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Korotkoff Sounds

KOROTKOFF SOUNDS Systolic blood pressure (SBP) 120 mm Hg Phase 1: A thud

110 mm Hg Phase 2: a blowing noise

100 mm Hg Phase 3: a softer thud

90 mm Hg Phase 4: a disappearing blowing noise (muffling)

Diastolic blood pressure (DBP) 80 mm Hg Phase 5: No korotkoff sounds

Types and Character of Korotkoff Sounds

AHA 2017 classification

Blood pressure (BP) category Systolic BP Diastolic BP

Normal <120 mm Hg And <80 mm Hg

Elevated 120–129 mm Hg And <80 mm Hg

Stage 1 hypertension 130–139 mm Hg Or 80–89 mm Hg

Stage 2 hypertension ≥140 mm Hg Or ≥90 mm Hg

Note: ESC guidelines 2018 and comparison table of JNC 7 and AHA 2017 are discussed in page 493 in

annexures.

Steps of examination blood pressure

Key steps Specific instructions

Step 1: Properly prepare the

patient

The patient should rest comfortably for 5 minutes prior to the measurement in the seated

position with their back supported. The patient’s legs should be uncrossed with feet flat on

the floor (Fig. 2B.20).

The patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measurement

Ensure that the patient has emptied his/her bladder

Neither the patient nor the observer should talk before or during the measurement

Measurements made while the patient is sitting or lying on an examining table do not fulfill

these criteria

Step 2: Use proper technique for

BP measurements

Use a BP measurement device that has been validated, and ensure that the device is

calibrated periodically.

The arm should be bare, supported and kept at heart level

Position the middle of the cuff on the patient’s upper arm at the level of the right atrium (the midpoint of the sternum) (Fig. 2B.21).

Use a cuff with an appropriate bladder size: Bladder width should be close to 40% of the

arm circumference and length should cover 80-100% of the arm circumference. The lower

edge of the cuff should sit 3 cm above the elbow crease with the bladder centered over the

brachial artery

Either the stethoscope diaphragm or bell may be used for auscultatory readings

Step 3: Take the proper measurements needed for

diagnosis and treatment of

elevated BP/hypertension

At the first visit, record BP in both arms. Use the arm that gives the higher reading for

subsequent readings

Repeat blood pressure measurements should be taken 1–2 minutes apart

Increase the pressure to 30 mm Hg above the level at which the radial pulse is extinguished

Place the bell or diaphragm of the stethoscope over the brachial artery

Open the control valve so that the rate of deflation of the cuff is 2 mm Hg per heart beat

Systolic blood pressure is the appearance of the first Korotkoff sound

The diastolic blood pressure is the point at which the sound disappears (phase 5 Korotkoff)

If Korotkoff sounds continue as the level approaches 0 mm Hg, listen for when the sound

becomes muffled to indicate the diastolic blood pressure

Step 4: Properly document

accurate BP readings

Record BP to the closest 2 mm Hg on the sphygmomanometer, as well as the arm used

and the position of the patient (supine, sitting or standing)

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Note the time of most recent BP medication taken before measurements

Step 5: Average the readings Use an average of ≥2 readings obtained on ≥2 occasions to estimate the individual’s level

of BP.

In presence of atrial fibrillation, minimum of 3 BP readings have to be estimated

Step 6: Provide BP readings to

patient

Provide patients the SBP/DBP readings both verbally and in writing

Fig. 2B.20: Demonstration of BP measurement. Fig. 2B.21: Demonstration of placement of BP cuff.

Selection Criteria for BP Cuff Size for Measurement of BP in Adults

Arm circumference Usual cuff size

22–26 cm Small adult

27–34 cm Adult

35–44 cm Large adult

45–52 cm Adult thigh

White Coat Hypertension

Normal blood pressure at home or on ambulatory blood pressure monitoring but elevated office blood

pressure.

Masked Hypertension

Elevated blood pressure at home or on ambulatory blood pressure monitoring but normal office blood

pressure.

Paroxysmal Hypertension

Episodic elevated BP.

Pheochromocytoma

Panic disorders

Labile hypertension

Carcinoid

Clonidine withdrawal

Hyperthyroidism

Coronary insufficiency

Cluster or migraine headaches

Seizure disorder

CNS lesions (such as stroke, tumor, hemorrhage)

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Renovascular hypertension

Hypoglycemia

Cheese reaction

Anxiety

Drugs—cocaine, lysergic acid diethylamide, amphetamine

Baroreflex failure

Factitious hypertension

Pseudohypertension

Defined as cuff diastolic blood pressure ≥15 mm Hg higher than simultaneously measured intra-arterial

blood pressure. A palpable although pulseless, radial artery while the BP cuff is inflated above systolic

pressure, is a positive Osler sign. Osler sign occurs due to Monckeberg’s sclerosis of arteries.

