1) The document defines and describes the arterial pulse, its determinants, sites where it can be palpated, and characteristics including rate, rhythm, volume, and waveform. 2) Key pulse points are described in detail including radial, brachial, carotid, femoral, and more. Characteristics of normal and abnormal pulse types are also outlined. 3) Assessment of pulse involves evaluating rate, rhythm, volume, and character, and comparing pulses at different sites can provide clinical information. Abnormal pulses may indicate various cardiovascular conditions.

1. MORNING
GOOD
DR. FARJAD IKRAM
HOUSE OFFICER ||| CARDIOLOGY

2. PULSE
BLOOD PRESSURE
JUGULAR VENOUS PRESSURE

3. OBJECTIVES
• Definition of pulse
• Determinants of arterial pulse
• Sites for arterial pulse
• Characteristics of arterial pulse
• Comparision of arterial pulses
• Jugular venous pulse

4. INTRODUCTION

5. “
Pulse is the rhythmic dilation of an artery or
a vein that results from beating of the heart.

6. WHAT IS A PULSE?
○ Pulse is a wave imparted by the contraction of ventricle
to the blood column.
○ The pressure wave travels faster than the blood itself.
○ It can be palpated particularly where the arteries are
superficial and pass over bone.
○ Study of pulse is know as sphygmology.

7. TYPES OF PULSES
VENOUS
ARTERIAL
• Pulses can be arterial or venous.
• Unless stated, pulse is usually inferred as arterial.
• Venous pulses can be visible, but not palpable.

8. ARTERY VS VEIN
ARTERY VEIN

9. DETERMINANTS
The arterial pulse waveform depends on:
• heart rate,
• stroke volume,
• peripheral resistance,
• left ventricular outflow obstruction, and
• the elasticity of peripheral vessels

10. SITES FOR PULSE

11. SITES FOR ARTERIAL PULSE
Temporal
Carotid
Brachial
Radial
Posterior tibial
Dorsalis pedis
Popliteal
Femoral
Aortic
Axillary
Facial

12. RADIAL PULSE
○ Most commonly felt pulse. Easily accessible.
○ Patient’s hand should be slightly flexed and pronated.
○ Press the wrist against the head of the radius, lateral
to flexor carpi radialis tendon.
○ Can also be palpated in the anatomical snuffbox.

13. ULNAR PULSE
○ Press the medial side of the wrist below the crease,
lateral to pisiform bone and flexor carpi ulnaris tendon
but medial to palmaris longus tendon.

14. WRIST PULSES

15. BRACHIAL PULSE
○ It is palpable in the ante-cubital fossa of a slightly
flexed elbow, medial to the biceps tendon.

16. AXILLARY PULSE
○ Press the axilla deep against the humerus behind the
anterior axillary fold in an abducted arm.

17. CAROTID PULSE
○ Press at angle of the jaw, anterior to the SCM muscle
and lateral to the thyroid cartilage.
○ Never press both the carotid arteries at the same time.

18. TEMPORAL PULSE
○ To palpate the superficial temporal artery, press
against the skull in front of tragus of the ear.

19. FACIAL PULSE
○ Press against the lower margin of the mandible,
inferior and postero-lateral to the angle of the mouth.

20. FEMORAL PULSE
○ Press just below the inguinal ligament, midway
between the anterior superior iliac spine (ASIS) and the
pubic symphysis.
○ It is immediately lateral to the femoral vein and
medial to the femoral nerve.

21. POPLITEAL PULSE
○ Lies posteriorly in relation to the knee joint.
○ Press deep in the popliteal fossa.
○ Better palpated in a slightly flexed knee.
○ Either in supine or prone position.

22. POSTERIOR TIBIAL PULSE
○ Press against the tibia, 2 cm below and posterior to the
medial malleolus, where it passes beneath the flexor
retinaculum between tendons of flexor digitorum longus
and flexor hallucis longus.

23. DORSALIS PEDIS PULSE
○ Passes lateral to the tendon of extensor hallucis longus.
○ Best felt at the proximal extent of the groove between
the first and second metatarsals.

24. AORTIC PULSE
○ Expansile pulsation of abdominal aorta may be felt by
pressing the fingertips of one or both hands deep into the
umbilical region.
○ Anterior expansion is normal and felt in lean people.
○ Lateral expansion may be because of aortic aneurysm.

25. EXAMINATION

26. CHARACTERISTICS
When palpating for arteries assess the following:
• pulse rate,
• pulse rhythm,
• character,
• volume,
• comparison with other pulses

27. PULSE RATE
○ Pulse rate usually, but not always, is equivalent to heart
rate. Resting heart rate is normally 60-100 bpm.
○ In order to determine the rate, count pulse for 1 minute.
○ Assess the pulse rate in the clinical context. i.e. resting
rate of 40 bpm can be normal in a fit young adult.

