The pulse is the pressure wave transmitted through the arteries, because of the contraction of the left ventricles.

The pressure wave expands the arterial wall as it travels , and the expansion is palpable as the pulse. The transmission of the arterial pulse = 6-10 meters/sec but the velocity of passage of blood =0.5m/sec. The pressure pulse generated by the contraction of the left ventricle is transmitted to the most peripheral artery almost immediately, and yet the blood that leaves the left ventricle takes several cardiac cycles to reach the same distance. Thus, it must be emphasized that pressure pulse wave transmission is different and not to be confused with actual blood flow transmission in the artery.

Pulse Wave Contour Since the pressure pulse normally travels very fast (m/s), the recorded arterial pressure wave at any site in the arterial system is usually the result of the combination of the incident pressure wave produced by the contracting left ventricle and the reflected wave from the periphery When one records the arterial pulse wave with a transducer, one may be able to identify three distinct components in its contour: The percussion wave, which is the initial systolic portion of the pressure pulse The tidal wave, which is the later systolic portion of the pressure pulse The dicrotic wave, which is the wave following the dicrotic notch (roughly corresponding to the timing of the second heart sound) and therefore diastolic.

Where to feel the pulse? Temporal artery at the temple above and to the outer side of the eye Carotid artery on the side of the neck Never compress both carotid arteries simultaneously Brachial artery on the inner side of the biceps Radial artery on the radial bone side of the wrist lateral to the flexor carpi radialis tendon \

Femoral artery in the groinIs felt at groin just below inguinal ligament midway b/w ant.sup.iliac.spine & symphysis pubis Popliteal artery behind the knee Posterior tibial pulse behind the inner ankle Dorsalis pedis artery on the upper front part (anteriosuperior aspect) of the foo tlateral to tendon of ext.hallucis longus.

Evaluation
Rate Rhythm Volume Character Vessel wall thickness Radio radial , radio- femoral delay Peripheral pulses Pulse deficit

Rate: The radial pulse is found at the wrist, lateral to the flexor carpi radialis tendon. A normal adult resting pulse rate is between 60-100 b.p.m. Bradycardia is a pulse rate of < 60 b.p.m. and tachycardia > 100.

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A normal cardiac rhythm is called sinus rhythm because it arises from the sinoatrial node. Sinus rhythm seldom produces a completely regular pulse because the heart speeds up during inspiration and slows at the beginning of expiration in response to changes in vagus nerve activity. This sinus arrhythmia is most obvious in children, young adults and athletes. Assessed by palpating radial artery Regularly irregular : Atrial Tachyarrhythmia with fixed AV block , Ventricular bigemini Irregularly irregular : atrial /ventricular ectopic,AF Volume Assessed by palpating carotid artery Pulse pressure accurate measure of pulse volume ( N 30 60 mm Hg ) Correlates with stroke vol High vol elderly anxiety emotional excitability

high output states, sys.htn Low vol ( pulsus parvus ) shock myocardial ds valvular ds pericardial ds hypovolemia Character anacrotic pulse / pulsus parvus et tardus / collapsing pulse / pulsus bisferiens / pulsus alternans / dicrotic pulse / pulsus bigeminus etc. Pulses paradoxes A more marked inspiratory decrease in arterial pressure exceeding 20 mmHg is termed pulsus paradoxus. In contrast to the normal situation, this is easily detectable by palpation, although it should be evaluated with a sphygmomanometer. When the cuff pressure is slowly released, the systolic pressure at expiration is first noted. With further slow deflation of the cuff, the systolic pressure during inspiration can also be detected. The difference between the pressures during expiration and inspiration is the magnitude of pulsus paradoxus. The inspiratory decrease in systolic pressure is accentuated during very deep inspiration or Valsalva; thus, assessment of pulsus paradoxus should be made only during normal respiration. Cardiac: cardiac tamponade constrictive pericarditis. One study found that pulsus paradoxus occurs in less than 20% of patients with constrictive pericarditis.[7] pericardial effusion cardiogenic shock Pulmonary: pulmonary embolism tension pneumothorax asthma chronic obstructive pulmonary disease Non-pulmonary and non-cardiac: anaphylactic shock superior vena cava obstruction

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Pulsus alternans It is a physical finding with arterial pulse waveform showing alternating strong and weak beats.[1] It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis. In left ventricular dysfunction, the ejection fraction will decrease significantly, causing reduction in stroke volume, hence causing an increase in end-diastolic volume. There may initially be a tachycardia as a compensatory mechanism to try to keep the cardiac output constant. As a result, during the next cycle of systolic phase, the myocardial muscle will be stretched more than usual and as a result there will be an increase in myocardial contraction, related to the Frank Starling physiology of the heart. This results, in turn, in a stronger systolic pulse.

