# Jugular distension



## Austin carawan (Jan 28, 2016)

if you have lung sounds on the right, but not on the left, and jugular veins are distended, and the trachea has shifted to the right, what is going on? Resp. 32 shallow pulse 120 and bp110/70 with cold clammy skin. Any help is appreciated


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## Summit (Jan 28, 2016)

What do you think the answer to your homework question might be?


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## Jim37F (Jan 28, 2016)

Sounds like a homework question. What do you think is going on and why? What would be causing those signs? What anatomy or physiology would be pulling on the trachea like that?


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## Austin carawan (Jan 28, 2016)

I'm pretty sure I'm dealing with a pneumothorax, but I always thought if you had right lung sounds, the trachea would be pushed and shifted to the left by the right lung, or have I got a tension pneumothorax?


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## Austin carawan (Jan 28, 2016)

Jim37F said:


> Sounds like a homework question. What do you think is going on and why? What would be causing those signs? What anatomy or physiology would be pulling on the trachea like that?


 was I looking at backwards? It's the air escaping the damaged lung filling the pleural space causing tracheal deviation isn't it???


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## Jim37F (Jan 28, 2016)

There's something in the chest (thats most def where it shouldn't be) that's affecting the left lung so you can't hear lung sounds on that side. Air and _____? Fill in the blank, apply a bit of logic to what the blank will do to the trachea and R lung from where it's sitting in the left side and you'll have your answer.


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## Austin carawan (Jan 28, 2016)

Is blood what you are hinting at?


Jim37F said:


> There's something in the chest (thats most def where it shouldn't be) that's affecting the left lung so you can't hear lung sounds on that side. Air and _____? Fill in the blank, apply a bit of logic to what the blank will do to the trachea and R lung from where it's sitting in the left side and you'll have your answer.


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## Jim37F (Jan 28, 2016)

Eh, I was actually trying to hint towards pressure, but I just reread what I wrote and I could've been clearer towards that ha, but basically what you said just above that....Air causes pressure pushing on all the other structures inside the chest.


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## Austin carawan (Jan 28, 2016)

Oh, yep I had it backwards entirely, so the pressure from the air builds up and pushes the whole system. I'm with you now. And that's a als procedure to do decompression.. As far as I know that's the only effective treatment for this patient


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## Gurby (Jan 28, 2016)

Austin carawan said:


> Oh, yep I had it backwards entirely, so the pressure from the air builds up and pushes the whole system. I'm with you now. And that's a als procedure to do decompression.. As far as I know that's the only effective treatment for this patient



Do you suppose ALS is going to stick a needle in this guy's chest?


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## Austin carawan (Jan 28, 2016)

That's what I had in mind yes, am I overlooking something?


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## Gurby (Jan 28, 2016)

Austin carawan said:


> That's what I had in mind yes, am I overlooking something?



What's the difference between a pneumothorax and a tension pneumothorax?


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## Austin carawan (Jan 28, 2016)

Let's see if I have this right, a pneumothorax is simply air in the pleural space, while a tension pneumothorax is when structures shift to the opposite side because of the built up pressure from that air


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## Jim37F (Jan 28, 2016)

Right, it'd a progression. Where in that progression would you see a particular sign an assessment will reveal that mark the difference and cause a medic to start thinking decompression? It's a sign you can find as an EMT and will find before the trachea has started to noticeably shift.


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## Gurby (Jan 28, 2016)

Austin carawan said:


> Let's see if I have this right, a pneumothorax is simply air in the pleural space, while a tension pneumothorax is when structures shift to the opposite side because of the built up pressure from that air



Not exactly... What complications could arise from a pneumothorax?  What are we most concerned about?


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## Austin carawan (Jan 28, 2016)

To Jim, jugular distension is a very late sign, so mark that out, would you find rigidness on that side of the chest? Or is the absence of lung sounds on only one side where I should be headed?