28. PULSE RATE
Bradycardia is a pulse rate <60 bpm.
 Physiologic i.e. athletes at rest
 Inappropriate i.e. heart blocks, vaso-vagal reflex,
beta blockers, calcium channel blockers
Tachycardia is a pulse rate of >100 bpm.
 Physiologic i.e. exercise
 Inappropriate i.e. fever, anxiety, tachyarrhythmia
Effect of respiration.
 Pulse rate increases with inspiration.
 Pulse rate decreases with expiration.

29. PULSE RHYTHM
Regular
 Intervals between two beats is constant
Regularly irregular
 Irregularity comes at regular intervals
 Causes include digoxin toxicity
Irregularly irregular
 There is no regularity at all
 Causes include atrial fibrillation / flutter, multiple ectopics
Pulses deficit
 Heart rate faster than pulse rate
 Atrial fibrillation, mitral stenosis, thyrotoxicosis, IHD

30. RATE & RHYTHM
NORMAL
IRREGULARLY
IRREGULAR
INTERMITENT
IRREGULAR
TACHYCARDIA
BRADYCARDIA

31. PULSE VOLUME
This is the amplitude of pulse wave and is determined
by the amount of displacement of palpating fingers
□ Normal volume
□ Low volume (weak) i.e. heart failure, hypovolemic shock
□ High volume (bounding) i.e. pregnancy, fever, anemia, AR
NORMAL
BOUNDING
WEAK

32. PULSE VOLUME
Pulse 4 point scale

33. PULSE CHARACTER
□ In certain diseases, pulse wave has a specific
waveform, or character.
□ A major pulse close to the heart (brachial, carotid
and femoral) should be palpated for this purpose.
□ A normal arterial waveform has an up-slope and a
down-slope.
□ The peak represents the systolic blood pressure.
□ The trough represents diastolic blood pressure.
□ Dicrotic notch in the downslope is due to closure
of aortic valve. Generally not palpable.

34. ARTERIAL PULSE WAVEFORM
Systolic phase Diastolic phase
Dicrotic notch

35. PULSE CHARACTER
Slow rising pulse (pulsus plateau)
□ A kind of low volume pulse
□ Has a slow upstroke and late peak (Tardus)
□ Low amplitude (Parvus)
□ Stays longer
□ Causes: severe AS
NORMAL PULSE PULSUS PLATEAU

36. PULSE CHARACTER
Collapsing / Corrigan / water-hammer pulse
□ High volume pulse
□ Normal upstroke, rapid downstroke
□ Wide pulse pressure ( > 60 mm Hg )
□ Exaggerated at radial pulse after lifting the arm
□ Causes: AR, ASD, PDA, severe anemia
NORMAL PULSE
WATER HAMMER PULSE

37. PULSE CHARACTER

38. PULSE CHARACTER
Pulsus bisfeirens (ancrotic pulse)
□ Is a double peaked pulse
□ Two systolic peaks are present in one pulse
□ Amplitude of the pulse is high
□ Causes: combined AS and AR
□ Unilateral pulsus bisfeirens in aortic dissection
NORMAL PULSE BISFEIRENS PULSE

39. PULSE CHARACTER
Pulsus dicroticus
□ Also called spike and dome pulse or jerky pulse
□ Blood ejection into aorta is normal initially
□ Then becomes suddenly obstructed by the contraction
of a band of muscle in aortic outflow tract
□ Causes: HOCM
NORMAL PULSE PULSUS DICROTICUS

40. PULSE CHARACTER
Pulsus paradoxus
□ Pulse is weak during inspiration. Normally, during inspiration
there is a fall in systolic blood pressure about 5 mmHg or less.
In pulsus paradoxus, fall is more than 5mmHg.
□ Causes: massive pericardial effusion (tamponade), constrictive
pericarditis, acute severe asthma.
□ Reverse pulsus paradoxus is seen in HOCM, intermittent
positive pressure ventilation (IPPV) and AV dissociation.

41. PULSE CHARACTER
Pulsus paradoxus

42. PULSE CHARACTER
Pulsus alternans
□ Strong beat alternates with a weak beat
□ Interval between beats is constant
□ Causes: left ventricular failure, SVT

43. PULSE CHARACTER
Pulsus bigeminus
□ Similar to pulsus alternans but interval between
beats is variable
□ Causes: digoxin toxicity
PULSUS BIGEMINUS

44. COMPARISION
WITH OTHER PULSES
Radio-radial delay
is seen in:
□ Pre-subclavian
coarctation of aorta
□ Thoracic inlet syndrome

45. COMPARISION
WITH OTHER PULSES
Radio-femoral delay
is seen in:
□ Coarctation of aorta
(COA)

46. PULSE IN DIFFERENT DISEASES

47. THANK
YOU!