Pulsus Parvus (Anacrotic pulse) The pressure is diminished, and the pulse feels weak and small, reflecting decreased stroke volume (e.g. heart failure), restrictive pericardial disease, hypovolemia, mitral stenosis, and increased peripheral resistance (e.g. exposure to cold, severe CHF). Pulsus Parvus et Tardus (weak and delayed: Aortic Stenosis

Pulsus Bisferiens The normal carotid arterial pulse tracing and the central aortic pulse waveform consist of an early, the percussion wave, that results from rapid left ventricular ejection, and a second smaller peak, the tidal wave, presumed to represent a reflected wave from the periphery. The tidal wave may increase in amplitude in hypertensive patients or in those with elevated systemic vascular resistance. Radial and femoral pulse tracings demonstrate a single sharp peak in normal circumstances. Pulsus bisferiens is characterized by two systolic peaks of the aortic pulse during left

ventricular ejection separated by a midsystolic dip. Both percussion and tidal waves are accentuated. It is difficult to establish with certainty that the two peaks are occurring in systole with simple palpation (pulsus bisferiens) versus one peak in systole and the other in diastole (dicrotic pulse). Etiology Pulsus bisferiens is frequently observed in patients with hemodynamically significant (but not mild) aortic regurgitation. In patients with mixed aortic stenosis and aortic regurgitation, bisferiens pulse occurs when regurgitation is the predominant lesion. The absence of pulsus bisferiens does not exclude significant aortic regurgitation. In most patients with hypertrophic cardiomyopathy the carotid pulse upstroke is sharp and the amplitude is normal; pulsus bisferiens is rarely palpable but often recorded. The rapid upstroke and prominent percussion wave result from rapid left ventricular ejection into the aorta during early systole. This is followed by a rapid decline as left ventricular outflow tract obstruction ensues, a result of midsystolic obstruction and partial closure of the aortic valve. The second peak is related to the tidal wave. Occasionally, a bisferiens pulse is not present in the basal state but can be precipitated by Valsalva maneuver or by inhalation of amyl nitrite. Pulsus bisferiens is occasionally felt in patients with a large patent ductus arteriosus or arteriovenous fistula. A bisferiens quality of the arterial pulse also is rarely noted in patients with significant mitral valve prolapse and, very rarely in normal individuals, particularly when there is a hyperdynamic circulatory state. 1. Aortic Regurgitation 2. Hypertrophic Cardiomyopathy

Bigeminal pulse Normal beat alternating with a premature contraction. SV of the premature beat diminished, and pulse varies in amplitude accordingly. May masquerade as pulsus alternans Causes: decreased BP (e.g. severe HF, hypovolemic shock, cardiac tamponade) and peripheral resistance (e.g. fever), s/p aortic valve replacement. Present in normal individuals after exercise.

Bounding Pulses A.K.A. water-hammer pulse or the Corrigan pulse. Most commonly in chronic, hemodynamically significant AR.

 Seen in many conditions associated with increased stroke volume: PDA, large arteriovenous fistula, hyperkinetic states, thyrotoxicosis anemia, and extreme bradycardia. Not seen in acute AR, since SV may not have increased appreciably

Vessel Wall Thickness Assess the state of medium sized arteries which are palpable. Method: palpate radial artery with middle 3 fingers. Occlude proximally & with index finger empty artety by pressing out blood distally. Applying pressure on either side roll the artery over underlying bone using middle finger. Delays Usually 2 radial pulses come simultaneously & femoral comes 5msec before ipsilateral radial pulse. Delay in femoral pulse obstruction of aorta coarctation , aortoarteritis