Dr. Nisheeth M PatelM.D (Medicine)

ARTERIAL PULSE

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: 30msRadial: 80msFemoral: 75ms Brachial: 60ms

IMPORTANCE: Also called the mirror of heartInformation about arterial wall conditionRough estimation of SBP n DBPState of heart n circulationDetect and diagnosis of arrythmiaDiagnosis in case of AR and acute LVF

The arterial pulse should be examined in all 4 limbs and both sides of the neck

1. Radials2. Brachials3. Carotids4. Femorals5. Popliteals6. Temporal7. Facial 8. Peripheral arteries of the legs :Dorsalis pedis Posterior tibial

How to feel the PulseThe Radial pulse:

The 3 middle fingers are usedThe palmar surface of the fingers overlies the radial

A. and encircles the wristAt first the artery is completely occluded, then

gradually release the pressure until maximum feeling of the pulse wave is perceived.

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

Brachial Artery

Rest the patient arm with elbow extended palm up

Use the thumb of the opposite handCup your hand under the patient elbowFeel the pulse just medial to biceps tendon

Femoral PulsePress deeply below the inguinal ligament

and about mid way between ASIS and SP

Popliteal PulsePatient 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

Dorsalis PedisFeel 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

Posterior TibialCurve your fingers behind and slightly below

the medial malleolus of the ankle

Comment on the Pulse1. Rate2. Rhythm3. Volume (amplitude)4. Force5. Tension 6. Comparison of the two sides7. Special character8. Condition of the arterial wall

RateRate 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

RhythmIs the rhythm regular or irregular?1.Normally regularly regular2.Sinus arrhythmia: phasic irregularity with

respiration, 3.Irregular:

1. Regularly irregular:1. PAT with Fixed AV Block2. Atrial flutter3. Ventricular bigeminy or trigeminy

2. Irregularly irregular:1. APCs, VPCs2. AF3. PAT with Varying degree of block

Volume (Amplitude)Degree of expansion between systole and diastoleMeasurement of pulse pressureHyperdynamic :

(high PP, SV)Anxiety ExerciseCHBARFeverAnemiaThyrotoxicosisAVFBeriberi

Hypovolemic: (low PP, SV)

ShockCHFChronic CPHypovolemiaStenotic Valvular

diseaseMycarditis Cardiomyopathies

Force and tension:Force

Indicates SBPHigh in : ISH, AR PDA, Hyperdynamic states:Low in: Shock, Cardiac failure, Stenotic

Valuvular lesion, Cardiac TemponadeTension:

Indicates DBP

Comparison of both sidesCauses of unequal pulse1. Genetic absence or change in the course

of the radial artery (anomalous radial artery)

2. Compression of the vessel3. Atheromatous plaque4. Embolus

Anacrotic Pulse (Pulsus Tardus):Slow rise, slow fallDuration of pulse is prolongedAmplitude is smallLazy in character (Tardus)In aortic stenosis

Dicrotic Pulse:One peak in systole, one in diastole Myocardial disease with reduced CO and TPRLVF, DCMCardiac TamponadeDehydration

Collapsing and Water hammer pulsecorriagan, bounding pulseRapid upstrokeRapid down strokeHigh amplitudeShort durationCauses:

Aortic incompetence PDAHyperdynamic states: Fever, Anaemia,

Thyrotoxicosis, pregnancy and AV fistula

Pulsus Bisferiens Pulse has 2 peaks: two peaks in systoled/t ejection of rapid jet of bloodAS + ARSevere ARHOCM

A double pulse is felt and seen in the carotid

Pulsus Parus:Small volume pulseLow COA/w Tachycardia, thready pulsePhysiological: cold, anxietyVessel occlusionCoA of AortaSevere Hypotension (Shock)Severe AS PSMISevere PAH

Jerky pulse:Small volume & collapsingHOCMSevere MRAR with LVF

Pulsus alterans:Alternate large and small volume pulseLV FailureCardia Arrythmias

Pulsus bigeminus:Pulse wave with normal beat f/b VPCs f/b

compensatory pauseDigitalis toxicity

Pulsus paradoxus:Exaggerated decrease in strength of arterial

pulse during inspiration, Inspiratory fall of SBP >10mmHgCardiac temponadeConstrictive pericarditisAcute asthmaSVC obstruction

Reverse pulsus paradoxus:HOCMIPPVAV dissociaton

Thank You…