EXAMINATION OF PULSE

DEFINITION OF PULSE
Expansion and elongation of arterial wall imparted by the column of blood,
passively produced by pressure changes during ventricular systole and
diastole.

ASSESSMENT OF PULSE
1. RATE (beats/min)
- Tachycardia(>100/min)
- Bradycardia(<60/min)
2. RHYTHM
- Regular
- Regularly Irregular (2nd degree heart block)
- Irregularly Irregular(Atrial Fibrillation, VPB, APB)
3. EQUALITY
4. CHARACTER
- Anacrotic Pulse
- Dicrotic Pulse
- Pulsus Bisferiens
- Pulsus Alternans
- Pulsus Parvus et Tardus
- Pulsus Bigeminus
- Pulsus Paradoxus
- Bounding Pulse
- Thready Pulse
- Waterhammer Pulse
5. PERIPHERAL PULSES(Femoral, Posterior Tibial, Dorsalis Pedis)
6. APEX PULSE DEFICIT(Atrial Fibrillation)
7. RADIO-RADIAL/RADIOFEMORAL DELAY

SINUS ARRHYTHMIA
Definition: Increase PR with inspiration and decrease in PR with expiration
Physiological phenomenon seen in children and athletes

Mechanism: Increase amount of blood which comes into LV increase SV.

This stimulates the baroreceptors and leads to slowing of HR.

Absent in: CCF and Autonomic Neuropathy

DISPROPORTIONATELY RAPID PULSE IN SHOCK

1. Acute MI
2. Septic Shock
3. Myocarditis
4. Tachyarrhythmia
 VARIATIONS IN PULSE RATE
TACHYCARDIA BRADYCARDIA
Pulse rate >100/min Pulse rate<60/min
Causes: Causes:
SINUS TACHYCARDIA: Athletes, Yoga meditation,
Exercise, emotion, excitement deep sleep
Intense pain Myxoedema
Heart failure Increased ICT
Thyrotoxicosis Hypothermia
Severe anemia 2nd degree HB/ CHB
Shock Sick sinus syndrome
Myocarditis Vasovagal attacks
Pregnancy Severe hypoxia
Hypoxia Drugs(beta blocker, digoxin)
Drugs (Beta2 agonist) SINUS BRADYCARDIA:
RELATIVE TACHYCARDIA: All the causes above except CHB
Pyrexia BRADY CARDIA associated with
PAROXYSMAL Convulsions:
TACHYCARDIA(>160/min) CHB(Stoke Adams syndrome)
Supraventricular(Atrial or nodal) Increased ICT
Ventricular Prior to myxoedema coma

APEX PULSE DEFICIT

Difference between HR and PR
1. Atrial Fibrillation (>10/min)
2. Multiple ectopics (<10/min)

ECTOPIC BEATS (PREMATURE BEAT/ EXTRASYSTOLE)

Definition: Impulse arises from sites other than SAnode(atrial wall, AVN,
ventricular wall)
Small, occurs, prematurely
Followed by compensatory pause

Causes:
1. Overindulgence of coffee, tea, alcohol, cigarettes
2. Anxiety
3. Dyspepsia
4. Rheumatic, Ischaemic, HTN, Thyrotoxic, Cardiomyopathic Heart diseases

Abolished by Vagotonic procedures:

1. Carotid sinus massage
2. Self-induced gagging or vomiting
3. Pressure over the eyeballs
4. Valsava manoeuvre
5. Coughing
 6. Breath holding
7. Head lowering between the knees
8. Stretching the arm and body
9. Drug: digoxin

Enhanced by vagolytic procedures:

1. Exercise
2. Drugs: Amyl nitrite, atropine

IRREGULAR RHYTHM WITH NORMAL HEART RATE

1. Multiple extrasystoles
2. Digitalised AF
3. Sinus arrhythmia

CAUSES OF ABSENT RADIAL PULSE

1. Anatomical abnormality
2. Severe artherosclerosis
3. Takayasu arteritis (Pulseless disease)
4. Embolism in radial artery
5. Death

CAUSES OF RADIO-RADIAL DELAY:

1. Normal anatomical variations
2. Thoracic inlet syndrome, e.g. cervical rib
3. Aneurysm of Arch of aorta
4. Presubclavian coarctation
5. Supravalvular aortic stenosis
6. Pulseless disease
7. Peripheral embolism or artheromatous plaques
8. Artherosclerosis of aorta
9. Pressure over axillary artery by lymph nodes
10.Iatrogenic, Blalock-Tausig shunt operation in TOF

CAUSES OF RADIOFEMORAL DELAY

1. Coarctation of aorta
2. Artherosclerosis of aorta
3. Thrombosis or embolism of aorta
4. Aortoarteritis

CATACROTIC PULSE
Normal arterial pulse:
1. Percussion waves, P - Produced by ejected blood in arterial system
2. Tidal wave, T - Generated along arterial wall
3. Dicrotic notch and dicrotic wave in downstroke of pulse, d/t elastic recoil
of vessel
 *wavy pattern is not felt in health since it is obliterated by normal vascular
tone

Pulse Characteristic Examples

Anacrotic Pulse Slow rising Aortic Stenosis
Twice beating
Both waves felt in systole
Pulsus Bisferiens Rapid rising Idiopathic Hypertrophic
Twice beating Subaortic Stenosis(jerky
Both waves felt in systole pulse)
Severe AR with mild AS
HOCM
Dicrotic Pulse Twice beating Fever (e.g. typhoid fever)
First wave in systole, second Endotoxic shock
wave in diastole CCF
(seen when PR and DP is low) Cardiac Tamponade
Felt due to hypotonia of Following open heart
vessel wall surgery
Pulsus Parvus et Slow rising Aortic Stenosis
Tardus Anacrotic wave not felt
Pulsus Alternans Strong and weak beat LVF
occurring alternately Toxic myocarditis

Pulsus Paradoxus SBP fall more than 10mmHg
during inspiration
(exaggeration of normal)
Does not happen if thoracic
cage is immobile
Reverse Pulsus Peripheral pulses disappear
Paradoxus on inspiration, while heart
sounds remain audible
Pulsus Bigeminus Coupling of the pulses waves
in pairs
Followed by a pause
Thready Pulse Pulse rate is rapid
Pulse wave is small and
disappear quickly
Bounding pulse Increased SV
High Volume Pulse Hyperkinetic circulatory states
Low Volume Pulse
Paroxysmal Tachycardias
Following Premature beat
SVC Obstruction
Lung conditions(Asthma,
emphysema, airway
obstruction)
Pericardial effusion
Constrictive pericarditis
Severe CCF
Patient on Continuos airway
pressure on mechanical
ventilator
Alternate premature beats
AV block
Sinoatrial block with Vent.
Escape
Cardiogenic shock
PHYSIOLOGICAL:
Fever, Pregnancy,
Alcoholism, Exercise
PATHOLOGICAL:
HIGH OUTPUT STATES:
Anemia
Beri-beri
Cor pulmonale
Cirrhosis
liver(hypoproteinemia)
Thyrotoxicosis
AV fistula
Pagets disease
CARDIAC CAUSE:
Aortic regurgitation
Bradycardia
Complete Heart Block
PDA
Systolic HTN
Rupture of sinus valsava
into heart chamber
Aortopulmonary window
Shock
Severe Aortic Stenosis
Tight Mitral Stenosis
 CCF
Pericardial Effusion
Constrictive Pericarditis
Waterhammer High volume pulse Aortic Regurgitation
Pulse(Corrigans Sharp rise
Pulse) Ill-sustained
Sharp fall
Pulse pressure is at least
60mmHg