In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would

Carotid Pulse

The carotid pulse should be examined in terms of its volume and contour. The carotid pulse (Fig. 50-5) may be increased in frequency and may be more intense than normal in patients with a higher stroke volume secondary to aortic regurgitation, arteriovenous fistula, hyperthyroidism, fever, or anemia. In aortic regurgitation or arteriovenous fistula, the pulse may have a bisferious quality. The carotid upstroke is delayed in patients with valvular aortic stenosis (Chapter 75) and has a normal contour but diminished amplitude in any cause of reduced stroke volume.

Carotid Pulses

The carotid pulses should be palpated for contour and timing in relation to the cardiac impulse. Abnormalities in the carotid pulse contour reflect underlying cardiac abnormalities (e.g., aortic stenosis) but are generally appreciated only after detecting an abnormal cardiac impulse or murmur (Chapter 50).

Many physicians listen for bruits over the carotid arteries because asymptomatic carotid bruits are associated with an increased incidence of cerebrovascular and cardiac events in older patients (Chapters 413 and 414Chapter 413Chapter 414). In asymptomatic patients, the presence of a carotid bruit increases the likelihood of a 70 to 90% stenotic lesion (LR 4 to 10), but the absence of a bruit is of uncertain value. Unfortunately, clinical data do not provide adequate data for judging the importance of detecting bruits in asymptomatic patients.

IV Pulsus Parvus ET Tardus

Cardiovascular examination

Examination of the blood pressure, pulse, neck veins, and carotid pulse has already been reviewed. Frequently, the apical impulse and point of maximal intensity are difficult to locate in a geriatric patient. Palpable thrills, especially over the aortic area, should be sought because of the frequency of systolic murmurs. Splitting of the second heart sound may be difficult to detect in older patients. The presence of a third heart sound is not physiologic in elderly patients, as it is in young adults. Debate exists about whether a fourth heart sound may be accepted as normal in aged patients. Because heart disease is so common in older persons, it is not surprising that fourth heart sounds are frequently reported. This does not mean, however, that a fourth heart sound is the inevitable consequence of aging; rather, it reflects the high prevalence of cardiac disease in the geriatric population.

Systolic heart murmurs have been reported in as many as one third to one half of octogenarians. These murmurs may be due to aortic sclerosis, aortic stenosis, mitral regurgitation from numerous causes, mitral valve prolapse, hypertrophic obstructive cardiomyopathy, tricuspid regurgitation, or atrial septal defect. Clinicians examining geriatric patients should, therefore, expect to hear systolic heart murmurs often and be prepared to assess patients further through maneuvers and associated findings to determine the cause of the murmurs. “Innocent” murmurs, described in children or young adults, are not found in the geriatric age group. Valvular pathology and cardiac dysfunction are the likely explanations of a murmur in a geriatric patient.

B Associated Cardiac Signs

Other traditional findings of severe aortic stenosis are the following: (1) a carotid pulse that is abnormally small in volume and delayed (pulsus parvus et tardus); (2) a palpable apical impulse that is abnormally sustained (see Chapter 38 for definition of sustained impulse); and (3) reduced intensity of the second heart sound, which occurs because the inflexible aortic leaflets close with less force than normal. Another traditional finding is a prominent A wave in the neck veins (i.e., the Bernheim phenomenon), although this wave is more often seen on pressure tracings than at the bedside. Its mechanism is disputed.4

Circulation (“C”)

The first assessment step is to determine if the patient has a pulse.27,28,46 The carotid pulse is the easiest and most accurate in the adult and child patient (Fig. 10.9).30 The carotid artery lies just under the sternocleidomastoid muscle in the neck. Do not palpate both carotid arteries simultaneously as pressure on the baroreceptors of the carotid sinuses may precipitate reflex bradycardia.27 When assessing the infant, the brachial pulse should be palpated.28,46

While assessing pulse, evaluate chest movement.28,46 If there is good rise and fall of the chest and a pulse, the patient likely has circulation. If the patient has no chest movement or a very slow, gasping type of breathing (agonal breathing), then assume there is no circulation.27,28,46 Begin chest compressions immediately (Box 10.2).46 EMS should simultaneously be activated. Allow full recoil of the chest after each compression; do not lean on the chest after each compression.46 Compressions should be fast and deep.46

Internal Jugular Vein Approach

I.

