different types of pulse, normal physiology

pulse can be defined as the pressure difference between systolic and diastolic pressure

1. Pulse

2. Definition It is the expansion and elongation of the arterial wall imparted by the column of blood, and it is passively produced by the pressure changes during ventricular systole and diastole. Ejection of blood from the left ventricle into the systemic arterial circulation creates a pressure wave that can be felt as a pulse where the arteries are superficial or they pass over the bone.

3. EXAMINaTION OF PULSE Pulse is examined in the following points 1. rate 2. rhythm 3. volume 4. character

4. rate By convention, rate is assessed by palpating the right radial pulse Rate is expressed in beats per minute Measured by counting the number of beats in a time period of 15 sec and multiplying by four but in patient with arrhythmia one must count the beats for 1 minute The pulse should be recorded when child is at rest or during sleep because crying, anxiety, activity and restlessness are likely to increase the pulse rate

5. ABNORMALITIES IN RATE 1.TACHYCARDIA Pulse rate above 100 bpm. SINUS TACHYCARDIA- Pulse rate is above 100 per minute where the impulse is originating from the SA node. The heart rate in sinus tachycardia varies from 100 to 160bpm Common causes-Physiological ( age related), Fever, Exercise, Emotional disturbances, Anaemia, Dehydration, Hypovolemia, shock, Myocarditis, cardiac failure, pulmonary embolism, thyrotoxicosis, pheochromocytoma, hypoglycemia , autonomic dysfunction , drugs like salbutamol, nifedipine, atropine

6. b. RELATIVE TACHYCARDIA: With per degree increase in temperature pulse rate will increase by 10bpm, in children the rise may be upto 1.2 to 15 bpm. But in relative tachycardia pulse rate will increase more than the normal increase. It is seen in Acute rheumatic carditis Tuberculosis Diptheritic myocarditis Polyarteritis nodasa

7. C. PAROXYSMAL TACHYCARDIA: Pulse rate more than 160bpm. Divided into 2 types 1. supraventricular tachycardia 2. ventricular tachycardia

8. 2.BRADYCARDIA Pulse rate less than 60bpm a. SINUS BRADYCARDIA athletes, myxoedema , obstructive jaundice, increased intracranial tension, hypothermia, sick sinus syndrome, vasovagal attacks, severe hypoxia, organophosphorus poisoning, drugs like beta blockers and digitalis b. RELATIVE BRADYCARDIA increase in pulse rate is less than 10bpm with per degree rise in temperature Seen in any viral fever, first week of enteric fever, pyogenic meningitis, brucellosis, psittacosis, weils disease

9. RHYTHM Rhythm is the spacing of successive beats in time. Normal pulse is regular in rhythm and is known as sinus rhythm, because is generated by SA NODE 1.REGULARLY IRREGULAR – Irregularity comes at regular interval . Seen in extrasystoles, 2 nd heart block, sinus arrhythmia, pulsus bigeminus 2. IRREGULARLY IRREGULAR- Irregularity in two pulse beats in every aspect. Seen in atrial fibrillation, multiple ventricular extrasystoles, atrial flutter with varying degree of heart block

10. volume It is the amplitude of the pulse wave, depends on , 1.complaiance 2.stroke volume It reflects width of pulse pressure Carotid, brachial or femoral arteries are more useful for assessing pulse volume

11. Based on pulse volume , pulse can be: PULSUS PARVUS Low Volume + Small Amplitude Due to decreased stroke volume Eg. Aortic Stenosis Severe Congestive Heart Failure PULSUS MAGNUS High Volume + Large Amplitude Due to increased stroke volume Eg. Aortic Regurgitation HYPERKINETIC/ BOUNDING PULSE Increased Stroke Volume + Rapid ejection eg. Pregnancy Anemia Thyrotoxicosis Beri beri Fever

