and digoxin

Heart block

Raised intracranial tension

(Cushing’s reflex)

Physiological:

Infants, children, emotion, exertion, anxiety and pregnancy

Pathological:

Tachyarrhythmias

High output states: Severe anemia, thyrotoxicosis, beri-beri, Paget’s disease of the bone,

cirrhosis of liver, AV fistula

Cardiac failure

Cardiogenic shock

Drugs (e.g. atropine, nifedipine, salbutamol, terbutaline, nicotine, and caffeine)

Relationship between pulse to temperature

For every degree F rise in temperature, the pulse rate increases by 10

Relative tachycardia Relative bradycardia

Acute rheumatic carditis

Diphtheric myocarditis

Tuberculosis

Yellow fever (Faget’s sign)

Dengue fever

First week of enteric fever

Pyogenic meningitis/intracerebral abscess

Brucellosis

Legionella

Psittacosis

Typhus

Q fever

Leptospirosis

Noninfectious:

Patients on β-blockers

Lymphomas

Factitious fever

Drug fever

Rhythm

Rhythm is assessed by palpating the radial pulse. The normal rhythm is regular.

Causes of irregular rhythm

Regularly irregular

Atrial tachyarrhythmias with fixed AV blocks, sinus arrhythmia, partial/second degree atrioventricular (AV) blocks

Ventricular bigeminy and trigeminy

Irregularly irregular

Ventricular ectopics/ventricular premature complexes (VPCs)

Atrial fibrillation (AF)

Atrial tachyarrhythmia with varying AV blocks

Regular with occasional irregularity

Extrasystoles

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Arrhythmias with Regular Rhythm

Atrial flutter

Ventricular tachycardia

First degree heart block

Second degree heart block

Pulse deficit (Apex-pulse deficit) (Fig. 2B.2) is the difference between the heart rate (counted by

auscultation) and pulse rate when counted simultaneously for one full minute by two individuals.

Causes

Pulse deficit of more than 10/minute occurs in atrial fibrillation (AF) and less than 10/minute may be

found with ventricular premature beats or slow/controlled AF.

Differences Between Atrial Fibrillation and Ventricular Premature complexes (VPCs)

Atrial fibrillation VPCs

Apex pulse deficit Usually >10 Usually <10

JVP ‘a’ wave Absent Normal

S1 Variable intensity Normal

Effect of exercise/hand grip Irregularity persists Pulse becomes regular

Fig. 2B.2: Demonstration of apex pulse deficit.

Volume of the Pulse

Volume of the pulse is a measure of the pulse pressure. The pulse pressure is the difference between

systolic and diastolic blood pressure.

Normal pulse pressure is 30–60 mm Hg

<30 mm Hg (low volume) Hypokinetic pulse >60 mm Hg (high volume) Hyperkinetic pulse

Congestive cardiac failure

Hypovolemia

Shock

Mitral stenosis

Aortic stenosis (pulsus minimus)

Constrictive pericarditis

Physiological:

Fever, pregnancy, alcoholism, and exercise

Pathological:

High output states: Anemia, beriberi, hypercarbia

Cirrhosis liver (hypoproteinemia) thyrotoxicosis,

Arterio-venous fistula (AV) fistula

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Paget’s disease of the bone

Cardiac causes (pulsus magnus):

Aortic regurgitation

Severe mitral regurgitation

Complete heart block

Patent ductus arteriosus (PDA)

Rupture of sinus of Valsalva and aortopulmonary window

Varying volume: Seen in atrial fibrillation

Anisosphygmia: Varying volume of pulses in bilateral brachial/radial vessels. Seen in Takayasu’s arteritis

Coanda effect: In supravalvular aortic stenosis, pulse volume is better in the right upper limb compared to left due to the

selective jet of the blood directed to the right subclavian vessel.

Note: Pulsus alternans, pulsus bigeminus, and pulsus paradoxus are also abnormalities in volume (described under the section of

character of pulse).

Grading of Pulse

The examination of the arterial pulses is tabulated using a scale as follows:

Grade Description

0 Complete absence of pulsation

1 Small or feeble/reduced pulsation

2 Palpable but diminished as compared to other side

3 Normal pulsation

4 Large or high volume/bounding pulsation

Character of Pulse

Best assessed in the carotids.

Exceptions:

Collapsing pulse which is appreciated better at radial artery

Pulsus bisferiens best appreciated in brachial artery.

Trisection Method

Varying degrees of pressure are applied with the finger pads of the thumb or first two fingers to assess

upstroke, systolic peak and diastolic slope of the pulse.

Components of pulse wave (Figs. 2B.3A and B):

Individual components of pulse waveform

Wave Description

Percussion wave It is due to arrival of the impulse generated by LV ejection

Tidal wave It is due to the reflected waves from the upper part of the body

Dicrotic wave It is due to the reflected waves from the lower part of the body

Dicrotic notch or incisura This corresponds to S2

(closure of aortic and pulmonary valves)

Speed of Pulse Wave and Time Taken to Reach the Peripheral Arteries

Speed of pulse wave 5 m/sec

Speed of blood flow 0.5 m/sec

Time taken for transmission of pulse to

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Carotid 30 ms

Brachial 60 ms

Femoral 75 ms

Radial 80 ms

Normally radial pulse is felt 5–10 msec later than femoral pulse.

