2. Pulse:
The pulse is a wave form that is felt by fingers and produced by
cardiac systole which travels through the peripheral arterial tree
in peripheral direction at a rate more faster than that of blood
columm.
Time lag from cardiac systole:
Carotid: 30ms
Radial: 80ms
Femoral: 75ms
Brachial: 60ms
3. IMPORTANCE:
Also called the mirror of heart
Information about arterial wall condition
Rough estimation of SBP n DBP
State of heart n circulation
Detect and diagnosis of arrythmia
Diagnosis in case of AR and acute LVF
4. The arterial pulse should be examined in all 4 limbs and both
sides of the neck
1. Radials
2. Brachials
3. Carotids
4. Femorals
5. Popliteals
6. Temporal
7. Facial
8. Peripheral arteries of the legs :Dorsalis pedis
Posterior tibial
5. How to feel the Pulse
The Radial pulse:
The 3 middle fingers are used
The palmar surface of the fingers overlies the radial A. and encircles the
wrist
At first the artery is completely occluded, then gradually release the
pressure until maximum feeling of the pulse wave is perceived.
6. The Carotids
The patient lies down with the head of the bed elevated
30 degrees
Carotid pulsations may be visible just medial to
sternomastoid
Place the left thumb on the right carotid A. in the lower
third of the neck at the level of the cricoid cartilage, just
inside the medial border of the sternomastoid and press
posteriorly
Never press both carotids at same time
7. Brachial Artery
Rest the patient arm with elbow extended palm up
Use the thumb of the opposite hand
Cup your hand under the patient elbow
Feel the pulse just medial to biceps tendon
9. Popliteal Pulse
Patient knee should be flexed –leg relaxed
Place the finger tips of both hands so that they meet in the
middle line behind the knee and press them deeply in the
popliteal fossa
10. Dorsalis Pedis
Feel the dorsum of the foot just lateral to the extensor
tendon of the big toe
If you cannot feel the pulse, explore the dorsum of the foot
more laterally
12. Comment on the Pulse
1. Rate
2. Rhythm
3. Volume (amplitude)
4. Force
5. Tension
6. Comparison of the two sides
7. Special character
8. Condition of the arterial wall
13. Rate
Rate of the pulse at radial artery
Normal at rest :60-90 beat / min
* if regular: count in 15 sec x 4
* if fast (tachycardia )
*slow (bradycardia) count in 1 min
*if irregular count at apex
weak beats may not be felt (pulsus deficit)
Apex pulse deficit: > 10 suggestive of AF
14. Rhythm
Is the rhythm regular or irregular?
1. Normally regularly regular
2. Sinus arrhythmia: phasic irregularity with respiration,
3. Irregular:
1. Regularly irregular:
1. PAT with Fixed AV Block
2. Atrial flutter
3. Ventricular bigeminy or trigeminy
2. Irregularly irregular:
1. APCs, VPCs
2. AF
3. PAT with Varying degree of block
16. Force and tension:
Force
Indicates SBP
High in : ISH, AR PDA, Hyperdynamic states:
Low in: Shock, Cardiac failure, Stenotic Valuvular lesion,
Cardiac Temponade
Tension:
Indicates DBP
17. Comparison of both sides
Causes of unequal pulse
1. Genetic absence or change in the course of the radial
artery (anomalous radial artery)
2. Compression of the vessel
3. Atheromatous plaque
4. Embolus
19. Anacrotic Pulse (Pulsus Tardus):
Slow rise, slow fall
Duration of pulse is prolonged
Amplitude is small
Lazy in character (Tardus)
In aortic stenosis
Dicrotic Pulse:
One peak in systole, one in diastole
Myocardial disease with reduced CO and TPR
LVF, DCM
Cardiac Tamponade
Dehydration
20. Collapsing and Water hammer pulse
corriagan, bounding pulse
Rapid upstroke
Rapid down stroke
High amplitude
Short duration
Causes:
Aortic incompetence
PDA
Hyperdynamic states: Fever, Anaemia, Thyrotoxicosis,
pregnancy and AV fistula
21. Pulsus Bisferiens
Pulse has 2 peaks:
two peaks in systole
d/t ejection of rapid jet of blood
AS + AR
Severe AR
HOCM
A double pulse is felt and seen in the carotid
22. Pulsus Parus:
Small volume pulse
Low CO
A/w Tachycardia, thready pulse
Physiological: cold, anxiety
Vessel occlusion
CoA of Aorta
Severe Hypotension (Shock)
Severe AS PS
MI
Severe PAH
23. Jerky pulse:
Small volume & collapsing
HOCM
Severe MR
AR with LVF
Pulsus alterans:
Alternate large and small volume pulse
LV Failure
Cardia Arrythmias
Pulsus bigeminus:
Pulse wave with normal beat f/b VPCs f/b compensatory pause
Digitalis toxicity
24. Pulsus paradoxus:
Exaggerated decrease in strength of arterial pulse during
inspiration, Inspiratory fall of SBP >10mmHg
Cardiac temponade
Constrictive pericarditis
Acute asthma
SVC obstruction
Reverse pulsus paradoxus:
HOCM
IPPV
AV dissociaton