The Cardiovascular Exam - Pulsus Paradoxus & Special Maneuvers (Strong Exam)

Discussion of the physiology of special cardiovascular exam maneuvers, along with demonstrations, and review of the evidence from the medical literature.
0:00 Introduction
0:41 Orthostatic hypotension
4:35 Signs of hypovolemia (e.g. capillary refill, passive leg raise)
7:57 Signs of heart failure (e.g. proportional pulse pressure, abdominojugular reflux)
10:16 Cardiac tamponade and pulsus paradoxus
References:
McGee S. Evidence Based Physical Diagnosis. 5th Ed. Elsevier; 2021.
Juraschek SP, et al. Association of History of Dizziness and Long-term Adverse Outcomes With Early vs Later Orthostatic Hypotension Assessment Times in Middle-aged Adults. JAMA Intern Med. 2017; 177:1316-1323.
McGee S, Abernethy WB, Simel DL. The Rational Clinical Examination. Is This Patient Hypovolemic? JAMA. 1999; 281:1022-1029.
Schriger DL, et al. Defining Normal Capillary Refill: Variation With Age, Sex, and Temperature. Ann Emerg Med. 1988; 17: 932-935.
Monnet X, Marik P, Teboul, JL. Passive Leg Raising For Predicting Fluid Responsiveness: A Systematic Review and Meta-Analysis. Intensive Care Med. 2016; 42: 1935-1947.
Mesquida J, Gruartmoner G, Ferrer R. Passive Leg Raising For Assessment of Volume Responsiveness: A Review. Curr Opin Crit Care. 2017; 23:237-243.
Sochowski RA, Dubbin JD, Naqvi SZ. Clinical and Hemodynamic Assessment of the Hepatojugular Reflux. Am J Cardiol. 1990; 66:1002-1006.
Butman SM, et al. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. 1993; 22:968-974.
Sternbach G. Claude Beck: Cardiac Compression Triads. Journal Emerg Med 1988; 6: 417-419.
Roy CI, et al. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007; 297:1810-1818. [A figure in this paper was the inspiration for the animation starting at @13:05]

[@mr.siddharthtyagi]

I've been watching all previous videos of this series and you had me worried it had stopped! Thanks for continuing and i hope to see each and every aspect of history and examination being covered👍

[@StrongMed]

Many more are coming. Sorry for worrying you! ;)

[@zaighamhashir7445]

Same feelings here

[@fjs1111]

@@StrongMed Yes, thank you Dr. Strong

[@tuboo_9158]

Been watching your videos since day 1 of med school, you have no idea how much on an impact you’ve had on my learning, much appreciation from a budding Canadian internist 😁

[@MuhammadHassan-px1hw]

From a humble distant student : Dr strong please🙏🏻 🙏🏻 just continue with this 🌾🌾

[@StrongMed]

As you might imagine, videos in this series require a lot more time than most others on the channel, so I can only record and edit them when my teaching and clinical duties are both low. But don't worry, more are coming this summer!

[@gabriellefortin8926]

Amazing! Clearest explanation of pulsus paradoxus ever! Happy to contribute monthly to Patreon!😊

[@literalantifaterrorist4673]

Really love this series, we have far more limited diagnostic tools as paramedics so physical exams are king.

[@peev2]

Always happy when I see a new video from you.

[@parkerjk11]

I think Bates may need an EBM update! Amazing content as always, thank you!

[@StrongMed]

My dissatisfaction with Bates as a primary reference for my students was one of the main motivations for this series!

[@daliaal-ansi5630]

I've been looking for this content! Thank you!

[@jakeesposito-leftwich9152]

Brilliant explanation, TYVM!

[@sunving]

oh wonderful lecture , so good .

[@Argendoom244]

Finally! Thank you so much!

[@Kalemalex]

Thank you professor

[@alirezazakaie1106]

Eventually it published...Thank you

[@panicbuyflax3461]

Eric, just curious. Why does capillary refill time vary between men and women? Cheers -Bradley

[@StrongMed]

I don't think anyone knows, and as I hope I conveyed in the video, it's just a single study that found this (which is also the only study that's ever looked at the question of whether there are age and sex differences in the normal range of cap refill time). The authors did not speculate as to the potential explanation. Interestingly, the *median* capillary refill time did not vary dramatically between men and women, but rather just the *mean* and thus the calculated upper limit of normal. In other words, most men and women were about the same, but a relatively small number of women were outliers who skewed the mean. (i.e. women had a much larger standard deviation). The relevant study: pubmed.ncbi.nlm.nih.gov/3415066/

[@damiensegers3555]

looking forward to your neurological examination

[@StrongMed]

It's coming, but will be a while. I didn't have a chance to film the neuro exam before our simulation center (where these are filmed) readopted a mandatory mask policy. Hopefully it gets dropped by late spring for a summer release.

[@parkerjk11]

With the growing availability and affordability of portable ultrasound units, do you think IVC collapsibility is a practical and accurate measure of intravascular volume and hypovolemia?

[@StrongMed]

Yes, I definitely think this is a helpful finding - particularly to distinguish volume responsiveness vs. diuretic responsiveness. As I had commented to another viewer, I had decided when planning out this series that I would not include discussion and demonstration of POCUS for this first iteration, but hope to add it down the road. In the meantime, the Stanford 25 KZbin channel has some great videos that cover it.

[@hafizalkaf]

What about ultraound finding such as IVC diameter and Collapsibility for hipovolemia and B lines for lung oedema

[@StrongMed]

This is great question! Those are all very helpful findings for assessing volume status. I made the decision when planning this series to not include POCUS findings in this its iteration because it's not yet commonplace around the world - though I do hope to circle back and later create separate videos in the same style describing POCUS for CV, pulm, and the abdominal exams. In the meantime, my colleagues with the Stanford 25 group have created a great series of POCUS videos covering those findings and many more: kzbin.info/aero/PLE6bR3gooUQs5rt_YQmruApuLcV3V7O3a

[@arjumandiqbal1787]

hello !! when will complete cardiovascular exam be out???

[@StrongMed]

Working on it now, but it's a monster! (i.e. about an hour in length...)

[@arjumandiqbal1787]

@@StrongMed you're my biggest inspiration!! I'm at the top of my class rn because of it and have my exam in about a week, so that's why I'm waiting for this specific exam , would it be possible that it's out in a week?

[@StrongMed]

​@@arjumandiqbal1787 Thanks for the kind words! Regarding the core CV exam video, my goal was to release it on Sunday, but I honestly don't think it will be ready by then. It may end up being my longest and most complicated video to date.

[@panicbuyflax3461]

Also I forgot to ask (apologies I know you’re busy). Could you do a video on Testosterone Replacement Therapy? My Uncle’s an endocrinologist specialized in hormone treatment and I think it would be really interesting! Merely a request

[@StrongMed]

Thank you for the suggestion. I'll add it to the list of topics suggested by viewers, but unfortunately that list is very long, so I can't make a prediction as to when I'll be able to do it.

[@TheJeenyus24]

I would argue that cardiac tamponade is a clinical diagnosis. An echo should not change the diagnosis unless the clinical features are somewhat borderline, then an echo can help.

[@StrongMed]

I don't disagree with you, but if there is a cardiologist out there who will perform an emergent pericardiocentesis on a patient with "clinical tamponade" but without evidence of tamponade on echo, I haven't met them.

[@alirezazakaie1106]

Still waiting...🤕