The document discusses examination of the arterial pulse, including definitions, waveform, examination techniques, and characteristics of normal and abnormal pulses. Key points include: 1) The arterial pulse is caused by the rhythmic expansion of arteries due to blood ejection from the heart. All major arterial pulses should be examined bilaterally for rate, rhythm, character, volume, and delays. 2) Abnormal pulses may indicate various cardiac conditions, such as aortic stenosis seen in a slow rising pulse with delayed peak, or aortic regurgitation seen in a collapsing pulse. 3) Other abnormal pulses and their causes are discussed, such as pulsus paradoxus in cardiac tamponade, and absent or delayed femoral pulses

1. ARTERIAL
PULSE
Dr UMMED SINGH
ASSISTANT PROFESSOR

2. DEFINITION
• Greek word meaning ‘move to and fro’.
• Rhythmic expansion of the arterial wall due to
transmission of pressure waves that travels
along the arteries due to forceful ejection of
blood during cardiac systole into the arterial
system.

3. WAVEFORM

4. EXAMINATION OF ARTERIAL PULSE
• All major arterial pulses should be bilaterally
examined for
– Rate of the pulse
– Rhythm
– Character
– Volume
– Condition of the arterial wall (thickness)
– Radio radial delay and radio femoral delay

5. S

6. EXAMINATION All arterial pulses should be examined
bilaterally
CAROTID ARTERY

7. • BRACHIAL
ARTERY

8. • RADIAL
ARTERY

9. • FEMORAL
ARTERY

10. POPLITEAL ARTERY

11. • POSTERIOR
TIBIAL

12. DORSALIS PEDIS

13. RATE OF PULSE
• In adult person - between 60 and 100 beats per
minute.
• In children average rate at
– 1 week of age 140/min
– 1 yr of age 120/min
– 6 yrs of age 100/min and
– Puberty 80/min

14. TACHYCARDIA
• Sinus tachycardia: A sinus rate above 100 beats per minute
– Physiological :
• Infancy
• Childhood
• Anxiety
• Stress
• Exercise
• Excitement

15. • Pharmacological :
– Medications:
• Atropine
• Epinephrine
• Isoproterenol
• Ephedrine
– Intoxicants:
• Alcohol
• Nicotine
• Caffeine

16. • Pathological :
– Cardiovascular
causes :
• CHF
• AMI
• Pulmonary embolism
• Myocarditis
• Shock
• Tachyarrhythmias

17. • Non-cardiac
causes :
– Fever
– Anemia
– Thyrotoxicosis
– Hemorrhage
– Hypotension
– Hypoxemia

18. BRADYCARDIA
• Sinus bradycardia : sinus rate of less than 60 beats
per minute
– Physiological: athletes ,during sleep .
– Pharmocological : Beta-blockers, Amiodorone,
Digoxin Non dihydropyridine CCB.

19. • Pathological:
– Cardiovascular
causes:
• Inferior wall MI
• Vasovagal syncope
• Bradyarrhthmias

20. • Non-cardiac causes –
– Myxedema.
– Increased intracranial
pressure.
– Hypothermia.
– Obstructive jaundice.
– Severe hypoxia.

21. RHYTHM
The normal pulse is regular in rhythm. If the pulse is
irregular, note whether it is regularly irregular or
irregularly irregular.

23. CHARACTER OF PULSE
• Best evaluated by
palpation of the carotid
pulse.
• PULSUS PARVUS ET
TARDUS
– Slow rising pulse with
delayed systolic peak
(nearer to S2) and
upstroke, associated
with a thrill in the
carotids (carotid
shudder) is
characteristic of AS.

24. • WATER-HAMMER (COLLAPSING) PULSE :
– Rapid upstroke (percussion wave) followed by rapid
descent (collapse) of the pulse wave without dicrotic
notch.

25. • Rapid upstroke is due to the rapid ejection of greatly
increased stroke volume.
• Rapid descent is due to
– Diastolic ‘run-off’ (back flow) into the left ventricle .
– Reflex vasodilatation mediated by carotid baroreceptors
secondary to large stroke volume.
– The rapid run-off to the periphery due to decreased
systemic vascular resistance.

