Examination of arterial pulse in clinical medicine

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Examination of arterial pulse in clinical medicine

• Dr.Vemuri Chaitanya

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Pulse

• The blood forced into aorta during systole not
  only moves the blood in the vessels forward but
  also sets up a pressure wave that travels along
  arteries. The pressure wave expands the arterial
  wall as it travels , and the expansion is
  palpable as the pulse.

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Normal Pulse
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Normal Arterial Pulse

• Pulse in ascending aorta rises rapidly to a
  rounded dome peak velocity of blood ejected
  from Lt.ventricle.
• Slight anacrotic notch/pause freq recorded but
  occasionally felt on asc.limb of pulse.
• Descending limb of central aortic pulse is less
  steep , interupped by incisura , a sharp
  deflection relation to closure of aortic valve.
  Immediately pulse wave rises slightly then
  declines gradually throughout diastole.

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Normal Arterial Pulse

• Percussion wave in central arterial pulse the
  rapidly transmitted impact of Lt.Ventricular EF
  results in a peak in early systole.
• Tidal wave second , smaller peak , presumed to
  represent the reflected wave from the periphery ,
  often recorded but not normally palpable.

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Evaluation

• Rate
• Rhythm
• Volume
• Character
• Vessel wall thickness
• Radio radial , radio- femoral delay
• Peripheral pulses
• Pulse deficit

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Rate

• Count the pulse for 1 min / atleast 30 sec
• Normal 60 100 /min
• Tachycardia gt100 /min
• Bradycardia lt60 /min

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Sinus Tachycardia

• Physiological infants , children , emotion,
  exertion.
• Pathological Tachyarrhythmia- SVT, VT
• High output states
  
• Drugs atropine, nifedipine, nicotine, caffiene
  

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Sinus Bradycardia

• Physiological atheletes, sleep
• Pathological severe hypoxia
  
• hypothermia
• sick sinus syn
• myxoedema
• obs.jaundice
• ac.inf wall MI
• raised ICT
• Drugs beta blockers, verapamil,diltiazem

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Relative Bradycardia

• Typhoid
• Hagic fever
• Lymphocytic choriomeningitis

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Rhythm

• Assessed by palpating radial artery
• Regularly irregular Atrial Tachyarrhythmia with
  fixed AV block , Ventricular bigemini
• Irregularly irregular atrial /ventricular
  ectopic
• AF
• Sinus Arrhythmia irregular in healthy
• accelration
  inspiration
• slowing down
  expiration
• due to variation in vagal tone children,
  young adult
  

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Diff b/w heart block ectopic

• Rhythm
• Irregularity changes with exertion extrasystole
  / ectopic
• Irregularity doesnt change with exertion Heart
  block

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Volume

• Assessed by palpating carotid artery
• Pulse pressure accurate measure of pulse volume
  ( N 30 60 mm Hg )
• Correlates with stroke vol
• High vol elderly
• anxiety
• emotional excitability
• high output states, sys.htn

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Volume

• Low vol ( pulsus parvus ) shock
• 
  myocardial ds
• 
  valvular ds
• 
  pericardial ds
• 
  hypovolemia

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Character

• Best assessed by palpating carotid artery
• Normal / Abnormal
• Abnormal anacrotic pulse / pulsus parvus et
  tardus / collapsing pulse / pulsus bisferiens /
  pulsus alternans / dicrotic pulse / pulsus
  bigeminus etc..

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Vessel Wall Thickness

• Assess the state of medium sized arteries which
  are palpable.
• Method palpate radial artery with middle 3
  fingers.
• Occlude proximally with index
  finger empty artety by pressing out blood
  distally.
• Applying pressure on either side
  roll the artery over underlying bone using middle
  finger.

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Radio femoral Delay

• Usually 2 radial pulses come simultaneously
  femoral comes 5msec before ipsilateral radial
  pulse.
• Delay in femoral pulse obstruction of aorta
  coarctation , aortoarteritis

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Peripheral PulsesRadial pulse

• At wrist , lateral to flexor carpi radialis
  tendon , place your three middle fingers over the
  radial pulse

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Carotid Pulse

• Palpate carotid pulse with the pt lying on a bed
  / couch
• Never compress both carotid arteries
  simultaneously.
• Use your left thumb for right carotid pulse
  vice versa.
• Place tip of thumb b/w larynx ant.border of
  sternocleidomastoid.

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Brachial pulse

• Use your thumb ( rt thumb for rt.arm vice versa
  ) with your fingers cupped round the back of the
  elbow.
• Brachial pulse felt in front of the elbow just
  medial to tendon of biceps.

