The document discusses arterial pulses, including: 1. The rate at which the pulse wave travels through arteries is independent of blood flow rate and is fastest in small arteries. 2. Common peripheral pulses that can be felt include the radial, carotid, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses. 3. Features of a pulse that can be assessed include rate, rhythm, volume, character, and conditions like radio-radial delay. Abnormal pulses include hypokinetic, collapsing, bisferiens, and paradoxical pulses.

1. ARTERIAL PULSES
By – Dr. Prateek Singh
PGY2 medicine

2. introduction
 A pulse wave is a waveform that is felt by the finger , produced
by the cardiac systole, which traverses the arterial tree in a
peripheral direction at a rate much faster than of the blood
column.
 Actively produced by expansion and elongation of arterial wall
imparted by the column of blood, passively produced by
pressure changes during ventricular systole and diastole.

3.  The rate at which the wave travels, which is independent of and
much higher than the velocity of blood flow, is about
- 4 m/s in the aorta,
-8 m/s in the large arteries,
-16 m/s in the small arteries of young adults.
Consequently, the pulse is felt in the radial artery at the wrist
about 0.1s after the peak of systolic ejection into the aorta.
 Carotid artery pulse waves occurs within 30ms of the ascending aortic
pulse and reflects aortic valve and ascending aortic function.

4. Normal arterial pulse : CATACROTIC PULSE

5. 1. Percussion waves = (P) Produced by systolic ejection of blood in
arterial system (just after S1).
2. Tidal wave = (T) echo of the percussion wave by the arterial
system;
3. Dichrotic notch = is the abrupt closure of the aortic valve
4. Dichrotic wave = (D) is the reflected wave from the peripheral
vasculature
5. DOWN SLOPE (CATACROTIC LIMB) = Slowly decreasing pressure
 wavy pattern is not felt since it is obliterated by normal vascular
tone
 The amplitude of the arterial pulse increases with the distance from
the heart.

6. The
peripheral
pulses

7. Peripheral Pulses -Radial pulse
 At wrist , lateral to flexor carpi
radialis tendon , place your three
middle fingers over the radial
artery.
 Absent radial pulse
- anatomical abnormality
- severe atherosclerosis
- takayasu’s disease
- embolism into the radial artery

8. Carotid Pulse
 Palpate carotid pulse with the pt lying on a bed / couch
 Never compress both carotid arteries simultaneously.
 Use your left thumb for right carotid pulse & vice versa.
 Place tip of thumb b/w larynx & ant.border of sternocleidomastoid.

9. BrachialPulse
 Use your thumb ( rt thumb for rt.arm & vice versa ) with your
fingers cupped round the back of the elbow.
 Brachial pulse – felt in front of the elbow just medial to tendon
of biceps.

10. Femoral Pulse
 Is felt at groin just below inguinal ligament midway b/w
ant.sup.iliac.spine & symphysis pubis.

11. Popliteal Pulse
 Knee to be flexed 40 deg. Heel resting on bed
 Place fingers over lower part of popliteal fossa & fingers
are moved sideways to feel pulsation of Popliteal.A
against post.aspect of tibial condyles.

12. Posterior Tibial Pulse
 Felt just behind medial malleolus , midway b/w medial
malleolus & tendo achillis.

13. Dorsalis Pedis Pulse
 Passes just lateral to tendon of ext.hallucis longus and is
best felt at the proximal extent of the groove between the
first and second metatarsals. It may be absent or
abnormally sited in 10% of normal subjects, sometimes
being replaced by a palpable perforating peroneal artery.

14. Determinants of Arterial Pressure Pulse and
Contour
1. Incident pressure wave
 Compliance of aorta
 Stroke volume
 Velocity of ejection
 Left ventricular pump
 Preload
 Afterload
 Contractility
 Pattern of ejection
 Impedance to ejection
2. Pulse wave velocity
 Mean arterial pressure
 Arterial stiffness/compliance
 Vasomotor tone

15. When taking pulse, assess:
 Rate
 Rhythm
 Volume
 Character
 Felt in all peripheral vessels
 Radio – radial / radio- femoral delay
 Apex pulse deficit
 Condition of the vessel wall

16.  Use the larger (brachial, carotid, femoral) arteries to assess the pulse
volume and character
Record individual pulses as:
 Normal +
 Reduced -/+
 Absent –
 Aneurysmal + +
 Note= both carotid should not be palpated simultaeneously

17. Pulse rate
 Should be counted for 1 minute by palpating radial artery
 Normal 60-100 bpm
 Bradycardia is less than 60 bpm
 Tachycardia is more than 100bpm

18. Normal Pulse Rates
Babies to age 1: 100–160
Children ages 1 to 10: 60–140
Children age 10+ & Adults: 60–100
Well-conditioned Athletes: 40–60

19. Causes of Bradycardia
Physiological:
 Athletes, Sleep, meditation, yoga.
Pathological:
 Severe hypoxia, hypothermia, Myxoedema, Obstructive jaundice,
Acute inferior MI, Raised intraocular or intracranial pressure, Heart
blocks, vasovagal attacks, Drugs;(Beta blockers,Verpamil, diltiazem,
Digoxin).
 Carotid sinus hypersensitivity
 Sick sinus syndrome
 2nd degree and complete heart block

