Examination of arterial pulse in clinical medicine

1. Examination of arterial pulse in clinical medicine Dr.Vemuri Chaitanya

2. 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.

3. Normal Pulse

4. 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.

5. 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.

6. Evaluation Rate Rhythm Volume Character Vessel wall thickness Radio � radial , radio- femoral delay Peripheral pulses Pulse deficit

7. Rate Count the pulse for 1 min / atleast 30 sec Normal : 60 � 100 /min Tachycardia : >100 /min Bradycardia : <60 /min

8. Sinus Tachycardia Physiological : infants , children , emotion, exertion. Pathological : Tachyarrhythmia- SVT, VT High output states Drugs � atropine, nifedipine, nicotine, caffiene

9. 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

10. Relative Bradycardia Typhoid H�agic fever Lymphocytic choriomeningitis

11. 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

12. Diff b/w heart block & ectopic Rhythm : Irregularity changes with exertion � extrasystole / ectopic Irregularity doesn�t change with exertion � Heart block

13. 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

14. Volume Low vol ( pulsus parvus ) � shock myocardial ds valvular ds pericardial ds hypovolemia

15. 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..

16. 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.

17. 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

18. Peripheral PulsesRadial pulse At wrist , lateral to flexor carpi radialis tendon , place your three middle fingers over the radial pulse

19. 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.

20. 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.

21. Femoral Pulse Is felt at groin just below inguinal ligament midway b/w ant.sup.iliac.spine & symphysis pubis.

22. 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.

23. Posterior Tibial Pulse Felt just behind medial malleolus , midway b/w medial malleolus & tendo achillis.

24. Dorsalis Pedis Pulse Felt just lateral to tendon of ext.hallucis longus.

25. Apex Pulse Deficit Diff b/w heart rate & pulse rate , when counted simultaneously for one minute. Diff b/w AF & Ectopics AF ( > 10 /min ), worsens with exertion. Ventricular premature beats ( < 10 /min )

26. 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 AS+AR, pure AR, HOCM

27. 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.

28. 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 >20mm

29. 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

30. 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

31. Pulsus Paradoxus Exaggerated reduction in strength of arterial pulse during normal inspiration due to exaggerated insp fall in sys.pressure (> 10 mm) >20mm Hg � detected by palpating brachial.a. Milder fall � by sphygmomanometry.

32. 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

33. Reversed Pulsus Paradoxus Inspiratory rise in arterial pressure HOCM

34. Collapsing Pulse Corrigan�s 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

35. 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

36. Pulsus Parvus et Tardus Small vol pulse with delayed systolic peak Severe AS

37. 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

38. Recording Of BP Pulsus paradoxus :inflate bp cuff to suprasystolic level & deflate slowly @ 2mm/heart beat. Note - Peak sys.pressure during expiration Now deflate more slowly � note pressure when korotkoff sound � audible throughout resp.cycle If diff > 10 mm Hg - pulsus pardoxus +

39. Recording BP Pulsus alternans :inflate BP cuff to suprasystolic level & deflate slowly . + if alteration of intensity of korotkoff sounds+

40. Thank You