26. • TWICE BEATING
PULSE
– Anacrotic pulse
– Pulsus bisferiens
– Dicrotic pulse

27. • Seen in AS
• The presence of anacrotic pulse
indicates 70mmHg pressure
gradient.

28. • BISFERIENS PULSE
– Characterized by two systolic peaks (percussion and tidal
waves) separated by a distinct midsystolic dip.

29. • CAUSES OF BISFERIENS PULSE
– Hyperkinetic circulatory states .
– AR.
– AR+AS.
– Hypertrophic obstructive cardiomyopathy.

30. • CAUSES OF BISFERIENS PULSE
– Hyperkinetic circulatory states .
– AR.
– AR+AS.
– Hypertrophic obstructive cardiomyopathy.

31. • The two waves are equal or tidal wave is prominent in AR,
AR+AS.
• In HOCM, percussion is more prominent than tidal wave.
• Bisferiens pulse disappears when the heart failure
supervenes

32. • DICROTIC PULSE
– Two peaks, one in systole (percussion wave) and the
other in diastole (dicrotic wave) immediately after S2.

33. • Commonly seen in low output states
such as:
– Enteric fever
– Cardiomyopathy
– Cardiac tamponade
– Myocarditis
– Hypovolemic shock

34. • PULSUS ALTERNANS
Alternating small and large volume pulse in regular
rhythm. precipitated by PVCs and is a sign of severe
LV dysfunction

35. • PULSUS PARADOXUS :
Exaggerated decrease in the strength (amplitude)
of the arterial pulse during normal quiet
inspiration due to the exaggeration of normal
inspiratory decline in the systolic arterial pressure
of 10 mmHg.

36. • Causes :
– Cardiac tamponade.
– Constrictive pericarditis.
– Massive pulmonary embolism.
– COPD: Severe emphysema, acute severe
bronchial asthma.

37. • Cardiac tamponade without pulsus paradoxus occurs
when associated with
– ASD
– VSD
– AR
– Pericardial adhesions

38. MECHANISMOF PULSUS PARADOXUS

39. VOLUME OF PULSE
• Idea of the pulse pressure -Depends on the stroke
volume and the compliance of the arteries.
• Types
• Pulsus parvus.
• Pulsus magnus.
• Hyperkinetic pulse .

40. • PULSUS MAGNUS :
– High volume large amplitude pulse because of an
increased stroke volume
– Seen in AR
• HYPERKINETIC OR BOUNDING PULSE
– Increased stroke volume and rapid ejection from
the left ventricle.
– Seen in hyperkinetic circulatory states.

41. RADIAL PULSE SYNCHRONICITY
Radial pulse on one side may be diminished or
absent in patients with
Pre subclavian COA
Takayasu arteritis .
Thoracic outlet syndrome.
Subclavian steal syndrome.
Aneurysm of arch of aorta
Dissection of aorta.

42. ABSENT OR DELAYED FEMORAL PULSATIONS
Noticeable delay in the arrival of femoral pulse is
suggestive of:
Coarctation of aorta
Occlusive disease of the bifurcation of the aorta,
common iliac or external iliac arteries.

43. ARTERIAL PULSE IN SPECIFIC CARDIAC DISORDERS
• AORTIC STENOSIS :
– Pulsus parvus et tardus
– Anacrotic pulse
• SUPRAVALVULAR AORTIC STENOSIS
– Differential streaming of central aortic blood flow
– Right carotid pulse is relatively normal
– Left carotid pulse has the characteristic features of aortic
valve obstruction

44. • HYPERTROPHIC
CARDIOMYOPATHY
– Tapping quality to the pulse
– Bifid or “spike and dome”
configuration

45. • COARCTATION OF AORTA
– carotid pulses are increased in amplitude but have normal
contour
– femoral pulses are small in volume and markedly delayed.
• AORTIC REGURGITATION
– Collapsing or bounding pulse
– Pure AR or AR + AS – Bisferiens
pulse
– With CCF, Bisferiens pulse
disappears