Where and how the examination is performed
Although the pulse can be palpated over the carotid, brachial, femoral, popliteal, and pedal arteries, the gold standard is palpation of the radial artery (a. radialis). In the distal part of the radius, the vessel lies superficially, directly beneath the skin, making this site maximally convenient.
Execution Technique:
- The physician grasps the patient's wrists so that the thumbs are on the dorsum of the hand and the 2nd and 3rd fingers lie on the anterior surface of the forearm where the artery runs.
- Palpation always begins simultaneously on both hands. This is necessary to detect asymmetry.
- If the pulse is symmetrical, further detailed assessment of its properties is continued on one hand only.
- The investigator gently compresses the artery with two or three fingers, varying the pressure up to complete cessation of blood flow in order to determine the properties of the vessel.
Basic characteristics of the pulse wave
During palpation, the physician sequentially analyzes six key parameters:
- Rate (frequens). Counted over 15–30 seconds (the result is multiplied by 4 or 2). If the rhythm is irregular, counting must be carried out for a full minute. In men, the normal rate is 60–70 bpm, in women — 70–80 bpm. Physiological elevation is possible with stress, physical exertion, eating, inspiration, and in asthenic individuals.
- Rhythm (rhythmus). Normally, waves occur at equal intervals (pulsus regularis). When intervals are disturbed, the rhythm is termed irregular (pulsus irregularis).
- Tension (tensio). Reflects the approximate level of blood pressure. This is the force required to compress the vessel. In hypertension, the pulse is hard/tense (pulsus durus); in hypotension, it is soft (pulsus mollis).
- Volume/Filling (repletio). Depends on stroke volume and circulating blood volume. Assessed by the change in vessel diameter after compression and release. Normal is a full pulse (pulsus plenus); in shock, it becomes empty (pulsus vacuus).
- Amplitude (Size). An integral parameter of wall amplitude (tension + volume). Can be large (pulsus magnus) and small (pulsus parvus), as well as equal and unequal.
- Symmetry. Equality of pulsation on the right and left sides.
Assessment of pulse contour
The shape of the pulse wave reflects the rate of pressure change inside the vessel, which directly depends on how quickly the left ventricle ejects blood.
- Water-hammer (bounding) pulse (pulsus celer): a steep rise and an equally sharp fall. A classic sign of aortic valve regurgitation. It is also encountered in strong nervous excitement (combined with high amplitude).
- Slow pulse (pulsus tardus): the rise and fall occur smoothly, prolonged in time. Typical for aortic stenosis.
Specific and pathological variants
Certain pulse alterations serve as markers of severe conditions and diseases:
- Differential pulse (pulsus differens): asymmetry between the arms caused by narrowing of the arterial lumen on one side. Causes: aortic dissection, embolism, aortitis, or Takayasu's arteritis.
- Pulse deficit (pulsus deficiens): characteristic of atrial fibrillation. Due to varying intervals between contractions, the left ventricle fills unevenly. Small systolic ejections fail to generate a wave capable of reaching the wrist.
- Thready pulse (pulsus filiformis): extremely small, barely palpable. Signals shock or acute heart failure.
- Alternating pulse (pulsus alternans): alternation of strong and weak beats with a regular rhythm. Indicates myocardial exhaustion and a poor prognosis.
- Paradoxical pulse (pulsus paradoxalis): a sharp drop in volume during inspiration (blood pressure drops by more than 10 mmHg). Indicates external compression of the heart, for example, in constrictive pericarditis or cardiac tamponade.
- Dicrotic pulse: felt as a double beat. Occurs due to the hydraulic shock of the return portion of blood against closed aortic valves when peripheral vascular tone is reduced.
Briefly: answers to topical questions
In which diseases or conditions is a water-hammer pulse (pulsus celer) observed?
A water-hammer pulse (pulsus celer) is indicated in sources for the following diseases or conditions:
- Aortic valve regurgitation — a classic cause of a water-hammer pulse; in aortic regurgitation, the pulse is described as pulsus celer, altus et magnus.
- Significant nervous excitement — in this case, the pulse is also high (pulsus altus), meaning with a large amplitude.
Which specific diseases or infections are characteristic of a dicrotic pulse?
Sources specifically indicate the following infections or diseases in which pulse dicrotism may occur:
- Typhoid fever — pulse dicrotism is possible during the period of maximal intoxication; relative bradycardia, regular rhythm, arterial hypotension, and muffled heart sounds are also described.
- Plague — in the dynamics of hemodynamic disturbances, the appearance of dicrotism, along with a decrease in pulse volume and tension, is possible.
How do pulse characteristics change in mitral stenosis?
In mitral stenosis, sources indicate the following pulse changes:
- Often weak volume — pulsus parvus.
- Arrhythmia in atrial fibrillation — pulsus irregularis, meaning the time intervals between pulse waves are unequal.
What properties of the vascular wall itself does the physician assess after compressing blood flow?
During artery palpation with gentle compression, in addition to pulse wave characteristics, the state of the vascular wall is assessed:
- Elasticity — normally, the artery is palpated as an elastic cord.
- Wall induration — a sign of an atherosclerotic process.
- Tortuosity of the artery — also indicated in an atherosclerotic process.
To memorize the properties of the pulse, use the acronym CRTVAS: Rate, Rhythm, Tension, Volume, Amplitude, Symmetry.
Class and exam questions
Why is pulse examination started simultaneously on both wrists?
This is necessary to assess symmetry. A differential pulse (asymmetry of characteristics or time of wave appearance) may indicate a local vascular stenosis, embolism, or Takayasu's arteritis.
How to calculate pulse deficit?
One must subtract the radial pulse rate from the heart rate calculated by cardiac auscultation. For example, if the heart rate is 90 and the pulse is 72, the deficit is 18 beats.
How to correctly describe the pulse of a healthy person?
Normally, the pulse is described as regular, of satisfactory volume, of satisfactory tension, and symmetrical on both arms.
What does a pulse that requires significant pressure to obliterate indicate?
This type of pulse is called tense or hard (pulsus durus). Most often it is an indirect palpatory sign of arterial hypertension.
What else to study on this topic
- Pathogenesis of pulsus alternans in myocardial exhaustion
- Hemodynamic mechanisms of the pulse in aortic valve defects (celer and tardus)
- Causes and diagnosis of Takayasu's arteritis
- Instrumental pulse recording (sphygmography) and analysis of the dicrotic wave
- Physiological mechanisms of respiratory arrhythmia in healthy individuals
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