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.

6. 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

8. EXAMINATION
All arterial pulses should be examined bilaterally
• CAROTID
ARTERY

9. • BRACHIAL ARTERY

10. • RADIAL ARTERY

11. • FEMORAL
ARTERY

12. POPLITEAL ARTERY

13. • POSTERIOR TIBIAL

14. DORSALIS PEDIS

15. 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

16. TACHYCARDIA
• Sinus tachycardia: A sinus rate above 100 beats per minute
• Physiological :
1. Infancy
2. Childhood
3. Anxiety
4. Stress
5. Exercise
6. Excitement

17. •Pharmacological :
1. Medications:
• Atropine
• Epinephrine
• Isoproterenol
• Ephedrine
2. Intoxicants:
• Alcohol
• Nicotine
• Caffeine

18. • Pathological :
• Cardiovascular causes :
• CHF
• AMI
• Pulmonary embolism
• Myocarditis
• Shock
• Tachyarrhythmias

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

20. BRADYCARDIA
• Sinus bradycardia : sinus rate of less than 60 beats per
minute
• Physiological : athletes ,during sleep .
• Pharmocological : Beta-blockers, Amiodorone, Digoxin ,
Non dihydropyridine CCB.

21. •Pathological :
• Cardiovascular causes:
• Inferior wall MI
• Vasovagal syncope
• Bradyarrhthmias

22. •Non-cardiac causes –
• Myxedema.
• Increased intracranial pressure.
• Hypothermia.
• Obstructive jaundice.
• Severe hypoxia.
RESPIRATORY CAUSES

23. 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

25. CHARACTER OF PULSE
• Best 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.

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

27. • 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.

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

30. • TWICE BEATING PULSE
1. Anacrotic pulse
2. Pulsus bisferiens
3. Dicrotic pulse

31. • ANACROTIC PULSE
• Low 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

32. • Seen in AS
• The presence of anacrotic pulse indicates
70mmHg pressure gradient.

33. • BISFERIENS PULSE
• Characterized by two systolic peaks (percussion and tidal waves)
separated by a distinct midsystolic dip.
NORMAL PULSE SEVERE AR HOCM

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

35. • 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

37. • DICROTIC PULSE
• Two peaks, one in systole (percussion wave) and the other in
diastole (dicrotic wave) immediately after S2.

38. • Commonly seen in low output states such as:
1. Enteric fever
2. Cardiomyopathy
3. Cardiac tamponade
4. Myocarditis
5. Hypovolemic shock

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

40. •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.

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

42. • Cardiac tamponade without pulsus paradoxus occurs when
associated with
1. ASD
2. VSD
3. AR
4. Pericardial adhesions

43. MECHANISMOF PULSUS PARADOXUS

44. VOLUME OF PULSE
• Idea of the pulse pressure
• Depends on the stroke volume and the compliance of the
arteries.
• Types
1. Pulsus parvus.
2. Pulsus magnus.
3. Hyperkinetic pulse .

45. • PULSUS MAGNUS :
• High volume large amplitude pulse because of an
increased stroke volume
• Seen in AR
• HYPERKINETIC OR BOUNDING PULSE
• Increased stroke volume and rapid ejection from the left
ventricle.
• Seen in hyperkinetic circulatory states.

46. CONDITION OF VESSEL WALL
• Flattening the artery by digital pressure and sliding it
sideways.
• Monckeberg’s medial sclerosis

47. 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.

48. ABSENT OR DELAYED FEMORAL PULSATIONS
• Noticeable 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.

49. 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

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

51. • 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

52. REFERENCES
1. Harrisons Internal Medicine 20th Edition
2. Essential of cardiac physical diagnosis –Jonathan abrams
3. Macleod clinical examination
4. Clinical examination in cardiology –Vijay raghawa rao
5. Hutchison clinical methods

53. THANK YOU