Pulse - Arterial Pulse - Types

Pulse - Arterial Pulse - type rate rhythm character delay vessel wall condition arrythmia strokes waves

1. ARTERIAL PULSE GUIDE : Dr Kalinga B E STUDENT: Dr Niranjan.M

2. DEFINITION Greek word meaning ‘move to and fro’. Rhythmic expansion of the arterial wall due to transmission of pressure waves that travels along the arteries due to forceful ejection of blood during cardiac systole into the arterial system.

3. WAVEFORM

4. PULSE WAVE PATTERN IN CENTRAL AND PERIPHERAL ARTERIES CENTRAL ARTERY (AORTA) PERIPHERAL ARTERY (BRACHIAL) Upstroke rises to a rounded dome. Upstroke is steeper. Ascending limb has an anacrotic notch. Anacrotic notch in the ascending limb disappears. Descending limb has dicrotic notch followed by dicrotic wave. Dicrotic notch in descending limb is lowered and is followed by dicrotic wave.

5. EXAMINATION OF ARTERIAL PULSE All major arterial pulses should be bilaterally examined for Rate of the pulse Rhythm Character Volume Condition of the arterial wall (thickness) Radio radial delay and radio femoral delay

6. EXAMINATION All arterial pulses should be examined bilaterally CAROTID ARTERY

7. BRACHIAL ARTERY

8. RADIAL ARTERY

9. FEMORAL ARTERY

10. POPLITEAL ARTERY

11. POSTERIOR TIBIAL

12. DORSALIS PEDIS

13. RATE OF PULSE In adult person - between 60 and 100 beats per minute. In children average rate at 1 week of age 140/min 1 yr of age 120/min 6 yrs of age 100/min and Puberty 80/min

14. TACHYCARDIA Sinus tachycardia: A sinus rate above 100 beats per minute Physiological : Infancy Childhood Anxiety Stress Exercise 6. Excitement

15. Pharmacological : Medications: Atropine Epinephrine Isoproterenol Ephedrine Intoxicants: Alcohol N icotine Caffeine

16. \ Pathological : Cardiovascular causes : CHF AMI Pulmonary embolism Myocarditis Shock Tachyarrhythmias

17. Non-cardiac causes : Fever Anemia Thyrotoxicosis Hemorrhage Hypotension Hypoxemia

18. BRADYCARDIA Sinus bradycardia : sinus rate of less than 60 beats per minute Physiological : athletes ,during sleep . Pharmocological : B eta-blockers , A miodorone , Digoxin , Non dihydropyridine CCB.

19. Pathological : Cardiovascular causes: Inferior wall MI Vasovagal syncope Bradyarrhthmias

20. Non-cardiac causes – Myxedema . I ncreased intracranial pressure. Hypothermia. Obstructive jaundice. Severe hypoxia . RESPIRATORY CAUSES

21. RHYTHM The normal pulse is regular in rhythm. If the pulse is irregular, note whether it is regularly irregular or irregularly irregular . REGULARLY IRREGULAR IRREGULARLY IRREGULAR Sinus arrhythmia Atrial fibrillation Pulsus bigeminus , pulsus trigeminy Multifocal atrial tachycardia Atrial flutter with fixed block Frequent PVCs Partial (1st and 2nd degrees) heart blocks Atrial flutter with variable block

22. CHARACTER OF PULSE B est evaluated by palpation of the carotid pulse. PULSUS PARVUS ET TARDUS Slow rising pulse with delayed systolic peak (nearer to S2) and upstroke, associated with a thrill in the carotids (carotid shudder) is characteristic of AS.

23. WATER-HAMMER (COLLAPSING) PULSE : Rapid upstroke (percussion wave) followed by rapid descent (collapse) of the pulse wave without dicrotic notch.

24. Rapid upstroke is due to the rapid ejection of greatly increased stroke volume. Rapid descent is due to Diastolic ‘run-off’ (back flow) into the left ventricle . Reflex vasodilatation mediated by carotid baroreceptors secondary to large stroke volume. The rapid run-off to the periphery due to decreased systemic vascular resistance .