The patient's head is rotated 45 degrees away from the planned insertion site (Fig. 3-2).

The carotid pulse is palpated and displaced medially with the nondominant hand. A small-gauge finder needle is inserted lateral to the carotid pulse at the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle, and is advanced toward the ipsilateral nipple. After localization of the IJ with the finder needle (as evidenced by blood return), an introducer needle is inserted along an immediately adjacent path, into the vein.

Venous (rather than arterial) catheterization can be confirmed by attaching intravenous extension tubing to the introducer needle and drawing blood into the tubing with a syringe. A column of venous blood readily descends down the intravenous tubing. On the other hand, if the needle is in the carotid artery, the column of blood will continue to ascend through the tubing. In the event that the artery is inadvertently cannulated, the needle should be removed immediately and firm pressure applied at the site.

THE COLOR OF THE BLOOD RETURN IS AN UNRELIABLE MARKER FOR VENOUS CATHETER PLACEMENT.

Head, neck, and cervical spine

A thorough screening to determine the probable aetiology of upper extremity pain usually begins with at least a routine evaluation of head, neck, and cervical spine. The few procedures outlined below are adequate to eliminate these structures as the probable source of pain in the initial assessment.

1.

Visual inspection, looking for deformities, atrophy, loss of normal contour

Palpation of spinous and transverse processes, thyroid gland, and carotid pulse

Range of movement of head and neck, with rotation right to left, flexion/extension, and lateral bending

Distraction or evaluation of the effect of cervical traction by placing hands on occiput and under chin

Compression: if neural foramina are compromised, this may produce or intensify pain

Valsalva manoeuvre to determine whether straining with breath holding reproduces pain

Lhermitte's sign: flexion or extension of the head and neck causes lancinating or ‘electric’ shock radiating from neck into hands (Brody and Wilkins 1969)

Adson's test: in the modified Adson's test, the patient's arm is abducted to 90° and externally rotated with the elbow flexed. The patient turns the head towards the abducted arm, takes a deep breath, and coughs. The test is positive if the radial pulse is reduced or absent. This may indicate compression of the subclavian artery (Adson 1951).

Testing for radiculitis is based on radiation of symptoms such as sensory changes, weakness, and loss of reflexes. If the symptoms are aggravated by cervical tests that stretch the nerve roots, increase intraspinal pressure (Valsalva manoeuvre), or decrease the spinal foramina (head compression), the diagnosis is implied.

Cervical spondylosis, which results in gradually increasing clinical signs, may present multiple levels of nerve root irritation and contribute to confusion of diagnosis, particularly in patients over 55 years of age. In younger age groups, single nerve root involvement due to cervical herniation is more common (see Chap. 19).

A summary of neurological levels relating to the upper extremity is shown in Table 6.2. Weakness in any of these extremity structures calls for further evaluation of the cervical spine in addition to assessment of the extremity itself.

20 How is aortic stenosis differentiated from aortic sclerosis by physical examination?

The following clinical findings are present in patients with aortic stenosis but absent with aortic sclerosis:

Diminished carotid arterial upstroke (i.e., the rate of rise of the carotid pulse is less steep)

Diminished peripheral arterial pulses (a finding consistent with moderate-to-severe aortic stenosis)

Late peaking of systolic murmur (as aortic stenosis worsens in severity, the systolic murmur peak becomes more delayed)

Loud or audible (or both) S4

Syncope, angina, or heart failure signs or symptoms

Loud systolic murmur associated with a systolic thrill