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## Austin carawan (Jan 28, 2016)

To gurby, your primary concern is your patients abcs,  should we be concerned that he is being adequately ventilated?


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## Gurby (Jan 28, 2016)

Austin carawan said:


> To gurby, your primary concern is your patients abcs,  should we be concerned that he is being adequately ventilated?



That's a concern, sure.  But what else could happen?  We have all that air building up in the chest, pushing on and compressing things... What else is in the chest that we need to worry about?

I'm certainly not an expert, but I think most patients with tension pneumo don't die from hypoxia secondary to ventilation issues.  They die of something else before it gets to that point...


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## Jim37F (Jan 28, 2016)

Gurby said:


> That's a concern, sure.  But what else could happen?  We have all that air building up in the chest, pushing on and compressing things... What else is in the chest that we need to worry about?
> 
> I'm certainly not an expert, but I think most patients with tension pneumo don't die from hypoxia secondary to ventilation issues.  They die of something else before it gets to that point...





Austin carawan said:


> if you have lung sounds on the right, but not on the left, and *jugular veins are distended*, and the trachea has shifted to the right, what is going on? Resp. 32 shallow pulse 120 and bp110/70 with *cold clammy skin*. Any help is appreciated


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## Gurby (Jan 28, 2016)

I feel like one part of that patient description is wrong...


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## Gurby (Jan 28, 2016)

Or how about this:

If this was my patient I would consider a needle decompression, but I would feel bad about it and call medical control first.  Medical control would likely tell me to hold off, drive fast, but be ready to pop a needle in if patient condition changes. 

Why do you suppose I feel bad about it, and why would medical control probably tell me to not decompress?


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## STXmedic (Jan 28, 2016)

Gurby said:


> Or how about this:
> 
> If this was my patient I would consider a needle decompression, but I would feel bad about it and call medical control first.  Medical control would likely tell me to hold off, drive fast, but be ready to pop a needle in if patient condition changes.
> 
> Why do you suppose I feel bad about it, and why would medical control probably tell me to not decompress?


Your Med control is a pansy.

To be fair, if the patient presented as described he likely would not have a BP of 110/something.


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## Gurby (Jan 28, 2016)

STXmedic said:


> Your Med control is a pansy.
> 
> To be fair, if the patient presented as described he likely would not have a BP of 110/something.



That's what I was getting at with "part of the patient description is wrong" - this would be a slam dunk needle decompression except that patient's blood pressure is seemingly stable.  Maybe med control would ask me to re-check the blood pressure, because the picture doesn't seem to make sense.  I doubt you could build up enough pressure to cause tracheal deviation without also causing significant hemodynamic compromise. 

I suppose this is outside of the scope of OP's question anyways.  I just wanted to make him/her think a bit more about what a pneumothorax is, what a tension pneumo is, what issues can come from it and the pathophysiology behind it.


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## Austin carawan (Jan 28, 2016)

That was word for word. I'm not too sure then... Ohhh! Hypoperfusion Jim!?!?


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## Austin carawan (Jan 28, 2016)

Please bare with me, as online schooling truly leaves several dark spots, would you expect to see a low blood pressure?


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## Austin carawan (Jan 28, 2016)

Or would syst. And diastolic grow closer together?


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## STXmedic (Jan 28, 2016)

So a tension pneumo causes a decreased preload. If the preload decreases, what would you expect to happen to the blood pressure? (Hint: think a hose a spray nozzle. If you king the hose, what happens to the nozzle)


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## Gurby (Jan 28, 2016)

STXmedic said:


> So a tension pneumo causes a decreased preload. If the preload decreases, what would you expect to happen to the blood pressure? (Hint: think a hose a spray nozzle. If you king the hose, what happens to the nozzle)



I wonder if OP can explain why/how tension pneumo reduces preload (basically the amount of blood in the heart just before it contracts)?


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## Flying (Jan 28, 2016)

Save for exceptional classes and instructors, preload just _isn't_ a thing at the EMT level guys.


