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Examination of arterial pulse in clinical medicine

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Palpation of radial, femoral, brachial pulses Palpation by light pressure, breath held in mid expiration Better sphygmomanometry, ... – PowerPoint PPT presentation

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Title: Examination of arterial pulse in clinical medicine


1
Examination of arterial pulse in clinical medicine
  • Dr.Vemuri Chaitanya

2
Pulse
  • The blood forced into aorta during systole not
    only moves the blood in the vessels forward but
    also sets up a pressure wave that travels along
    arteries. The pressure wave expands the arterial
    wall as it travels , and the expansion is
    palpable as the pulse.

3
Normal Pulse
4
Normal Arterial Pulse
  • Pulse in ascending aorta rises rapidly to a
    rounded dome peak velocity of blood ejected
    from Lt.ventricle.
  • Slight anacrotic notch/pause freq recorded but
    occasionally felt on asc.limb of pulse.
  • Descending limb of central aortic pulse is less
    steep , interupped by incisura , a sharp
    deflection relation to closure of aortic valve.
    Immediately pulse wave rises slightly then
    declines gradually throughout diastole.

5
Normal Arterial Pulse
  • Percussion wave in central arterial pulse the
    rapidly transmitted impact of Lt.Ventricular EF
    results in a peak in early systole.
  • Tidal wave second , smaller peak , presumed to
    represent the reflected wave from the periphery ,
    often recorded but not normally palpable.

6
Evaluation
  • Rate
  • Rhythm
  • Volume
  • Character
  • Vessel wall thickness
  • Radio radial , radio- femoral delay
  • Peripheral pulses
  • Pulse deficit

7
Rate
  • Count the pulse for 1 min / atleast 30 sec
  • Normal 60 100 /min
  • Tachycardia gt100 /min
  • Bradycardia lt60 /min

8
Sinus Tachycardia
  • Physiological infants , children , emotion,
    exertion.
  • Pathological Tachyarrhythmia- SVT, VT
  • High output states
  • Drugs atropine, nifedipine, nicotine, caffiene

9
Sinus Bradycardia
  • Physiological atheletes, sleep
  • Pathological severe hypoxia
  • hypothermia
  • sick sinus syn
  • myxoedema
  • obs.jaundice
  • ac.inf wall MI
  • raised ICT
  • Drugs beta blockers, verapamil,diltiazem

10
Relative Bradycardia
  • Typhoid
  • Hagic fever
  • Lymphocytic choriomeningitis

11
Rhythm
  • Assessed by palpating radial artery
  • Regularly irregular Atrial Tachyarrhythmia with
    fixed AV block , Ventricular bigemini
  • Irregularly irregular atrial /ventricular
    ectopic
  • AF
  • Sinus Arrhythmia irregular in healthy
  • accelration
    inspiration
  • slowing down
    expiration
  • due to variation in vagal tone children,
    young adult

12
Diff b/w heart block ectopic
  • Rhythm
  • Irregularity changes with exertion extrasystole
    / ectopic
  • Irregularity doesnt change with exertion Heart
    block

13
Volume
  • Assessed by palpating carotid artery
  • Pulse pressure accurate measure of pulse volume
    ( N 30 60 mm Hg )
  • Correlates with stroke vol
  • High vol elderly
  • anxiety
  • emotional excitability
  • high output states, sys.htn

14
Volume
  • Low vol ( pulsus parvus ) shock

  • myocardial ds

  • valvular ds

  • pericardial ds

  • hypovolemia

15
Character
  • Best assessed by palpating carotid artery
  • Normal / Abnormal
  • Abnormal anacrotic pulse / pulsus parvus et
    tardus / collapsing pulse / pulsus bisferiens /
    pulsus alternans / dicrotic pulse / pulsus
    bigeminus etc..

16
Vessel Wall Thickness
  • Assess the state of medium sized arteries which
    are palpable.
  • Method palpate radial artery with middle 3
    fingers.
  • Occlude proximally with index
    finger empty artety by pressing out blood
    distally.
  • Applying pressure on either side
    roll the artery over underlying bone using middle
    finger.

17
Radio femoral Delay
  • Usually 2 radial pulses come simultaneously
    femoral comes 5msec before ipsilateral radial
    pulse.
  • Delay in femoral pulse obstruction of aorta
    coarctation , aortoarteritis

18
Peripheral PulsesRadial pulse
  • At wrist , lateral to flexor carpi radialis
    tendon , place your three middle fingers over the
    radial pulse

19
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.

