Clinical Value of Examination of Radial and Carotid Pulses at Bedside

This presentation is a description of examination of radial and carotid pulses. it is an overview of rate, rhythm and character of pulse.

1. بسم الله الرحمن الرحیم

2. Clinical Value of Examination of Radial and Carotid Pulses at Bedside An overview

3. Procedure Study of peripheral arterial pulses include the examination of radial, brachia!, carotid, femoral, popliteal, posterior tibial and dorsalis pedis pulses. Examination should be performed under the following headings : Rate Character or quality Rhythm Condition of vessel wall Volume Radiofemoral delay

4. Pulse volume is best assessed by palpating carotid artery. Pulse character is best assessed by palpating carotid artery except collapsing pulse that is better appreciated at radial artery .

5. Rate Radial pulse is used to assess the rate. Normal-resting pulse rate of 60-100 beats/minute Bradycardia-resting pulse rate less than 60 beats/minute Tachycardia-resting pulse rate more than 100 beats/minute

6. Bradycardia (less than 60 beats/minute) Tachycardia (more than 100 beats/minute) • Athletes • Hypothyroidism • Vasovagal syncope • Drugs-Beta-blockers • Heart block • Sick sinus syndrome • Hypothermia • Anxiety • Fever • Pregnancy • Hyperthyroidism • Cardiac failure • Tachyarrhythmias • Drugs-salbutamol, terbutaline

7. " Pulse deficit" (apex-pulse deficit) • Definition-The difference between the heart rate counted by auscultation and pulse rate is called pulse deficit. • Significance-Pulse deficit occurs in atrial fibrillation. Can also occur with multiple ventricular premature beats. • Mechanism-Atrial fibrillation is characterized by cycles of varying lengths of diastole. This results in varying stroke volumes with some of the ventricular contractions too weak and unable to open the aortic valve, but at the same time many are good enough to close the mitral valve, thereby producing heart sounds (for further details, refer "atrial fibrillation"). In multiple ventricular premature beats, ectopic beats may not be conducted to radial artery resulting in pulse deficit.

8. Rhythm • Radial pulse is used to assess the rhythm. Completely irregular (irregularly irregular) • Atrial fibrillation • Frequent extrasystoles Irregularity with a recurring pattern (regularly irregular) • Sinus arrhythmia • Pulsus bigeminus • Pulsus trigeminus • Partial AV blocks Otherwise regular with occasional irregularity • Extrasystoles

9. Volume • Carotid artery is used to assess the volume of pulse. • Hypokinetic pulse (weak pulse; pulsus parvus ) is seen in conditions associated with : • Decreased left ventricular stroke volume • Narrow pulse pressure • Increased peripheral vascular resistance • Hyperkinetic pulse (bounding pulse) is seen in conditions associated with: • Increased left ventricular stroke volume • Wide pulse pressure • Decreased peripheral vascular resistance

10. Hypokinetic pulse Hyperkinetic pulse • Hypovolemia • Shock • Congestive cardiac failure • Acute myocardial infarction • Constrictive pericarditis • Mitral stenosis • Aortic stenosis • Hyperkinetic circulation ( anaemia , fever, thyrotoxicosis, exercise) • Mitral regurgitation • Aortic regurgitation • Patent ductus arteriosus • Ventricular septal defect • Peripheral arteriovenous fistulae • Complete heart block

11. Character or Quality • Carotid artery is generally used to assess the character of pulse, though sometimes radial artery gives better information . Pulsus Parvus • A hypokinetic pulse, which is of low amplitude. • Occurs as a result of a reduction in left ventricular stroke volume (e.g. congestive heart failure) or a decrease in systemic arterial pressure. Pulsus Tardus • A slow rising pulse that peaks late in systole. • Seen in aortic stenosis. Pulsus Parvus et Tardus • Description-This is a small volume (' parvus ') pulse that rises slowly ' tardus ') to a late systolic peak. There is an associated coarse systolic thrill. • Mechanism-This is the result of mechanical obstruction to left ventricular ejection. • Significance-Seen in aortic stenosis. Anacrotic Pulse • Description-This is a variant of ' pulsus parvus et tardus ', in which a notch is palpable on the upstroke of the pulse wave. • Significance-Occurs in severe aortic stenosis.

12. Collapsing (Water-Hammer) Pulse • Description-This is a pulse characterized by a rapid upstroke, rapid down stroke and a high volume. • Mechanism-The rapid upstroke is due to the markedly increased stroke volume. The rapid down stroke or the collapsing character is due to two factors: • The diastolic leak back into left ventricle. • Rapid run-off to the periphery because of low systemic vascular resistance. • Significance-Collapsing pulse is seen typically in aortic regurgitation. Similar pulse may also be seen in other conditions .

