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Arterial Pulse assessment

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Version Jan 2023

Arterial pulse waveform is composed of percussion wave travelling along artery which is at a much higher speed than the actual passage of blood with a dicrotic notch which represents the closure of the aortic valve.

About

Feel character and count the rate.
Assess the rhythm and its regularity or lack of
Test to see if it is collapsing.
Compared right radial with left radial and femoral artery looking for delay.

Character

Pulse characteristics
Good volume	Normal
Bounding	High output e.g. post exercise, thyrotoxicosis, fever, Hyperdynamic circulation, severe Paget's disease
Collapsing pulse	Aortic regurgitation or AV fistula. Low diastolic pressure. Wide pulse pressure.
Plateau pulse	Slow rising small "pulsus parvus" seen with Aortic stenosis. Narrow pulse pressure.
Jerky pulse	Hypertrophic obstructive cardiomyopathy
Pulsus Bisferiens	Mixed collapsing and plateau pulse with mixed aortic valve disease
Pulsus alternans	Alternating large and small beats and suggests severe LV dysfunction
Pulsus bigeminus	caused by a premature beat before every QRS complex
Pulsus paradoxus	Normal BP fall with inspiration is exaggerated > 10 mmHg. Feel pulse weakens with inspiration. Consider Cardiac Tamponade, pericardial constriction and acute severe asthma where inspiration will affect cardiac filling. Pulse weakens during inspiration.
Absent	dissection if aorta with ipsilateral subclavian involved, arterial thrombosis or embolism in subclavian or brachial or may be seen post catheterisation (angiography now done via radial artery), Takayasu's disease
Radiofemoral delay	Suggests Coarctation of aorta. Be sure to check blood pressure at arm and legif suspicious.

Rate (normal resting adult 60-90 bpm)

Bradycardia (Rate < 60): Sinus bradycardia,
Complete heart block, AV Block 2:1, Atrial flutter or fibrillation with AV block, Sinus arrest with Nodal rhythm
Tachycardia (Rate > 100): Sinus tachycardia, Supraventricular tachycardia (AVRT, AVNRT), Atrial flutter (Rate = 300 / (2-4)), Atrial fibrillation, Ventricular tachycardia, Ventricular flutter
Pulseless: Ventricular fibrillation, Ventricular tachycardia, Asystole, Pulseless electrical activity, death.
If atrial fibrillation should actually count rate at the cardiac apex rather than the pulse as some beats will below the volume and undetectable at the wrist.

Rhythm

Regular	Sinus Rhythm, Sinus tachycardia, Sinus bradycardia, Atrial flutter with 2:1 or 3:1 block, Complete heart block (slow!)
Regularly irregular	Bigemini (normal beat followed by ectopic), Mobitz type II block
Irregularly irregular	Atrial fibrillation (commonest abnormality) , SR with multiple ectopics

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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