Pulse

Examination of peripheral pulses as a very important step in cardiovascular examination. A normal pulse has upstroke (anacrotic limb) followed by a downstrolte (dicrotic limb). The classical method of examination of radial pulse by three finger method is good for rate, rhythm and conditioll of arterial wall but character of pulse is better appreciated by palpating brachial or better carotid artely by thumb.

Examinalion of pulse in all peripheral arteries is strongly recommended as si~nple demonstration of radiolbrachio-femoral delay will ~ualte a diagnosis oFCoarctation of Aorta which otherwise may be completely missed. An exaggerated pulsation at the root of neck in an young individual on inspection denote a high strolte volulne (a(-riic regurgition, PDA and Coarctation of Aorta).

Normal pulse waveform correlation with PCGtECG

Character of Pulse

A normal pulse wave has an upstroke and downstroke. Dicrotic notch present on direct arterial traces is impalpable.

Arterial pulse

a) Large volume pulse (Hyperkinetic) indicates geilerally a high output state;physiologically post-exercise, pathologically, severe anaeinia, fever, anxiety and restlessness.

b) Small volume pulse (Hypokinetic) is indicative of either low stroke volume(SV) due to LV dysfi~nction or obstruction to LV outflow tract due to aoi-tic stenosis when the pulse rises slowly and voluine is low. (Anacrotic Pulse).Pulsus parvus et tardus means a slow rising sir~all volume pulse typically in severe aortic stenosis with preserved LV function.

Pulsus parvus et tardus

A collapsing pulse: Typically found in aortic regurgitation, PDA, any undue aortic run off like arteriovenous fistula and is characterized by a sharp rise, sharp fall and no sustenance. It is better elicitated by grasping the wrist with palm over radial and ulnar arteries and lifting the wrist above the head of the patient when the arterial thrust is maximally felt. Pulsus Bisferians: A condition in which double notch is found near or at the height of pulse wave. Typically it is associated with hypertrophic obstructive cardioinyopathy and aortic stenosis with aortic regurgitation.
 

Pulsus Paradaxus: Pulse volun~e becoines smaller in inspiration and larger in expiration. This is an exaggeration of llorlnally occurring phenomenon and is produced either by impaired diastolic filling of venlricle as typically in constrictive pericarditis, pericardial effusion or due to decreased lung compliance, as in advanced emphysema large pleural effusion etc. In a typical case applying graded pressure on brachial artery while palpating radial artery for disappearance or reappearance of pulse wave may be easily evident. In mild cases when difference is sinall like 10inr11 or below application of a sphygmonietric cuff on the arm and slow decompression will easily demonstrate appearance or disappearance of palpable pulse at wrist.Normally a difference of 10mm is accepted as within physiological limits and becomes pathological beyond 1 Omin of Hg .

Haemodynamic mechanisms in development of pulsus paradoxus

Pulsus bigerniny or trigeminy: After every 2nd or 3rd beat respectively there will be a longer interval. This is due to occurrence of a premature beat every 2nd or 3rd beat.

Presence of bruit: Presence of bruit over peripheral pulses especially over the carotids and renal arteries are very important clinical finding denoting stenosis.in these arteries.