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• To assess rate and rhythm.
• Simultaneously with femoral to detect delay.
• Not good for pulse character.

• Medial border of humerus at elbow medial to biceps tendon.
• Either with thumb of examiner's right hand or index and middle of left hand.

• To assess cardiac output.
• To detect radiofemoral delay.
• To assess peripheral vascular disease.

• Deep within the popliteal fossa.
• Compress against posterior of distal femur with knee slightly flexed.

• As above.

• With the flat of the hand per abdomen, as body habitus allows.

What is the pulse rate?

• A normal pulse rate after a period of rest is between 60 and 80 beats per minute (bpm). It is faster in children. However, if tachycardia is defined as a pulse rate in excess of 100 bpm and bradycardia is less than 60 bpm then between 60 and 100 bpm must be seen as normal.
• An irregular pulse or a slow pulse should be measured over a longer time. As a guide, it is unwise to measure a regular rate for less than 20 seconds (30 seconds being preferable) and an irregular pulse should not be measured over less than 30 seconds, preferably a full minute.
• Bradycardia may be physiological in a trained athlete, even if training was many years ago.
• Paroxysmal tachycardia can last a few minutes to several hours. It might be too transient to allow an ECG recording during an attack so that only clinical examination is available.
• Paroxysmal atrial fibrillation (AF) or, more rarely, atrial flutter, produces a ventricular rate that is dependent upon the refractory time of the A-V node.
• Re-entry tachycardia such as Wolff-Parkinson-White syndrome can produce a very fast rate in the region of 200 bpm.
• As a general rule, supraventricular tachycardia (SVT) produces a rate above 160 bpm and ventricular tachycardia (VT) below 160 bpm.
• Even in young people, very fast rates of 200 bpm or more can precipitate heart failure.

Peripheral Pulses +3

What is the pulse rhythm?

• Sinus arrhythmia occurs when there is variation of rate with breathing. It accelerates a little on inspiration and slows a little on expiration. This can be quite marked in children and adolescents but is uncommon over the age of 30. It can persist a little longer in the physically fit.
• Pulsus paradoxus:
• The pulse slows on inspiration in pulsus paradoxus and it can occur with pericardial effusion, constrictive pericarditis and severe pneumothorax, especially tension pneumothorax, severe asthma and severe chronic obstructive pulmonary disease (COPD).^[1]
• In normal circumstances, the systolic blood pressure often falls slightly, by less than 10 mm Hg on inspiration; however, in pulsus paradoxus it falls by more than this.^[2]This fall can be used to assess the severity of cardiac tamponade.
• Irregularity is more difficult to discern if the rate is fast.
• Note if it is regularly irregular of irregularly irregular:
  • Variable heart block or premature ventricular excitation will cause either an extra beat or a missed one. Premature ventricular contraction may cause a missed beat because the ventricle has not had time to fill adequately and so the stroke volume is low. The beat following a missed beat, whether due to premature excitation or failure of the ventricle to beat, may be rather stronger than the others, as the ventricle has filled more in the longer diastole. This irregularity will follow a regular pattern.
  • A much more random irregularity is a feature of AF. If the rate is fast in AF, it may be difficult to note if the irregularity is random or even if there is irregularity at all. It may be helpful to measure the rate at both the cardiac apex and the wrist and in AF there is usually a deficit at the radial pulse. This is usually done with two people timing simultaneously but it can be done alone, not timing but merely noting if the rates differ. The rate in AF and the rarer atrial flutter depends upon the degree of A-V block but it can be very fast.
  • It has been suggested that a way to distinguish between causes of irregularity is to get the patient to exercise to increase the pulse rate. In premature ventricular excitation it will reduce or disappear. In AF it will increase the irregularity or at least not reduce it.
  • Currently, most clinicians would use the ECG for a more reliable means of distinction.

What is the character of the pulse?

Finally, note the character of the pulse. This incorporates an assessment of the pulse volume (the movement imparted to the finger by the pulse) and what has been described as the 'form of the pulse wave'. The pulse character must be interpreted in the light of pulse rate.

• Cardiac output is the product of stroke volume and heart rate. Thus, a slow pulse may be associated with a high stroke volume and, as there is a long time between each ejection, the pulse pressure (the difference between systolic and diastolic pressure) will be high.
• In shock, the pulse will be fast but weak. This might be from hypovolaemia or cardiogenic. In congestive heart failure one of the first features is tachycardia.
• A hyperdynamic circulation occurs in emotion, heat, exercise, anxiety, pregnancy, fever, anaemia and thyrotoxicosis. The pulse rate is raised but the pulse is full and bounding. Cardiac output is high and peripheral resistance is low.
• Disease of the aortic valve will affect the nature of the pulse wave:
  • In aortic stenosis, the wave is slow to rise and the pattern of the arterial pressure is rather flat - the slow rising pulse.
  • In aortic regurgitation, the stroke volume is high because a significant amount of blood sinks back into the ventricle and has to be pumped again. Furthermore, the incompetent valve will let the arterial pressure fall markedly in diastole. Hence, a bounding, dynamic pulse collapses to give a very wide pulse pressure. This is called a collapsing or water hammer pulse. The water hammer is a piece of Victorian engineering that is rarely seen these days. The collapse of the pulse pressure can be felt with even greater effect if the patient's hand is raised over his or her head so that the radial artery is palpated at a level rather above the heart. Severe aortic regurgitation, classical of syphilitic aortitis, can cause the head to jerk with each pulse (de Musset's sign).
  • In mild aortic stenosis with reflux, the pulse detected may have two peaks as well as being slow rising. This is the so called bisferiens pulse.

Studies have correlated markers of arterial stiffness (eg, pulse-wave velocity and pulse pressure) with risk for the development of fatal and non-fatal cardiovascular events.^{[3, 4]}

The next step

Peripheral Pulses 3+

This systematic examination of the pulse will give a great deal of information. Examination of the rest of the cardiovascular system should give a very clear idea of the diagnosis or at least put the examiner in a position to make a rational request for further investigations. Systematic examination of the pulse remains an essential part of clinical practice.

1. Khasnis A, Lokhandwala Y; Clinical signs in medicine: pulsus paradoxus. J Postgrad Med 200248:46-9

2. Hamzaoui O, Monnet X, Teboul JL; Pulsus paradoxus. Eur Respir J. 2013 Dec42(6):1696-705. doi: 10.1183/09031936.00138912. Epub 2012 Dec 6.

3. Liao J, Farmer J; Arterial stiffness as a risk factor for coronary artery disease. Curr Atheroscler Rep. 2014 Feb16(2):387. doi: 10.1007/s11883-013-0387-8.

4. Boutouyrie P, Fliser D, Goldsmith D, et al; Assessment of arterial stiffness for clinical and epidemiological studies: methodological considerations for validation and entry into the European Renal and Cardiovascular Medicine registry. Nephrol Dial Transplant. 2014 Feb29(2):232-9. doi: 10.1093/ndt/gft309. Epub 2013 Sep 30.

Peripheral Pulses 2+

I have my regular 8 month visit coming up with my cardiologist soon. Have had a ATA for over 5 years with little to no growth(around 5.3 cm). I've told when the time comes, the only treatment is...

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