25. CAUSES OF COLLAPSING PULSE Hyperkinetic circulatory states . AR,AS WITH AR, PDA, aortopulmonary window, AV fistula.

26. TWICE BEATING PULSE A nacrotic pulse Pulsus bisferiens D icrotic pulse

27. ANACROTIC PULSE L ow rising pulse ( pulsus tardus ), a distinct notch ( anacrotic ) on the upstroke of the carotid pulse with two separate waves ( anacrotic and percussion) can be palpated Normal pulse Anacrotic pulse

28. Seen in AS T he presence of anacrotic pulse indicates 70mmHg pressure gradient.

29. BISFERIENS PULSE C haracterized by two systolic peaks (percussion and tidal waves) separated by a distinct midsystolic dip. NORMAL PULSE SEVERE AR HOCM

30. CAUSES OF BISFERIENS PULSE Hyperkinetic circulatory states . AR. AR+AS. Hypertrophic obstructive cardiomyopathy.

31. The two waves are equal or tidal wave is prominent in AR, AR+AS. In HOCM, percussion is more prominent than tidal wave. Bisferiens pulse disappears when the heart failure supervenes

32. DICROTIC PULSE T wo peaks, one in systole (percussion wave) and the other in diastole ( dicrotic wave) immediately after S2.

33. Commonly seen in low output states such as: Enteric fever Cardiomyopathy Cardiac tamponade Myocarditis Hypovolemic shock

34. PULSUS ALTERNANS Alternating small and large volume pulse in regular rhythm. precipitated by PVCs and is a sign of severe LV dysfunction

35. PULSUS PARADOXUS : Exaggerated decrease in the strength (amplitude) of the arterial pulse during normal quiet inspiration due to the exaggeration of normal inspiratory decline in the systolic arterial pressure of 10 mmHg.

36. Causes : Cardiac tamponade . Constrictive pericarditis . Massive pulmonary embolism. COPD : Severe emphysema, acute severe bronchial asthma .

37. Cardiac tamponade without pulsus paradoxus occurs when associated with ASD VSD AR Pericardial adhesions

38. MECHANISMOF PULSUS PARADOXUS

39. VOLUME OF PULSE I dea of the pulse pressure D epends on the stroke volume and the compliance of the arteries. Types Pulsus parvus . P ulsus magnus . H yperkinetic pulse .

40. PULSUS MAGNUS : H igh volume large amplitude pulse because of an increased stroke volume Seen in AR HYPERKINETIC OR BOUNDING PULSE I ncreased stroke volume and rapid ejection from the left ventricle. S een in hyperkinetic circulatory states.

41. CONDITION OF VESSEL WALL F lattening the artery by digital pressure and sliding it sideways . Monckeberg’s medial sclerosis

42. RADIAL PULSE SYNCHRONICITY Radial pulse on one side may be diminished or absent in patients with Pre subclavian COA Takayasu arteritis . Thoracic outlet syndrome. Subclavian steal syndrome. Aneurysm of arch of aorta Dissection of aorta.

43. ABSENT OR DELAYED FEMORAL PULSATIONS N oticeable delay in the arrival of femoral pulse is suggestive of: Coarctation of aorta Occlusive disease of the bifurcation of the aorta, common iliac or external iliac arteries.

44. ARTERIAL PULSE IN SPECIFIC CARDIAC DISORDERS AORTIC STENOSIS : Pulsus parvus et tardus Anacrotic pulse SUPRAVALVULAR AORTIC STENOSIS Differential streaming of central aortic blood flow Right carotid pulse is relatively normal Left carotid pulse has the characteristic features of aortic valve obstruction

45. HYPERTROPHIC CARDIOMYOPATHY Tapping quality to the pulse Bifid or “spike and dome” configuration

46. COARCTATION OF AORTA carotid pulses are increased in amplitude but have normal contour femoral pulses are small in volume and markedly delayed. AORTIC REGURGITATION Collapsing or bounding pulse Pure AR or AR + AS – Bisferiens pulse With CCF, Bisferiens pulse disappears

47. REFERENCES Harrisons Internal Medicine 20 th Edition Essential of cardiac physical diagnosis –Jonathan abrams Macleod clinical examination Clinical examination in cardiology –Vijay raghawa rao Hutchison clinical methods

48. THANK YOU