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## Austin carawan (Jan 28, 2016)

Ohh, so basically the heart cannot fill up with blood efficiently therefore causing it to pump less blood out. Low bp. Kind of like vasodilation except but vice versa? Ie instead of arteries expanding you have less fluid? You guys are a great help, emailing the instructor only leads me to believe I didn't read well enough, thank you all


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## Flying (Jan 28, 2016)

Austin carawan said:


> Ohh, so basically the heart cannot fill up with blood efficiently therefore causing it to pump less blood out. Low bp. Kind of like vasodilation except but vice versa? Ie instead of arteries expanding you have less fluid? You guys are a great help, emailing the instructor only leads me to believe I didn't read well enough, thank you all


A better way to describe it is that the heart is being smothered. If you press on all sides of the heart at once (which is what the air pressure is doing) you will end up with poor filling of blood and poor ejection of blood.







Instead of a hand, you have air pressure that isn't supposed to be in the thoracic cavity. You can probably figure out why you get JVD and reduced pressure.

Think of reasons this might happen in the first place and how a pneumothorax would evolve into a tension pneumo.


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## Austin carawan (Jan 28, 2016)

i understand, would the lack of circulation be of greater importance than the air in the pleural space? Or remove the air and the heart problem fixes itself?


Flying said:


> A better way to describe it is that the heart is being smothered. If you press on all sides of the heart at once (which is what the air pressure is doing) you will end up with poor filling of blood and poor ejection of blood.
> 
> 
> 
> ...


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## Gurby (Jan 28, 2016)

Flying said:


> A better way to describe it is that the heart is being smothered. If you press on all sides of the heart at once (which is what the air pressure is doing) you will end up with poor filling of blood and poor ejection of blood.



I'm not sure if it's actually pressure on the vena cava that does it, or if it's pressure exerted directly on the heart.  The vein is probably easier to compress, so I'd imagine that happens first.  Same idea either way.

On the topic of physical findings, at least in my experience, you are not actually very likely to see tracheal deviation or JVD (but it's good to recognize those signs for the test, no doubt).  You are more likely to see subcutaneous emphysema: air going elsewhere in the body into places it shouldn't go, causing what looks like swelling:






Actually it looks like there might be some TD in this next one.  Cool!


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## STXmedic (Jan 28, 2016)

Flying said:


> Save for exceptional classes and instructors, preload just _isn't_ a thing at the EMT level guys.


Both programs I've taught at, we've taught basics about the concepts hemodynamics, including preload and after load. But that's only two programs I suppose.



Austin carawan said:


> Ohh, so basically the heart cannot fill up with blood efficiently therefore causing it to pump less blood out. Low bp. Kind of like vasodilation except but vice versa? Ie instead of arteries expanding you have less fluid? You guys are a great help, emailing the instructor only leads me to believe I didn't read well enough, thank you all



Yes and no. You've got the idea right. They will be hypotensive because their heart can't fill as much. Less in = less out. Especially when you factor in the Frank-Starling law (that is one you likely didn't cover). It also doesn't necessarily "push on all sides at once". That's more descriptive of cardiac tamponade. What the tension pneumo _is_ doing is displacing the heart to the side- away from the injury. Now going back to the hose analogy, what supplies the preload to the heart?


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## Flying (Jan 28, 2016)

Gurby said:


> I'm not sure if it's actually pressure on the vena cava that does it, or if it's pressure exerted directly on the heart. The vein is probably easier to compress, so I'd imagine that happens first. Same idea either way.


From what I understood, it doesn't really matter what is being compressed, just that thoracic pressure works against the entire system additively/subtractively. Probably an oversimplification.


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## Austin carawan (Jan 28, 2016)

The venue cavae!