Paradoxical Hypertension

On starting treatment with antihypertensives, the BP rises instead of falling in the following conditions.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for a

patient with renal artery stenosis

Beta-blockers given to a patient with pheochromocytoma

Beta-blockers in a patient with diabetic autonomic neuropathy.

HYPOTENSION

Hypotension is defined as blood pressure that is lower than 90/60 mm Hg.

Reference: NIH

Causes (Fig. 2B.22)

Fig. 2B.22: Cause of hypotension according to age group.

Postural Hypotension/Orthostatic Hypotension

A drop in blood pressure (hypotension) due to a change in body position (posture) when a person

moves to a more vertical position, i.e. from sitting to standing or from lying down to sitting or standing.

Postural (orthostatic) hypotension is diagnosed when, within 2–5 minutes of quiet standing (after a 5- minute period of supine rest), one or both of the following is present:

At least a 20 mm Hg fall in systolic pressure

At least a 10 mm Hg fall in diastolic pressure.

Many disorders can cause orthostatic hypotension, with the two major mechanisms being autonomic

failure, which can be caused by multiple disorders, and severe volume depletion.

Autonomic failure Volume depletion

Diabetic neuropathy

Parkinson disease

Dementia with Lewy bodies

MSA (Shy-Drager syndrome)

Acute or subacute volume depletion (due to diuretics, hyperglycemia,

hemorrhage, or vomiting)

Chronic hypovolemia, a frequent feature of autonomic failure, exacerbates

orthostatic symptoms

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Spinal cord transection

Chronic kidney disease

Amyloidosis

Guillain-Barré syndrome

Paraneoplastic autonomic neuropathy

Familial dysautonomia (Riley-Day syndrome)

Primary autonomic failure (BradburyEggleston syndrome)

Postprandial Hypotension

In postprandial hypotension, blood pressure falls occur within one to two hours after a meal.

JUGULAR VENOUS SYSTEM

Jugular Venous Pulse

It is defined as undulating top of oscillating column of blood in right internal jugular vein that faithfully

represents the pressure and volumetric changes in the right side of heart which changes with various

stages of cardiac cycle and respiration.

Why is the Right IJV Preferred?

Right side internal jugular vein (IJV) is in direct connection and in straight line.

Veins in the left side of the neck reach the heart by crossing the mediastinum, where they may be

compressed by the normal aorta; causing the left jugular venous pressure to appear elevated even

when the CVP and right atrial pressures are normal.

Why internal jugular vein preferred over external jugular vein for JVP assessment?

Internal jugular External jugular

Straight communication with right

atrium

Not in straight communication with right atrium

Less valves More valves

Less influenced by fascial planes More kinked by fascial planes

Less affected by sympathetic system More affected by sympathetic system

Vasoconstriction secondary to hypotension (in CCF) can make EJV small and barely

visible

Differences between carotid and JVP

Carotid pulse Jugular venous pulse

Better felt Better seen

Cannot be obliterated Can be obliterated (by pressure at root of neck)

One positive wave Two positive and two negative waves

Medially seen Laterally seen

Seen in lower part Seen in upper part

Definite upper level absent Definite upper level present

Expansile impulse (outward) Retractile impulse (inward)

Does not change with position Changes with position

Does not change with respiration Changes with respiration

Does not change with abdominal compression Changes with abdominal compression

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Steps of Examination of JVP (Figs. 2B.24 and 2B.25)

Patient comfortably lying in semi reclined position (45° position).

The patient’s neck should be slightly turned towards the left side.

Shine a torch light onto the neck tangentially from the left side.

Observe for pulsation between two heads of sternocleidomastoid

Trace the pulsation and locate the upper level

Take two scales. Place one scale at the upper level of the JVP, parallel to the ground.

Now place the second scale at the level of the sternal angle, perpendicular to the first scale.

Measure the vertical height on the second scale.

Express as ___ cm of water above sternal angle. Add 5 cm to this value to determine the right atrial

pressure.

Conversion: 1.36 cm of H2O or blood = 1 mm Hg

The normal JVP is less than 4 cm above the sternal angle; or is just visible above the clavicle in 45°

position.

Normal CVP is <7 mm of Hg or 9 cm H2O.

Fig. 2B.23: Anatomy of the right IJV.

Fig. 2B.24: Method of measuring the JVP.

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