12. Character The volume, waveform, and some special features ( eg. Collapsing nature) altogether give rise to character of the pulse which is often helpful to clinical diagnosis of specific disease or disorder

13. Character PULSUS TARDUS WATER HAMMER PULSUS PARADOXUS TWICE BEATING IRREGULARLY IRREGULAR ANACROTIC PULSUS BISFIRIENS DICROTIC PULSUS BIGEMINUS PULSUS ALTERNANS

14. PULSUS TARDUS It is a slow rising pulse with delayed systolic peak and upstroke. Often occurs with Pulsus Parvus (low volume pulse), known as Pulsus Parvus et tardus . Seen in Aortic Stenosis.

15. ANACROTIC PULSE It is also a slow rising pulse with a distinct notch ( anacrotic ) on the upstroke of carotid pulse with two separate waves ( anacrotic and percussion) can be palpated. Also seen in Aortic stenosis. Lower the notch, more is the severity of AS

16. PULSUS BISFIRIENS High volume double beating pulse Characterised by two systolic peaks (percussion and tidal), separated by a distinct mid systolic dip. Better appreciated in Carotid artery than radial artery. Technique: Apply graduated pressure or obliterate completely and gradually release to appreciate the two waves.

17. DICROTIC PULSE when an upstroke is felt in the descending limb of the pulse wave, it is known as dicrotic pulse Characterised by two peaks, one in systole (Percussion) and one in diastole (dicrotic).the dicrotic wave is felt due to hypotonia of the vessel wall Better appreciated in Radial artery than Carotid artery. Found in second week of typhoid fever, endotoxic Shock, hypovolemic shock, diffuse myocardial disease

18. WATER HAMMER PULSE Also known as Corrigan’s pulse or Pulsus Celer . It is characterised by rapid upstroke (percussion wave) followed by rapid descent (collapse) of the pulse wave without dicrotic notch. Best appreciated at radial pulse. Technique: Hold the patient’s right elbow with your left hand and with your right hand hold the palmar side of the patient’s wrist in a way that webs fall on the radial artery and rest of the palm over the ulnar artery. While supporting the forearm, elevate the entire arm suddenly above the level of the heart.

19. In water hammer pulse the volume increases from the basal level after elevation of the upper limb , and the pulse strikes the palpating palm with a rapid and forceful jerk. Abrupt downstroke of the pulse produces the collapsing feel

20. PULSUS BIGEMINUS Irregular rhythm Clinically two beats and a pause thereafter recur repeatedly,the second beat is an ectopic and thus there is a pause after it. Due to Premature contractions of the ventricle Causes alteration in the strength of pulse occurs in digitalis toxicity

21. PULSUS ALTERNANS Regular rhythm Strong beat alternates with weak beat A sign of severe Left ventricular dysfunction, in LVF some ventricular muscle fibres are healthy and some are degenerated and thus produce normal and weak beat respectively

22. PULSUS PARADOXUS Exaggerated decrease in the strength (amplitude) of the arterial pulse during normal inspiration due to exaggerated inspiratory decline of systolic blood pressure by >10mm Hg, occurs due to exaggerated inspiratory decline in the stroke volume by >=7% Detection: Inflate the BP cuff 20mmHg above the systolic BP Deflate slowly @2mmHg/heart beat. Initially the Korotkoff sound is heard only during expiration, note the BP. Deflate the cuff more slowly till Korotkoff sound is heard both in inspiration and expiration. Difference between the two is the magnitude of the pulsus paradoxus.

