PULSE - HOW TO MEASUREMENT

 PULSE

 INTRODUCTION:

• The pulse is a wave of blood created by alternate expansion and recoil of elastic arteries after each systole of the left ventricle creating a traveling pressure wave that is called the PULSE. 

• The pulse may be felt in any artery that lies near the surface of the body that can be compressed against a bone or other firm structure. 

• Pulse wave travels faster than blood with velocity of 5-8m/sec(bl.flows at velocity of 0.5/sec.) 

• Importance :-

• Also called the mirror of heart 

• Information about arterial wall condition

• State of heart and circulation 

• Rough estimation of SBP and DBP

• Diagnosis in case of AR and acute LVF

• Detect and diagnosis of arrhythmia

• THE NORMAL pulse rate is 60-100bpm.

• It is under control of ANS.

• HR increases with incr. Sympathetic activity. 

• Decrease with increased parasympathetic activity. 

• A HR more than 100 - Tachycardia. 

• HR less than 60- Bradycardia. 

• Normally higher in children and low in elderly. 

• HR is higher in inspiration and lower in expiration.. 

• PULSE DELAY :-

• Delay in appearance between radial and femoral pulse is useful for diagnosis of –

• Coarctation of aorta.

• SIGNIFICANCE:-

• To assess the state of myocardium ,valves.

• To assess cardiac arrhythmias.

• To assess condition of vessels wall.

• Rough guide to estimate the arterial BP.

• DICROTIC PULSE :-

• There are two palpable waves...

• 1 in systole other in diastole.

• Encountered in patients with very low stroke volume  

• In those with dilated (congestive )cardiomyopathy , infarction. 

• PLATEAU PULSE:-

• Pulse wave rises slowly 

• Delayed and sustained peak

• Pulse fades away slowly 

• Such pulse is sometimes seen in aortic stenosis. 

• PULSE SITES :-

• Radial 

• Temporal 

• Carotid 

• Apical 

• Radial pulse 

• Brachial 

• Femoral 

• Popliteal 

• Posterior tibial 

• Dorsalis pedis

• Radial.... 

1. Temporal :- the site is above and lateral to the eye where the temporal artery passes over the temporal bone of the head.

2.Carotid:- at the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle. 

3.Apical :- at the apex of the heart. 

4.Brachial :- at the inner aspect of the biceps muscle of the arm or medially in the antecubital space. 

5.Radial :- at the thumb side of the inner aspect of the wrist where the radial artery runs along the radial bone .

6.Femoral:- where the femoral artery passes alongside the inguinal ligament. 

7. Popliteal :- where the popliteal artery passes behind the knee 

8.Posterior tibial:- on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus . 

9.Dorsalis pedis :- where the dorsalis pedis artery passes over the bones of the foot ,on an imaginary line drawn from the middle of the ankle to the space between the big and second toes. 

• A peripheral pulse is a pulse located away from the heart .

• From ex :- in the foot or wrist. 

• The apical pulse is the central pulse as it is located at the apex of the heart. 

• It is also referred to as the point of maximal impulse (PMI).

• COMMON PALPABLE SITES :-

• Sites can be divided into peripheral pulses and central pulses.

•  Central pulses include the carotid, femoral, and brachial pulses 

• UPPER LIMB :-

• Axillary pulse: located inferiorly of the lateral wall of the axilla 

• Brachial pulse: located on the inside of the upper arm near the elbow, frequently used in place of carotid pulse in infants (brachial artery) 

• Radial pulse: located on the lateral of the wrist (radial artery). It can also be found in the anatomical snuff box. 

• Ulnar pulse: located on the medial of the wrist (ulnar artery). 

• Lower limb 

• Femoral pulse: located in the inner thigh, at the mid-inguinal point, halfway between the pubic symphysis and anterior superior iliac spine (femoral artery). 

• Popliteal pulse: Above the knee in the popliteal fossa, found by holding the bent knee. 

• The patient bends the knee at approximately 124°, and the health care provider holds it in both hands to find the popliteal artery in the pit behind the knee (Popliteal artery). 

• Dorsalis pedis pulse: located on top of the foot, immediately lateral to the extensor of hallucis longus (dorsalis pedis artery). 

• Tibialis posterior pulse: located on the medial side of the ankle, 2 cm inferior and 2 cm posterior to the medial malleolus (posterior tibial artery).

•  It is easily palpable over Pimenta's Point. 

• Head and neck

• Facial pulse: located on the mandible (lower jawbone) on a line with the corners of the mouth (facial artery). 