20
Brachial pulse
  • 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.

21
Femoral Pulse
  • Is felt at groin just below inguinal ligament
    midway b/w ant.sup.iliac.spine symphysis pubis.

22
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.

23
Posterior Tibial Pulse
  • Felt just behind medial malleolus , midway b/w
    medial malleolus tendo achillis.

24
Dorsalis Pedis Pulse
  • Felt just lateral to tendon of ext.hallucis
    longus.

25
Apex Pulse Deficit
  • Diff b/w heart rate pulse rate , when counted
    simultaneously for one minute.
  • Diff b/w AF Ectopics
  • AF ( gt 10 /min ), worsens with exertion.
  • Ventricular premature beats ( lt 10 /min )

26
Bisferiens Pulse
  • 2 systolic peaks ,the percussion tidal waves
    separated by distinct midsystolic dip.
  • Detected more rapidly by palpating carotid
    artery.
  • Valsalva / inhalation amyl nitrate
  • ASAR, pure AR, HOCM

27
Dicrotic Pulse
  • 2 peaks .
  • 2nd peak is in diastole after S2.
  • Normally a small wave that follows aortic valve
    closure ( dicrotic notch ) is exaggerated
  • Due to very low stroke vol per. Resistance.
  • LVF, typhoid, dehydration.

28
Pulsus Alternans
  • Alternating strong weak pulse.
  • Palpation of radial, femoral, brachial pulses
  • Palpation by light pressure, breath held in mid
    expiration
  • Better sphygmomanometry, when sys.pressure
    alternates by gt20mm

29
Pulsus Alternans
  • A sign of severe LV dysfn
  • Following paroxysmal tachycardia
  • AR, sys.htn, reducing venous return by adm NTG
    exaggerate pulsus alternans help in detection

30
Pulsus Bigeminus
  • Pulse wave with a normal beat followed by a
    premature beat a compensatory pause, occuring
    in rapid succession alternation of strength of
    pulse.
  • Confused with pulsus alternans ( no compensatory
    pause )
  • Sign of digitalis toxicity

31
Pulsus Paradoxus
  • Exaggerated reduction in strength of arterial
    pulse during normal inspiration due to
    exaggerated insp fall in sys.pressure (gt 10 mm)
  • gt20mm Hg detected by palpating brachial.a.
  • Milder fall by sphygmomanometry.

32
Pulsus Paradoxus
  • Exaggerated insp fall in sys.pressure reduced
    LV stroke vol transmission of ve intrathoracic
    pressure to aorta.
  • Cardiac tamponade, constrictive pericarditis,
    severe airway obs , SVC obstruction

33
Reversed Pulsus Paradoxus
  • Inspiratory rise in arterial pressure
  • HOCM

34
Collapsing Pulse
  • Corrigans pulse / water hammer pulse
  • Large vol pulse with rapid upstroke ( high
    sys.pressure ) rapid downstroke ( low
    diastolic pressure )
  • Rapid upstroke increased stroke vol
  • Rapid downstroke diastolic runoff into Lt.Ven
    decreased PR rapid runoff to periphery.
  • PDA , AR, AV fistula

35
Pulsus Tardus
  • Upstroke thrill (carotid shudder)
  • Peak reduced
  • Occurs late in systole
  • Fixed LV obs Valvular AS , Cong.fibrous
    subaortic stenosis
  • Notch on upstroke of carotid pulse (anacrotic
    notch)- 2 separate waves anacrotic pulse

36
Pulsus Parvus et Tardus
  • Small vol pulse with delayed systolic peak
  • Severe AS

37
Hypokinetic Hyperkinetic Pulses
  • Hypokinetic pulse small vol, narrow pulse
    pressure
  • Eg cardiac failure, MS, AS, Shock
  • Hyperkinetic pulse large vol , wide pulse
    pressure
  • Eg high output states , MR, VSD

38
Recording Of BP
  • Pulsus paradoxus inflate bp cuff to
    suprasystolic level deflate slowly _at_ 2mm/heart
    beat.
  • Note - Peak sys.pressure during expiration
  • Now deflate more slowly note pressure when
    korotkoff sound audible throughout resp.cycle
  • If diff gt 10 mm Hg - pulsus pardoxus

39
Recording BP
  • Pulsus alternans inflate BP cuff to
    suprasystolic level deflate slowly .
  • if alteration of intensity of korotkoff sounds

40
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