STXmedic said:


> Both programs I've taught at, we've taught basics about the concepts hemodynamics, including preload and after load. But that's only two programs I suppose.
> 
> 
> 
> Yes and no. You've got the idea right. They will be hypotensive because their heart can't fill as much. Less in = less out. Especially when you factor in the Frank-Starling law (that is one you likely didn't cover). It also doesn't necessarily "push on all sides at once". That's more descriptive of cardiac tamponade. What the tension pneumo _is_ doing is displacing the heart to the side- away from the injury. Now going back to the hose analogy, what supplies the preload to the heart?


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## STXmedic (Jan 28, 2016)

Austin carawan said:


> The venue cavae!


Exactly. So the heart/mediastinum gets displaced away from the injury due to pressure. The vena cava have some give, but not a ton. As the heart shifts, they start to shift with it and "flatten". Flatten the garden hose and you see what's now giving the heart it's preload. Significantly less flow, yeah?


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## Gurby (Jan 28, 2016)

Flying said:


> From what I understood, it doesn't really matter what is being compressed, just that thoracic pressure works against the entire system additively/subtractively. Probably an oversimplification.



Lots of factors at work I guess.  Increased pressure alone will drop preload, as seen with CPAP.


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## Austin carawan (Jan 28, 2016)

Yea definitely!  So is you primary concern, circulation or the air in pleural space? 
My thoughts are, fix the air pressure, and the heart will find itself back where it should be. Is that incorrect? 


STXmedic said:


> Exactly. So the heart/mediastinum gets displaced away from the injury due to pressure. The vena cava have some give, but not a ton. As the heart shifts, they start to shift with it and "flatten". Flatten the garden hose and you see what's now giving the heart it's preload. Significantly less flow, yeah?


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## STXmedic (Jan 28, 2016)

Gurby said:


> Lots of factors at work I guess.  Increased pressure alone will drop preload, as seen with CPAP.


Yeah, very true. CPAP is causing positive pressure and hyperinflation in both pleural spaces, so that would be a little more descriptive of pressure from all sides. The pressure also works on baroreceptors.


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## STXmedic (Jan 28, 2016)

Austin carawan said:


> Yea definitely!  So is you primary concern, circulation or the air in pleural space?
> *My thoughts are, fix the air pressure, and the heart will find itself back where it should be.* Is that incorrect?


That's exactly correct. It's impressive how fast they experience relief after relieving the pressure. As a basic though, what can/will you do? And even better, how much will it help?


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## luke_31 (Jan 28, 2016)

Austin carawan said:


> Yea definitely!  So is you primary concern, circulation or the air in pleural space?
> My thoughts are, fix the air pressure, and the heart will find itself back where it should be. Is that incorrect?


That's correct. A lot of what is done as definitive treatment is fixing the underlying problem which in this case is removing the air from where it's not supposed to be. Most EMS treatments involve alleviating symptoms, but some cases we can actually provide a definitive treatment,  this case we are only able to temporarily alleviate the underlying cause as a chest tube is a more definitive treatment for the tension pneumothorax that you described in your scenario.


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## Jim37F (Jan 28, 2016)

I'm really liking this thread, it could easily have petered out after a couple of replies saying "Read your damn book", instead we have a great mini lesson for all to read up on pneumos


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## Austin carawan (Jan 28, 2016)

Jim37F said:


> I'm really liking this thread, it could easily have petered out after a couple of replies saying "Read your damn book", instead we have a great mini lesson for all to read up on pneumos


 Haha I knew it should have been simple, but the book didn't provide a definitive answer, neither did the instructor, thank you for your patience tho


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## luke_31 (Jan 28, 2016)

Austin carawan said:


> Haha I knew it should have been simple, but the book didn't provide a definitive answer, neither did the instructor, thank you for your patience tho


Congratulations, you're learning that sometimes even when you read the book it doesn't give you everything that you need to understand the answer.  You can always ask us questions here, but expect us to first see what you know, and we can help guide you to understanding. Using the Internet to search for additional information is also helpful too.  A good A and P book will also help with a foundation of knowledge on the body which will make understanding a lot of what we do easier.


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## Austin carawan (Jan 29, 2016)

I agree, one chapter was not enough


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