Jugular engorgement

Specialty: Cardiovascular.

• jugular venous distension
• cervical venous engorgement
• elevated jugular venous pressure

Why it occurs

• Right ventricular failure secondary to pulmonary hypertension
• Advanced biventricular or left heart failure
• Cardiac tamponade
• Constrictive pericarditis
• Stenosis or insufficiency of the tricuspid valve
• Superior vena cava syndrome

Initial workup

Urgent transthoracic echocardiogram (TTE) to evaluate pericardial effusion, signs of right chamber collapse in diastasis or diastole, estimation of the diameter and collapsibility of the inferior vena cava (IVC) and calculation of right atrial pressure; 12-lead electrocardiogram (ECG) to assess low voltage of the QRS complexes or electrical alternans; Chest x-ray to analyze the cardiac silhouette ("canteen" image in large effusions); Computed tomography (CT) of the chest if mediastinal pathology or superior vena cava syndrome is suspected.

Standard management

• Furosemide — loop diuretic indicated if engorgement is due to volume overload due to heart failure; 40 mg to 80 mg intravenously under monitoring of blood pressure and electrolytes
• Dobutamine — positive inotrope indicated in severe right ventricular failure with low cardiac output; continuous infusion of 2 to 10 mcg/kg/min, contraindicated in severe mechanical obstructions
• Milrinone — phosphodiesterase III inhibitor with inodilator effect, useful in pulmonary hypertension with right heart failure; 0.375 to 0.75 mcg/kg/min as continuous intravenous infusion
• 0.9% physiological solution (in case of cardiac tamponade as a temporary measure to maintain preload and cardiac output before pericardiocentesis; infusion controlled according to hemodynamic response).