20. Causes of Tachycardia
Physiolocal: Infants, Children, Emotion, Exertion,Pregnancy
Pathological:
 Tachyarrythmias= Supraventricular & ventricular
 High output status: Anemia, pyrexia, Beriberi, thyrotoxicosis,
pheochromocytoma,AV Fistula,
 Low output states- Acute ant. wall MI, Heart failure, Cardiogenic
shock, hypovolemia,myocarditis, Hypotention.
 Tachyarrhythmia- SVT,VT
 Drugs: Atropin, Nefidipin, Beta agonists; sulbutamol, thyroxin,
catecholamines, nicotine, caffeine.

21. Relative bradycardia
 Physiological pulse-temperature relationship : For each degree increase in
temperature in Fahrenheit, there is corresponding increase in heart rate of 10
bpm (and vice versa)
 Pulse temperature deficit : relative bradycardia
 Causes :
Non- infectious
beta blockers
CNS lesion- tumor, bleed
lymphoma

22. Infectious
viral fever (yellow Fever:faget sign )
typhoid
legionella
drug fever
leptospira
psittacosis
Brucella
typhus,dengue

23. Relative tachycardia
 Acute rheumatic carditis
 TB
 Diphtheretic myocarditis
 Polyarthritis nodosa

24. Rhythm
It maybe regular or irregular
If irregular:
 Regularly irregular. eg: 2nd degreeAV block,
BIGEMINY,TRIGEMINY, CHB, Second degree HB with fixed
response.
 Irregularly irregular. eg: AF, ectopics (VPB,APB) Second
degree HB with variable response

25.  The Rhythm varies slightly with respiratory cycle and is mediated by
vagus nerve and is most pronounced in children, young adults or
athelets (sinus arrhythmia)
 During inspiration, parasympathetic tone falls and the heart rate
increases, on expiration ; the heart rate decreases.

27. Pulse volume
 It is best assessed by palpating carotid artery
Pulse pressure (difference between SBP & DBP) gives the accurate
measure of pulse volume
 Normal volume is when pulse pressure is between 30-60mmHg
 Small volume pulse is when pulse pressure is less than 30mmHg
 Large volume pulse is when pulse pressure is more than 60mmHg
Depends on the stroke volume and arterial compliance

28.  Low pulse volume
 Hypokinetic pulse
 Decreased stroke volume(SBP) or
increased PVR(DBP)
narrow pulse pressure
 Causes :
hypovolemia & shock
cardiac failure – decreased SV
mitral stenosis
aortic stenosis ( pulsus parvus
et tardus)
 High pulse volume
 Hyperkinetic or bounding
 Increased stroke volume(SBP) or
decreased PVR(DBP)
wide pulse pressure
 Causes :
high CO states – fever, anemia,
exercise, thyrotoxicosis, pregnancy,
beri-beri,AV fistula, paget’s disease
-complete heart block
-rapid runoff of blood from arterial
system – Aortic insufficiency,
PDA, peripheralAV shunt, MR

29. Pulse character
 Best assessed in carotid arteries
 Referres to wave form or shape of the arterial pulse
 Hypokinetic pulse
 Anacrotic pulse ( pulsus parvus et tardus )
 Hyperkineic pulse
 Collapsing pulse ( water-hammer pulse, corrigans pulse)
 Pulsus bisfriens
 Pulsus dicroticus
 Pulsus alternans
 Pulsus bigeminus
 Pulsus paradoxus

30. Hypokinetic pulse (slow rate of rise)
 Small weak pulse ( small volume and narrow pulse pressure <30
mmhg)
 Causes: Heart failure, shock, AS, MS
How to feel?
 Rise is slow with no tap then the sensation is one of a caressing lift, a
gentle push or a nudge.
Slow rate of rise in carotid signifies:
 Aortic stenosis due to fixed obstruction to aortic flow
 Thrill of AS maybe palpated over the left carotid than on the right.

31.  In supravalvular AS have both rate of rise and blood
pressure greater on RIGHT carotid and subclavian than on
the LEFT Because streaming on the jet straight up along the
ascending aorta toward the innominate, right carotid and
right subclavian arteries.

35. Anacrotic pulse (parvus et Tardus)
Low amplitude pulse (parvus) with a slow rising and late peak (tardus)
 In severe valvular Aortic Stenosis
 Appreciated by palpation of carotid arteries
 Delay is assessed during simultaneous auscultation of the heart
sounds; carotid upstroke should coincide with S1

36. normal parvus et tardus

38. Hyperkinetic pulse
High amplitude pulse with a rapid rise (large volume & wide pulse
pressure >60 mmhg,
 Mitral Regurgitation (MR)
 Ventricular septal defects (VSD)
 Hypertrophic obstructive cardiomyopathy (HOCM)
 MR andVSD receives 2 sources of blood from diastole
 In HOCM no obstruction until the outflow tract contracts
and approximates the thickened septum to a mitral leaflet.

