sufficient cardiac output, JVD is not possible.

[zzyzx]

Here's an interesting statistic: "More than 70% of patients who die from a pulmonary embolism are not suspected of having had one before death." (Egan's Fundamentals of Respiratory Care)