23. Seen in 1.acute severe asthma 2. chronic obstructive pulmonary disease 3. cardiac tamponade 4. chronic constrictive pericarditis 5.restrictive cardiomyopathy

24. CONDITION OF THE ARTERIAL WALL Technique: It is examined by the flattening the artery by digital pressure and sliding it sideways. Eg.1.Atherosclerotic vessels: Hard and tube like 2.Mockenberg’s degeneration: Hard and calcified

25. . Radial pulse synchronicity To examine if the radial pulses are equal bilaterally. Radial pulse on either side may be absent or reduced in certain conditions such as,1.Coarctation of Aorta 2.Aortic arch syndrome ( Takayasu’s arteritis) 3.Thoracic outlet syndrome

26. radio-femoral delay Method: While palpating the radial pulse, place fingers of the other hand over the femoral pulse. A noticeable delay is pathological is suggestive of, 1.Coarctation of aorta 2.Occlusive disease of the bifurcation of the aorta, common iliac or external iliac.

27. PALPATION OF THE PERIPHERAL ARTERIES The technique/method varies with the artery being examined: RADIAL PULSE Position: The patient's forearm should be supported in one of the examiner's hands and his other hand used to palpate along the radio- alvolar aspect of the subject's forearm at the wrist, with the patients forearm slightly pronated and wrist slightly flexed. Location: To be pressed against the head of the radius . Technique: Trisection method: By using the three fingers, usually Index, Middle and the Ring finger) Proximal finger: To fix the artery. Distal finger : Obliterates the back flow from the Ulnar artery via the Palmar Arch Middle : To asses the character.

28. . BRACHIAL PULSE Position : Subject's upper arm should be abducted, the elbow slightly flexed, and the forearm externally rotated. Location : Medial to the biceps tendon and lateral to the medial epicondyle of the humerus . Technique : For examining subjects Right brachial artery 1. The examiner can examine either by using the left thumb finger or 2. By supporting the patient's forearm in examiner’s left hand, the examiner's right hand is then curled over the anterior aspect of the elbow to palpate along the course of the artery. The position of the hands should be switched when examining the opposite limb

29. CAROTID PULSE Position : Patient’s sternocleidomastoid muscles should be relaxed and head should be slightly rotated towards the examiner Location : Lower half of the neck, against the thyroid cartilage. Technique : Use left thumb for patient’s right carotid artery and vice versa. Thumb should gently and slowly exert pressure on the carotid pulse to elicit the maximal systolic impact. AVOID : Simultaneous palpation of both the carotid to avoid Carotid sinus syndrome.

30. FEMORAL Position : Patient should be in supine position. Location : The  common femoral artery  emerges into the upper thigh from beneath the inguinal ligament midway between the pubis and the anterior superior iliac spine. Technique : The examiner standing on the ipsilateral side of the patient and the fingertips of the examining hand pressed firmly into the groin.

31. POPLITEAL Position : Patient’s knee should be flexed at around 120 degree. Location : The artery  passes vertically through the deep portion of the popliteal space just lateral to the midplane. Technique : The examiner's hands should encircle and support the knee from each side. The pulse is detected by pressing deeply into the popliteal space with the supporting fingertip and the thumb should rest on the patient’s patella

32. . POSTERIOR TIBIAL ARTERY Position : After making the patient supine, patient’s foot should be relaxed between plantar and dorsiflexion. Location : The artery can be palpated 1cm behind the medial malleolus of the Tibia. Technique : Can be felt by curling the fingers of the examining hand anteriorly around the ankle, indenting the soft tissues in the space between the medial malleolus and the Achilles tendon, above the calcaneus. The thumb can be applied to the opposite side of the ankle in a grasping fashion to provide stability

33. . DORSAL PEDIS ARTERY Position : The  dorsalis pedis artery is examined with the patient in the supine position and the ankle relaxed. Location : Commonly felt between the tendons of the first and the second toe, 5- 7.5cm below the joint crevice. Technique : The examiner stands at the foot of the examining table and places the fingertips transversely across the dorsum of the forefoot near the ankle, pressing against the tarsal bones. Patient’s right dorsal pedis is palpated by the examiner’s right hand and vice versa. Alternatively, both the arteries can be palpated simultaneously. NOTE: The dorsal pedis artery may not be palpable in around 10% of the population due to anomalous course.

34. summary

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