Fig. 2B.3A: Arterial pulse tracing. Fig. 2B.3B: Waveform showing different components of pulse

wave.

Characters of pulse (Fig. 2B.4)

Character Description Condition seen

Catacrotic pulse It is the normal character of the pulse

Pulsus parvus et

tardus

A low amplitude pulse (parvus) with a slow rising

and late peak (tardus)

Severe aortic stenosis (AS)

Pulsus anacroticus Single peak low volume Severe aortic stenosis

Spike and Dome pulse Seen in HOCM

Water hammer pulse

or collapsing pulse or Watsons pulse or

pulsus celer

High (large) volume pulse

Sharp rise (systolic pressure is high)

Ill-sustained, sharp fall (diastolic pressure is low)

Pulse pressure is at least 60 mm Hg

Aortic regurgitation, patent ductus arteriosus

(PDA), aortopulmonary window, rupture of sinus

of valsalva, arteriovenous fistula, severe mitral

regurgitation

Twin beating pulse

Pulsus bisferiens Two peaks in systole Severe aortic regurgitation (AR)

Moderate AR +AS

Hypertrophic obstructive cardiomyopathy

(HOCM)

Pulsus dicroticus One peak in systole, other peak in diastole. Seen

when pulse rate and diastolic pressure is low

Typhoid fever

Severe left ventricular failure (LVF)

Dehydration

Dilated cardiomyopathy endotoxic shock

Alternating volume pulses

Pulsus alternans Alternating high volume and low volume pulse Left ventricular failure

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Regular rhythm

Korotkoff sounds double on lowering cuff

pressures

Pulsus bigeminus Pulse wave with normal beat followed by a

premature beat and a compensatory pause,

occurring in rapid succession, resulting in alteration

of the strength of pulse

Digoxin toxicity

Pulsus paradoxus

Pulsus paradoxus Systolic blood pressure falls more than 10 mm Hg

during inspiration (exaggeration of normal

phenomenon)

Constrictive pericarditis

Acute severe asthma/chronic obstructive

pulmonary disease (COPD)

Cardiac tamponade, tension pneumothorax,

and massive pulmonary embolism

Others—anaphylactic shock, and obesity

Reverse pulsus paradoxus (inspiratory rise in pulse volume and pressure): seen in intermittent positive-pressure ventilation in

the presence of left ventricular failure, hypertrophic obstructive cardiomyopathy (HOCM) and isorhythmic AV dissociation

Absent pulsus paradoxus in constrictive pericarditis: If associated with large atrial septal defect/ventricular septal

defect/aortic regurgitation (ASD/VSD/AR)/pericardial adhesions

Method of Eliciting Pulsus Paradoxus (Fig. 2B.5)

Pulsus paradoxus refers to an exaggerated fall in a patient’s blood pressure during inspiration by

greater than 10 mm Hg

Patient is placed in a semirecumbent position; respirations should be normal. Do not instruct them to

change their breathing pattern as the depth of respiration influences the magnitude of pulsus

paradoxus and will be amplified in patients with pulmonary disease

The blood pressure cuff is inflated to at least 20 mm Hg above the systolic pressure and slowly

deflated until the first Korotkoff sounds are heard

Initially sounds will be heard only during expiration. Note the level

As the cuff is further deflated, the first korotkoff sound will be heard during both inspiration and

expiration. Note this level.

If difference between the two is more than 10 mm Hg, then it is pulsus paradoxus

Fig. 2B.4: Image showing different pulse waveforms.

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Fig. 2B.5: Pulsus paradoxus.

This is not a true paradox as it is an exaggeration of normal phenomenon of fall of BP during

inspiration.

Then, What is the Paradox?

The paradox is that, in patients in patients with constrictive pericarditis, during inspiration the blood

pressure might drop significantly enough that the peripheral pulses will be absent; however, the heart

sounds will still be heard.

Other Paradoxes in Medicine

French paradox: The observation that the French suffer a relatively low incidence of coronary

heart disease, despite having a diet relatively rich in saturated fats.

“Thrombotic paradox” of hypertension (or) “Birmingham paradox”: Hypertension is a

prothrombotic state, hence paradoxially thrombotic strokes are more common than hemorrhagic.

Venous paradox—Kussmaul sign is a paradoxical rise in jugular venous pressure (JVP) on

inspiration, or a failure in the appropriate fall of the JVP with inspiration.

Ulnar paradox: Higher the lesion minimal is the deficit.

Paradoxical respiration: It causes the chest to contract while inhaling and to expand during

exhaling, the opposite of how it should move. The causes of paradoxical breathing include chest

trauma and diaphragmatic paralysis. Neurological problems that can paralyze the diaphragm.

Kinesia paradoxa: Seen in parkinsonism, patients who generally cannot move but under certain

circumstances exhibit a sudden, brief period of mobility (walking or even running).

Method of Elicitation of Pulsus Alternans (Fig. 2B.6)

Pulsus alternans refers to alternating high and low volume pulses.

Patient is placed in a semirecumbent position.

The blood pressure cuff is inflated to at least 20 mm Hg above the systolic pressure and slowly

deflated until the first Korotkoff sounds are heard.

Initially, the Korotkoff’s sounds due to the high volume pulses will be heard.

On lowering the blood pressure, Korotkoff sounds will be heard due to both high volume and low

volume pulses.

This will produce doubling of Korotkoff’s sounds.

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