41. Bounding pulse, Collapsing pulse, Water-
Hammer pulse,
Large volume pulse with a rapid upstroke (systolic pressure high) and a
rapid down stroke (diastolic pressure low)
Rapid upstroke – increased stroke volume.
Rapid downstroke – diastolic runoff into Lt.Ven & decreased PR & rapid
runoff to periphery.
Cardiac causes:
 AR, PDA, Coarctation, AV Fistula, Rupture of sinus ofValsalva, Severe
Bradycardia
Non cardiac causes
 Thyrotoxicosis, Pregnancy, SevereAnemia, Fever

42. Pseudo collapsing pulse – high vol pulse which abruptly falls – mitral
incompetance
Traube’s sign or Pistol shot sounds
 Loud sounds heard when the stethoscope is placed over the rapidly
rising large pulsation of femoral artery in AR

43. Pulsus Bisferiens
A double peaked arterial pulse with a mid systolic dip in systole
 Best felt in brachial and femoral arteries
 Due to ejection of a rapid jet of blood through the aortic valve
Causes:
 HOCM
 SevereAR
 AS with AR

44. AR HOCM

45. Pulsus Dicroticus
 Single pulse wave with one peak in systole and one peak in diastole
due to very low stroke volume with decreased peripheral resistance.
Causes:
 LVF
 Enteric fever
 Sepsis
 Dehydration
 DCM and CardiacTamponade
 IABP

47. Pulsus Alternans
 Alternating fluctuation of pulse pressure with regular rhythm Best
appreciated by palpating Radial or Femoral.
Causes:
 Myocardial damage (HF) especially LVF
 Without HF; secondary to hypertrophy and increased afterload.
Eg: HTN and AS
 Following paroxysmal tachycardia

49. Pulsus Bigeminus
A pulse wave with normal beat followed by a premature beat and a
compesatory pause
 Occuring in rapid succession resulting in alternation of the strength of
the pulse.
Causes
 Alternate premature beats
 AV block
 Sinoatrial block withVent. Escape
 Digitalis toxicity
In pulsus alternans compensatory pause is absent whereas in pulsus
bigeminus it is present.

51. Pulsus Paradoxus
 It is marked fall in systolic BP (more than 10mmHg) on inspiration
 Lung capacity increases with inspiration and the pulmonary
vascular bed expands so that less blood moves from the lung
into the left heart.
 Inspiratory decline of LV stroke volume due to an increase in RV
end-diastolic volume and decreased LV end diastolic volume
 In cardiac tamponade, the interventricular septum shifts
toward the LV cavity during inspiration (reverse Bernheim
phenomenon) a result of the normal increase in venous return
to the right side, thereby decreasing LV preload.

52. Sign of Pericardial or Pulmonary disease
 Cardiac tamponade
 constrictive pericarditis
 severe airway obs
 Partial SVC obstruction
 Hypovolemic shock
 Tension pneumothorax
 Rarely with pulmonary embolism, marked obesity, pregnancy.

54. Reverse Pulsus Paradoxus
It’s inspiratory rise in arterial systolic and diastolic pressure due to
inspiratory increase in LV stroke output.
Causes:
 HOCM
 Intermittent positive pressure ventilation
 IsorhythmicAV dissociation.

55. Apex-pulse deficit
 Difference between the heart rate at the apex and the rate
palpable at the wrist.
 Causes : ectopic beats ,atrial fibrillation
Features Atrial fibrillation Ectopics
Pulse deficit > 10 / min < 10 / min
On exertion Persists/increase Decrease
rhythm Irregularly irregular Regularly irregular

56. ECTOPIC BEATS (PREMATURE BEAT/EXTRASYSTOLE)
Impulse arises from sites other than SA node (atrial wall, AVN, ventricular
wall)
Small, premature and followed by compensatory pause
Causes:
 Normally
 Over indulgence of coffee, tea, alcohol, cigarettes
 Anxiety
 Rheumatic, Ischemic, HTN,Thyrotoxic,
 Cardiomyopathic Heart diseases

58. Radio-radial delay
 Obstructive arterial diseases, most commonly atherosclerosis
 Aortic dissection
 Aortic aneurysm
 Takayasu disease
 Preductal coarctation of aorta
 Supravalvular aortic stenosis
 Subclavian steal syndrome
 Thoracic inlet syndrome eg. Cervical rib and scalene syndrome
 Pressure over axillary artery by tumor, lymph node etc.
 Traumas

59. Radio-femoral delay
 In coarctation of aorta, femoral pulse maybe significantly delayed
compared to radial
 Supravalvular aortic stenosis
 Atheroscelerosis of aorta
 Thrombosis or embolism of aorta
 Block at bifurcation of aorta
 aortoarteritis
 Iatrogenic trauma

60. Condition of arterial wall
 Only changes in the medial layer of the radial artery can
be assessed by palpation.
 Thickening or tortuosity detected commonly in the
arteries of elderly people.These changes, however, do not
indicate the presence of luminal narrowing due to
atherosclerosis.Therefore, this sign is of little clinical value

61. THANK YOU
HAVE A GOOD DAY