the arterial pulse
TRANSCRIPT
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Dr. Nisheeth M PatelM.D (Medicine)
ARTERIAL PULSE
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Pulse:The pulse is a wave form that is felt by fingers
and produced by cardiac systole which travels through the peripheral arterial tree in peripheral direction at a rate more faster than that of blood columm.
Time lag from cardiac systole:Carotid: 30msRadial: 80msFemoral: 75ms Brachial: 60ms
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IMPORTANCE: Also called the mirror of heartInformation about arterial wall conditionRough estimation of SBP n DBPState of heart n circulationDetect and diagnosis of arrythmiaDiagnosis in case of AR and acute LVF
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The arterial pulse should be examined in all 4 limbs and both sides of the neck
1. Radials2. Brachials3. Carotids4. Femorals5. Popliteals6. Temporal7. Facial 8. Peripheral arteries of the legs :Dorsalis pedis Posterior tibial
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How to feel the PulseThe Radial pulse:
The 3 middle fingers are usedThe palmar surface of the fingers overlies the radial
A. and encircles the wristAt first the artery is completely occluded, then
gradually release the pressure until maximum feeling of the pulse wave is perceived.
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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
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Brachial Artery
Rest the patient arm with elbow extended palm up
Use the thumb of the opposite handCup your hand under the patient elbowFeel the pulse just medial to biceps tendon
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Femoral PulsePress deeply below the inguinal ligament
and about mid way between ASIS and SP
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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
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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
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Posterior TibialCurve your fingers behind and slightly below
the medial malleolus of the ankle
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Comment on the Pulse1. Rate2. Rhythm3. Volume (amplitude)4. Force5. Tension 6. Comparison of the two sides7. Special character8. Condition of the arterial wall
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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 )
*slow (bradycardia) count in 1 min *if irregular count at apex weak beats may not be felt (pulsus
deficit)Apex pulse deficit: > 10 suggestive of AF
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RhythmIs the rhythm regular or irregular?1.Normally regularly regular2.Sinus arrhythmia: phasic irregularity with
respiration, 3.Irregular:
1. Regularly irregular:1. PAT with Fixed AV Block2. Atrial flutter3. Ventricular bigeminy or trigeminy
2. Irregularly irregular:1. APCs, VPCs2. AF3. PAT with Varying degree of block
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Volume (Amplitude)Degree of expansion between systole and diastoleMeasurement of pulse pressureHyperdynamic :
(high PP, SV)Anxiety ExerciseCHBARFeverAnemiaThyrotoxicosisAVFBeriberi
Hypovolemic: (low PP, SV)
ShockCHFChronic CPHypovolemiaStenotic Valvular
diseaseMycarditis Cardiomyopathies
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Force and tension:Force
Indicates SBPHigh in : ISH, AR PDA, Hyperdynamic states:Low in: Shock, Cardiac failure, Stenotic
Valuvular lesion, Cardiac TemponadeTension:
Indicates DBP
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Comparison of both sidesCauses of unequal pulse1. Genetic absence or change in the course
of the radial artery (anomalous radial artery)
2. Compression of the vessel3. Atheromatous plaque4. Embolus
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Anacrotic Pulse (Pulsus Tardus):Slow rise, slow fallDuration of pulse is prolongedAmplitude is smallLazy in character (Tardus)In aortic stenosis
Dicrotic Pulse:One peak in systole, one in diastole Myocardial disease with reduced CO and TPRLVF, DCMCardiac TamponadeDehydration
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Collapsing and Water hammer pulsecorriagan, bounding pulseRapid upstrokeRapid down strokeHigh amplitudeShort durationCauses:
Aortic incompetence PDAHyperdynamic states: Fever, Anaemia,
Thyrotoxicosis, pregnancy and AV fistula
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Pulsus Bisferiens Pulse has 2 peaks: two peaks in systoled/t ejection of rapid jet of bloodAS + ARSevere ARHOCM
A double pulse is felt and seen in the carotid
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Pulsus Parus:Small volume pulseLow COA/w Tachycardia, thready pulsePhysiological: cold, anxietyVessel occlusionCoA of AortaSevere Hypotension (Shock)Severe AS PSMISevere PAH
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Jerky pulse:Small volume & collapsingHOCMSevere MRAR with LVF
Pulsus alterans:Alternate large and small volume pulseLV FailureCardia Arrythmias
Pulsus bigeminus:Pulse wave with normal beat f/b VPCs f/b
compensatory pauseDigitalis toxicity
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Pulsus paradoxus:Exaggerated decrease in strength of arterial
pulse during inspiration, Inspiratory fall of SBP >10mmHgCardiac temponadeConstrictive pericarditisAcute asthmaSVC obstruction
Reverse pulsus paradoxus:HOCMIPPVAV dissociaton
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Thank You…