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ABNORMAL FINDINGS IN PULSEAbnormality can be in the:
Rate
Rhythm
Volume
Character
Condition of vessel wall
Radiofemoral delay
TACHYCARDIASinus rhythm Arrhythmia
Exercise Atrial Fibrillation
Infants Atrial flutter
Excitement/Anxiety Ventricular Tachycardia
Pheochromocytoma
Fever
Hyperthyroidism
MEDICATION:
Ca channel blockers(Nifedipine)
Sympathomimetics(e.g. salbutamol)
Vasodilators
BRADYCARDIA
Sinus rhythm Arrhythmia
Sleep Carotid Sinus hypersensitivity
Athletic training Sick Sinus Syndrome
Hypothyroidism Second-Degree heart block
MEDICATION: Complete heart block
Beta-blockers
Digoxin
Verapamil, Diltiazem
ABNORMAL FINDINGS IN RHYTHM
If Irregular:
Occasionally irregular
Regularly Irregular
Irregularly Irregular
CAUSES OF AN IRREGULAR PULSEOccassionally Irregular Pulse
• Extrasystole
Regularly Irregular Pulse
• Ectopic beat occuring at a regular interval
• Second degree atrioventricular block
• Sinus arrhythmia
Irregularly Irregular Pulse
• Atrial Fibrillation
• Multiple ectopics
PULSE APEX DEFICITDifference in heart rate and
pulse rate
Atrial Fibrillation (>10/min)
Multiple ectopics (<10/min)
High Volume PulsePhysiological causes:Exercise
Pregnancy
Advanced Age
Increased Environmental
Temperature
Pathological causes• Arteriosclerosis
• Aortic regurgitation
• PDA
• Arteriovenous fistula
• Fever
• Thyrotoxicosis
• Anaemia
• Beri-Beri
• Complete heart block
• Cirrhosis liver
Low Volume PulseCauses:
Left Ventricular Failure
Hypovolemia
Peripheral arterial disease
Shock
Severe Aortic Stenosis
Pericardial Effusion
Varying Volume Combination of low, normal or high
volume pulse in varying manner
Seen in:
Atrial fibrillation
Ventricular Tachycardia
CONDITION OF VESSEL WALLCan be:
Normal-Soft
Thickened-firm to hard and cord-like
Elderly due to artherosclerosis
CHARACTER OF PULSE Collapsing pulse
Slow rising pulse
Pulsus bisferiens
Pulsus parvus et tardus
Pulsus bigeminus
Pulsus alternans
Pulsus paradoxus
Anacrotic pulse
Dicrotic pulse
Collapsing pulse Sharp rise
Ill-sustained
Sharp fall
Wide pulse pressure(>80mmHg)
High volume collapsing pulse in:
Aortic regurgitation
PDA
Normal volume collapsing pulse in:
Mitral Regurgitation
Mechanism
In aortic regurgitation, during diastole:
Left ventricle receives
normal pulmonary venous return+portion of blood
ejected into the aorta => large stroke volume-
vigorously ejected=> rapidly rising carotid pulse
Collapses in early diastole – backflow through
aortic valve
Exaggerated at the radial artery by liftng the
arm.
Slow Rising Pulse Gradual upstroke with a reduced peak
Occur late in systole
Seen in severe aortic stenosis
Mechanism
Fixed obstruction restricts the rate at which
blood can be ejected from the left ventricle.
Pulsus Bisferiens Increased pulse with double systolic peak
seperated by a distinct mid-systolic dip.
Causes:
Aortic regurgitation
Concomitant aortic stenois and regurgitation
Pulsus Parvus et Tardus Weak and delayed pulse
Seen in conditions with:
diminished left ventricular stroke volume
Narrow pulse pressure
Increased peripheral vascular resistance
Aortic stenosis
Pulsus bigeminus Regular alteration of pulse pressure
amplitude.
Caused by premature ventricular contraction that follows each regular beat
Occurs in:
AV block
Sinoatrial block with Ventricular Escape
Pulsus alternans Beat-to-beat variation in pulse volume with a
normal rhythm.
Rare
Occurs in :
Advanced heart failure
Toxic myocarditis
Paroxysmal Tachycardias
Following Premature beat
Pulsus Paradoxus Exaggeration of the normal variability of
pulse volume with breathing.
Inspiratory decline in systolic pressure greater than 10mm Hg.
Occurs in:Cardiac tamponade
Constrictive pericarditis
Percardial effusion
Dicrotic Pulse Twice beating
First wave in systole, second wave in
diastole
Seen when PR and DP is low
Felt due to hypotonia of vessel wall
Seen in:
Fever (e.g. typhoid fever)
CCF
Cardiac Tamponade
RADIO-FEMORAL DELAY Most common cause: Coarctation of aorta
Children:
Upperlimb pulses are usually normal
Reduced volume lowerlimb pulses
Adults:
Usually presents hypertension and heart failure
Other causes:
• Atherosclerosis of aorta
• Thrombosis or embolism of aorta
OTHER PERIPHERAL PULSATIONS
Normal-All pulsations felt equally
Absence of peripheral pulsations:
Peripheral vascular disease
Coarctation of aorta- decreased and delayed
femoral pulsation
Takayasu’s disease: decreased upper limb
pulsation
CAUSES OF ABSENT RADIAL PULSE
Anatomical abnormality
Severe atherosclerosis
Takayasu arteritis (Pulseless disease)
Embolism in radial artery
Death
ABNORMAL FINDINGS IN JUGULAR VENOUS PULSE
Raised in :
Right sided heart failure caused by chronic
pulmonary hypertension in severe lung
disease(COPD)
Cor pulmonale
Increased intrathoracic pressure-tension
pneumothorax or severe acute asthma.
Massive pulmonary embolism- very high JVP
Giant ‘a’ wave: Tricuspid valve stenosis
Cannon ‘a’ wave: Complete heart block & Ventricular tachycardia
Giant ‘v’ wave: Tricuspid Regurgitation
Prominent ‘x’ and ‘y’ descents: Constrictive pericarditis