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Femoral Pulse

• Is felt at groin just below inguinal ligament
  midway b/w ant.sup.iliac.spine symphysis pubis.

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Popliteal pulse

• Knee to be flexed 40 deg. Heel resting on bed
• Place fingers over lower part of popliteal fossa
  fingers are moved sideways to feel pulsation of
  Popliteal.A against post.aspect of tibial
  condyles.

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Posterior Tibial Pulse

• Felt just behind medial malleolus , midway b/w
  medial malleolus tendo achillis.

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Dorsalis Pedis Pulse

• Felt just lateral to tendon of ext.hallucis
  longus.

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Apex Pulse Deficit

• Diff b/w heart rate pulse rate , when counted
  simultaneously for one minute.
• Diff b/w AF Ectopics
• AF ( gt 10 /min ), worsens with exertion.
• Ventricular premature beats ( lt 10 /min )

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Bisferiens Pulse

• 2 systolic peaks ,the percussion tidal waves
  separated by distinct midsystolic dip.
• Detected more rapidly by palpating carotid
  artery.
• Valsalva / inhalation amyl nitrate
• ASAR, pure AR, HOCM

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Dicrotic Pulse

• 2 peaks .
• 2nd peak is in diastole after S2.
• Normally a small wave that follows aortic valve
  closure ( dicrotic notch ) is exaggerated
• Due to very low stroke vol per. Resistance.
• LVF, typhoid, dehydration.

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Pulsus Alternans

• Alternating strong weak pulse.
• Palpation of radial, femoral, brachial pulses
• Palpation by light pressure, breath held in mid
  expiration
• Better sphygmomanometry, when sys.pressure
  alternates by gt20mm

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Pulsus Alternans

• A sign of severe LV dysfn
• Following paroxysmal tachycardia
• AR, sys.htn, reducing venous return by adm NTG
  exaggerate pulsus alternans help in detection

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Pulsus Bigeminus

• Pulse wave with a normal beat followed by a
  premature beat a compensatory pause, occuring
  in rapid succession alternation of strength of
  pulse.
• Confused with pulsus alternans ( no compensatory
  pause )
• Sign of digitalis toxicity

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Pulsus Paradoxus

• Exaggerated reduction in strength of arterial
  pulse during normal inspiration due to
  exaggerated insp fall in sys.pressure (gt 10 mm)
• gt20mm Hg detected by palpating brachial.a.
• Milder fall by sphygmomanometry.

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Pulsus Paradoxus

• Exaggerated insp fall in sys.pressure reduced
  LV stroke vol transmission of ve intrathoracic
  pressure to aorta.
• Cardiac tamponade, constrictive pericarditis,
  severe airway obs , SVC obstruction

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Reversed Pulsus Paradoxus

• Inspiratory rise in arterial pressure
• HOCM

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Collapsing Pulse

• Corrigans pulse / water hammer pulse
• Large vol pulse with rapid upstroke ( high
  sys.pressure ) rapid downstroke ( low
  diastolic pressure )
• Rapid upstroke increased stroke vol
• Rapid downstroke diastolic runoff into Lt.Ven
  decreased PR rapid runoff to periphery.
• PDA , AR, AV fistula

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Pulsus Tardus

• Upstroke thrill (carotid shudder)
• Peak reduced
• Occurs late in systole
• Fixed LV obs Valvular AS , Cong.fibrous
  subaortic stenosis
• Notch on upstroke of carotid pulse (anacrotic
  notch)- 2 separate waves anacrotic pulse

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Pulsus Parvus et Tardus

• Small vol pulse with delayed systolic peak
• Severe AS

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Hypokinetic Hyperkinetic Pulses

• Hypokinetic pulse small vol, narrow pulse
  pressure
• Eg cardiac failure, MS, AS, Shock
• Hyperkinetic pulse large vol , wide pulse
  pressure
• Eg high output states , MR, VSD

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Recording Of BP

• Pulsus paradoxus inflate bp cuff to
  suprasystolic level deflate slowly _at_ 2mm/heart
  beat.
• Note - Peak sys.pressure during expiration
• Now deflate more slowly note pressure when
  korotkoff sound audible throughout resp.cycle
• If diff gt 10 mm Hg - pulsus pardoxus

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Recording BP

• Pulsus alternans inflate BP cuff to
  suprasystolic level deflate slowly .
• if alteration of intensity of korotkoff sounds

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Thank You