The Arterial Pulse

With each contraction ,the left ventricle ejects a volume of blood into the aorta and on into the arterial tree

A pressure wave moves rapidly through the arterial system where it can be felt as the arterial pulse

The arterial pulse should be examined in all 4 limbs and both sides of the neck

1. Radials2. Brachials3. Carotids4. Femorals5. Popliteals6. Peripheral arteries of the legs :Dorsalis

pedis Posterior

tibial

How to feel the PulseThe 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.

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

Brachial ArteryRest the patient arm with elbow extended

palm upUse the thumb of the opposite handCup your hand under the patient elbowFeel the pulse just medial to biceps tendon

Femoral PulsePress deeply below the inguinal ligament and

about mid way between ASIS and SP

Popliteal PulsePatient 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

Dorsalis PedisFeel 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

Posterior TibialCurve your fingers behind and slightly below

the medial malleolus of the ankle

Comment on the Pulse1. Rate2. Rhythm3. Volume (amplitude)4. Comparison of the two sides5. Special character6. Condition of the arterial wall

RateRate of the pulse at radial artery Normal at rest :60-90 beat / min * if regular: count in 15 sec x 4 * if fast (tachycardia ) or slow

(bradycardia) count in 1 min *if irregular count at apex weak beats may not be felt (pulsus

deficit)

RhythmIs the rhythm regular or irregular?

If irregular: - Totally irregular (atrial fibrillation)- Irregular beats in a basically

regular rhythm (premature beats)

Volume (Amplitude)

A--Large amplitude (Bounding pulse) big difference between systolic and diastolic

BP * High systolic: increased stroke volume rigidity of aorta * low diastolic :aortic regurge

B--Small amplitude (weak pulse)

1- low stroke volume shock (thready) severe mitral stenosis

2- Aortic stenosis

C--Variation in amplitude

1-pulsus alternans 2-pulsus paradoxus

Comparison of both sidesCauses of unequal pulse1. Genetic absence or change in the course of

the radial artery2. Compression of the vessel3. Atheromatous plaque4. Embolus

Special character

Factors affecting the form

Upstroke (rise)DurationDownstroke (fall)

Types of Pulses

Collapsing and Water hammer pulseRapid upstrokeRapid down strokeHigh amplitudeShort duration Found in :Aortic incompetence Hyperdynamic states: Fever Anaemia

Thyrotoxicosis

Anacrotic Pulse (Plateau pulse)

Upstroke is slow with a notch on itDuration of pulse is prolongedAmplitude is smallIn aortic stenosis

Pulsus Bisferiens In combined aortic stenosis and regurgePulse has 2 peaks: Upstroke is sharp and rises high to the first

peakFalls and rises again to a second peak

A double pulse is felt and seen in the carotid