The arterial pulse

Full examination of pulse and clinical examination

1. Dr. Nisheeth M Patel
M.D (Medicine)
ARTERIAL PULSE

2. Pulse:
The pulse is a wave form that is felt by fingers and produced by
cardiac systole which travels through the peripheral arterial tree
in peripheral direction at a rate more faster than that of blood
columm.
Time lag from cardiac systole:
Carotid: 30ms
Radial: 80ms
Femoral: 75ms
Brachial: 60ms

3. IMPORTANCE:
Also called the mirror of heart
Information about arterial wall condition
Rough estimation of SBP n DBP
State of heart n circulation
Detect and diagnosis of arrythmia
Diagnosis in case of AR and acute LVF

4. The arterial pulse should be examined in all 4 limbs and both
sides of the neck
1.Radials
2.Brachials
3.Carotids
4.Femorals
5.Popliteals
6.Temporal
7.Facial
8.Peripheral arteries of the legs :Dorsalis pedis
Posterior tibial

5. How to feel the Pulse
The Radial pulse:
The 3 middle fingers are used
The palmar surface of the fingers overlies the radial A. and encircles the
wrist
At first the artery is completely occluded, then gradually release the
pressure until maximum feeling of the pulse wave is perceived.

6. The Carotids
The patient lies down with the head of the bed elevated
30 degrees
Carotid pulsations may be visible just medial to
sternomastoid
Place the left thumb on the right carotid A. in the lower
third of the neck at the level of the cricoid cartilage, just
inside the medial border of the sternomastoid and press
posteriorly
Never press both carotids at same time

7. Brachial Artery
Rest the patient arm with elbow extended palm up
Use the thumb of the opposite hand
Cup your hand under the patient elbow
Feel the pulse just medial to biceps tendon

8. Femoral Pulse
Press deeply below the inguinal ligament and about mid way
between ASIS and SP

9. Popliteal Pulse
Patient knee should be flexed –leg relaxed
Place the finger tips of both hands so that they meet in the
middle line behind the knee and press them deeply in the
popliteal fossa

10. Dorsalis Pedis
Feel the dorsum of the foot just lateral to the extensor
tendon of the big toe
If you cannot feel the pulse, explore the dorsum of the foot
more laterally

11. Posterior Tibial
Curve your fingers behind and slightly below the medial
malleolus of the ankle

12. Comment on the Pulse
1.Rate
2.Rhythm
3.Volume (amplitude)
4.Force
5.Tension
6.Comparison of the two sides
7.Special character
8.Condition of the arterial wall

13. Rate
Rate of the pulse at radial artery
Normal at rest :60-90 beat / min
* if regular: count in 15 sec x 4
* if fast (tachycardia )
*slow (bradycardia) count in 1 min
*if irregular count at apex
weak beats may not be felt (pulsus deficit)
Apex pulse deficit: > 10 suggestive of AF

14. Rhythm
Is the rhythm regular or irregular?
1.Normally regularly regular
2.Sinus arrhythmia: phasic irregularity with respiration,
3.Irregular:
1.Regularly irregular:
1.PAT with Fixed AV Block
2.Atrial flutter
3.Ventricular bigeminy or trigeminy
2.Irregularly irregular:
1.APCs, VPCs
2.AF
3.PAT with Varying degree of block

15. Volume (Amplitude)
Degree of expansion between systole and diastole
Measurement of pulse pressure
Hyperdynamic : (high
PP, SV)
Anxiety
Exercise
CHB
AR
Fever
Anemia
Thyrotoxicosis
AVF
Beriberi
Hypovolemic: (low PP,
SV)
Shock
CHF
Chronic CP
Hypovolemia
Stenotic Valvular disease
Mycarditis
Cardiomyopathies

16. Force and tension:
Force
Indicates SBP
High in : ISH, AR PDA, Hyperdynamic states:
Low in: Shock, Cardiac failure, Stenotic Valuvular lesion,
Cardiac Temponade
Tension:
Indicates DBP

17. Comparison of both sides
Causes of unequal pulse
1.Genetic absence or change in the course of the radial
artery (anomalous radial artery)
2.Compression of the vessel
3.Atheromatous plaque
4.Embolus

19. Anacrotic Pulse (Pulsus Tardus):
Slow rise, slow fall
Duration of pulse is prolonged
Amplitude is small
Lazy in character (Tardus)
In aortic stenosis
Dicrotic Pulse:
One peak in systole, one in diastole
Myocardial disease with reduced CO and TPR
LVF, DCM
Cardiac Tamponade
Dehydration

20. Collapsing and Water hammer pulse
corriagan, bounding pulse
Rapid upstroke
Rapid down stroke
High amplitude
Short duration
Causes:
Aortic incompetence
PDA
Hyperdynamic states: Fever, Anaemia, Thyrotoxicosis,
pregnancy and AV fistula

21. Pulsus Bisferiens
Pulse has 2 peaks:
 two peaks in systole
d/t ejection of rapid jet of blood
AS + AR
Severe AR
HOCM
A double pulse is felt and seen in the carotid

22. Pulsus Parus:
Small volume pulse
Low CO
A/w Tachycardia, thready pulse
Physiological: cold, anxiety
Vessel occlusion
CoA of Aorta
Severe Hypotension (Shock)
Severe AS PS
MI
Severe PAH

23. Jerky pulse:
Small volume & collapsing
HOCM
Severe MR
AR with LVF
Pulsus alterans:
Alternate large and small volume pulse
LV Failure
Cardia Arrythmias
Pulsus bigeminus:
Pulse wave with normal beat f/b VPCs f/b compensatory pause
Digitalis toxicity

24. Pulsus paradoxus:
Exaggerated decrease in strength of arterial pulse during
inspiration, Inspiratory fall of SBP >10mmHg
Cardiac temponade
Constrictive pericarditis
Acute asthma
SVC obstruction
Reverse pulsus paradoxus:
HOCM
IPPV
AV dissociaton

25. Thank You…