13. Causes of Collapsing Pulse Patent ductus arteriosus • Ruptured sinus of Valsalva • Large arteriovenous fistulae • Truncus arteriosus • Aortic regurgitation (may not be seen in acute aortic regurgitation) • Hyperkinetic circulatory states (anemia, fever, thyrotoxicosis, exercise, pregnancy, Paget's disease, beriberi) • Mitral regurgitation (occasional) • Complete heart block (occasional) • Corrigan's pulse is largely used to describe abrupt distension and quick collapse of carotid pulse whereas the term "water-hammer pulse" is used for the characteristic pulse seen in peripheral arteries like the radial artery .

14. Bisferiens Pulse • Description This is a pulse with double peak (two peaks), both being felt in systole. • Mechanism This is due to a combination of the slow rising pulse of aortic stenosis and collapsing pulse of aortic regurgitation. • Significance Bisferiens pulse is seen in the following conditions: Combination of aortic stenosis and aortic regurgitation Severe aortic regurgitation Hypertrophic cardiomyopathy

15. Dicrotic Pulse • Description Dicrotic pulse has two palpable waves, one in systole and other in diastole. Diastolic wave follows dicrotic notch. • Mechanism Due to very low stroke volume. • Significance Seen in the following conditions: • Dilated (congestive) cardiomyopathy • Extreme dehydration • Advanced cardiac failure • Cardiac tamponade

16. Pulsus Alternans • Description This is an alternation of large and small volume beats, with a normal rhythm. There is a difference of 10-40 mmHg in systolic pressure between beats. • Mechanism Alternans is due to alternating left ventricular contractile force, i.e. the ventricle beats strongly, then weakly, alternating with each other. • Significance-Seen in acute left ventricular failure. It may occur following paroxysmal tachycardia.

17. Pulsus Bigeminus • Description Pulse with regular alteration of pressure pulse amplitude. This is clinically felt as two beats followed by a pause, thereby producing irregular rhythm (in contrast to pulsus alternans where rhythm is regular). • Mechanism It is caused by coupled ectopic beats, i.e. an ectopic beat following each regular beat.

18. Pulsus Paradoxus Description Pulsus paradoxus is characterized by the following features. • A decrease in systolic blood pressure more than 10 mmHg during inspiration. • A radial pulse that gets smaller in volume (and may even disappear) with inspiration and larger in volume with expiration. It is important to note the following points in relation to pulsus paradoxus : • A decrease in systolic blood pressure by 3-10 mmHg and a small reduction in the volume of pulse during inspiration are physiological . Pulsus paradoxus is merely an exaggeration of this and NOT a reversal of this. • The "paradox" in the pulse is that heart sounds are still audible at a time when no radial pulse is felt. • Mild cases of pulsus paradoxus may not alter the radial pulse volume, which may appear normal. But sphygmomanometric measurement of systolic pressure during slow respiration will detect a more than 10 mmHg fall during inspiration .

19. Mechanism of Pulsus Paradoxus • In normal people, during inspiration there is a reduction in intrathoracic pressure, resulting in the following: • Pooling of blood in pulmonary vasculature • Pooling of blood in the right ventricle due to increased venous return • This generalised pooling of blood results in a reduction in the venous return to the left atrium and left ventricle. The net result is a reduction in cardiac output resulting in a drop of systolic blood pressure by 3-10 mmHg. In pulsus paradoxus , during inspiration the increased right ventricular volume of blood results in a bulging of the interventricular septum into the left ventricular cavity. This results in a reduction in the left ventricular volume leading to a further reduction in cardiac output. This exaggerates the normal inspiratory reduction in blood pressure, allowing it to exceed 10 mmHg. In patients with severe asthma, obstructive airway disease or tension pneumothorax, the degree of negative pressure generated during inspiration is exaggerated. This results in enhanced pooling of blood, thereby causing pulsus paradoxus .

20. Conditions Associated with Pulsus Paradoxus • Constrictive pericarditis • Cardiac tamponade • Pericardial effusion (rare) • Restrictive cardiomyopathy • Chronic obstructive airway disease (severe) • Severe bronchial asthma • Tension pneumothorax

21. Reverse Pulsus Paradoxus • Indicates inspiratory rise in arterial blood pressure • Seen in hypertrophic cardiomyopathy, intermittent positive pressure ventilation and AV dissociation

22. Radiofemoral Delay • Occurs in coarctation of aorta • Elicited by simultaneous palpation of right radial artery and one femoral artery • Features of radiofemoral delay are the following: • Femoral pulse is of small volume • Femoral pulse occurs after radial pulse • Lower limb blood pressures will be lower than upper limb blood pressures.

23. Characters of Pulse