• Temporal pulse: located on the temple directly in front of the ear (superficial temporal artery).

• VARIATIONS IN PULSE BY AGE :-

• Newborn    :80–180beats /min.

• 1 year :  80 –140 beats /min.

• 5–8 years :75 –120 beats /min.

• 10 years:  50 –90 beats /min.

• Teen :50 –90 

• Adult  : 60 –100

• Older adult :  60 –100

• ABNORMAL FINDINGS IN PULSE :-

• Rate 

• Rhythm 

• Volume 

• Characters 

• Condition of vessels wall 

• Radiofemoral delay 

• CHARACTERISTICS OF PULSE:-

• A..Rate :- number of beats per min

• Tachycardia (pulse rate >100bpm)

• Bradycardia (pulse rate <60 bpm)

• B...Rhythm:- pattern or regularity of the beats .

• The length of time between beats should be same.

• ABNORMAL FINDINGS IN RHYTHM:-

• If Irregular :-

• Occasionally Irregular 

• Regularly Irregular

• Irregularly Irregular

• CAUSES OF AN IRREGULAR PULSE:-

1.Occasionally Irregular pulse :-

• Extrasystole 

2.Regularly Irregular pulse 

• Sinus arrhythmia

• Second degree atrioventricular block

• Ectopic beat occuring at a regular interval 

3. Irregularly Irregular pulse 

• Atrial fibrillation 

• Multiple ectopics 

• C.Volume:- amount of blood pumped with each beat. 

• Abnormalities in pulse volume:-

1. High volume pulse 

2. Low volume pulse 

3. Varying volume 

1. High volume pulse 

• Physiological causes:-

• Exercises 

• Pregnancy

• Advanced age 

• Increased environmental temperature 

• Pathological causes :-

• PDA

• Beri-Beri

• Fever

• Complete heart block 

• Arteriosclerosis

• Anemia 

• Cirrhosis liver

2.LOW VOLUME PULSE:-

• CAUSES :-

• Shock

• Hypovolemia 

• Peripheral arterial disease 

• Pericardial effusion

• Left ventricular failure 

3. Varying volume:-

• Combination of low ,normal and high volume pulse in varying manner .

• Seen in...

• Atrial fibrillation 

• Ventricular tachycardia 

• Arterial wall elasticity:- the artery wall should feel soft and flexible under the fingers .

• D..CONDITION OF VESSELS WALL :-

• Can be :-

• Normal -soft 

• Thickened -firm to hard and cord -like 

• Elderly due to atherosclerosis 

• E..CHARACTER of PULSE 

• Collapsing pulse 

• Slow rising pulse 

• Pulsus bisferiens 

• Pulsus parvus at tardus 

• Pulsus bigemius 

•   Pulsus alternaus

• Pulsus  Paradoxus 

• Anacrotic pulse 

• Dicrotic pulse 

1.Collapsing pulse 

• 2.Slow rising pulse 

• 3.Pulsus bisferiens 

4.Pulsus parvus at tardus 

5.Pulsus bigemius 

6.  Pulsus alternaus

7.Pulsus  Paradoxus 

8.Anacrotic pulse 

9.Dicrotic pulse 

• F..RADIO - FEMORAL DELAY :-

• Most common cause :-  coarctation of aorta 

• Children :-

• Upper limb pulses are usually normal 

• Reduce volume lower limb pulses 

• Adults:-

• Usually presents hypertension and heart failure 

• Other causes:-

• Atherosclerosis of aorta 

• Thrombosis or embolism of aorta 

• PULSE APEX DEFICIT:-

• Difference in heart rate and pulse rate 

• Atrial fibrillation (>10/min)

• Multiple ectopics (<10/min)

• FACTORS AFFECTING PULSE:-

• Age :- as age increases ,the pulse rate gradually decreases overall. 

• Sex :- after puberty , the average Male's pulse rate is slightly  lower than female's.

• Exercises:- pulse rate increases with activity. 

• Fever :- pulse rate increases with elevated body temperature because of the increased metabolic rate .

• Medications :- some medications decrease the pulse rate ,and some increase it.

• Stress :- stress increases the rate as well as the force of the heartbeat. 

• Position:- when the person is upright , the heart rate is usually faster than when lying down. 

• Hypovolemia/dehydration:- loss of blood from the vascular system increases the pulse rate 

• Heart disease 

• READING THE PULSE:-

• While palpatine radial pulse:-

• Middle 3 fingers are used :-

• Index finger is used for occlusion or compression. 

• Middle is used for assessing the volume and rate of pulse. 

• Ring finger to study the condition of vessel wall.