For other uses, see Pulse (disambiguation).
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Pulse evaluation at the radial artery.
In medicine, one's pulse represents the tactile arterial palpation of the heartbeat by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed against a bone, such as at the neck (carotid artery), on the inside of the elbow (brachial artery), at the wrist (radial artery), at the groin (femoral artery), behind the knee (popliteal artery), near the ankle joint (posterior tibial artery), and on foot (dorsalis pedis artery). Pulse (or the count of arterial pulse per minute) is equivalent to measuring the heart rate. The heart rate can also be measured by listening to the heart beat directly (auscultation), traditionally using a stethoscope and counting it for a minute. The study of the pulse is known as sphygmology.
Contents
- 1 Physiology
- 2 Characteristics of pulse
- 2.1 Rate
- 2.2 Rhythm
- 2.3 Volume
- 2.3.1 Hypokinetic pulse
- 2.3.2 Hyperkinetic pulse
- 2.4 Force
- 2.5 Tension
- 2.6 Form
- 2.7 Equality
- 2.8 Condition of arterial wall
- 2.9 Radio-femoral delay
- 3 Patterns
- 4 Common palpable sites
- 4.1 Upper limb
- 4.2 Lower limb
- 4.3 Head and neck
- 4.4 Torso
- 5 See also
- 6 References
Physiology[edit]
The pulse is a decidedly low tech/high yield and antiquated term still useful at the bedside in an age of computational analysis of cardiac performance. Claudius Galen was perhaps the first physiologist to describe the pulse.[1] The pulse is an expedient tactile method of determination of systolic blood pressure to a trained observer. Diastolic blood pressure is non-palpable and unobservable by tactile methods, occurring between heartbeats.
Pressure waves generated by the heart in systole moves the arterial walls. Forward movement of blood occurs when the boundaries are pliable and compliant. These properties form enough to create a palpable pressure wave.
The heart rate may be greater or lesser than the pulse rate depending upon physiologic demand. In this case, the heart rate is determined by auscultation or audible sounds at the heart apex, in which case it is not the pulse. The pulse deficit (difference between heart beats and pulsations at the periphery) is determined by simultaneous palpation at the radial artery and auscultation at the heart apex. It may be present in case of premature beats or atrial fibrillation.
Pulse velocity, pulse deficits and much more physiologic data are readily and simplistically visualized by the use of one or more arterial catheters connected to a transducer and oscilloscope. This invasive technique has been commonly used in intensive care since the 1970s.
The rate of the pulse is observed and measured by tactile or visual means on the outside of an artery and is recorded as beats per minute or BPM.
The pulse may be further indirectly observed under light absorbances of varying wavelengths with assigned and inexpensively reproduced mathematical ratios. Applied capture of variances of light signal from the blood component hemoglobin under oxygenated vs. deoxygenated conditions allows the technology of pulse oximetry.
Characteristics of pulse[edit]
Rate[edit]
Normal pulse rates at rest, in beats per minute (BPM):[2]
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Infant heartbeat
Infant heartbeat
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newborn
(0–3 months old) |
infants
(3 – 6 months) |
infants
(6 – 12 months) |
children
(1 – 10 years) |
children over 10 years
& adults, including seniors |
well-trained
adult athletes |
| 100-150 |
90–120 |
80-120 |
70–130 |
60–100 |
40–60 |
The pulse rate can be used to check overall heart health and fitness level. Generally lower is better, but bradycardias can be dangerous. Symptoms of a dangerously slow heartbeat include weakness, loss of energy and fainting.[3]
Rhythm[edit]
A normal pulse is regular in rhythm and force. An irregular pulse may be due to sinus arrhythmia, premature beats, ectopic beats, atrial fibrillation, paroxysmal atrial tachycardia, atrial flutter, partial heart block etc. Intermittent dropping out of beats at pulse is called "intermittent pulse". Examples of regular intermittent (regularly irregular) pulse include pulsus bigeminus, pulsus trigeminus. An example of irregular intermittent (irregularly irregular) pulse is delirium cordis.
Volume[edit]
The degree of expansion displayed by artery during diastolic and systolic state is called volume. It also known as amplitude, expansion or size of pulse.
Hypokinetic pulse[edit]
A weak pulse signifies narrow pulse pressure. It may be due to low cardiac output (as seen in shock, congestive cardiac failure), hypovolemia, valvular heart disease (such as aortic outflow tract obstruction, mitral stenosis, aortic arch syndrome) etc.
Hyperkinetic pulse[edit]
A bounding pulse signifies high pulse pressure. It may be due to low peripheral resistance (as seen in fever, anemia, thyrotoxicosis, hyperkinetic heart syndrome, A-V fistula, Paget's disease[disambiguation needed], beriberi, liver cirrhosis), increased cardiac output, increased stroke volume (as seen in anxiety, exercise, complete heart block, aortic regurgitation), decreased distensibility of arterial system (as seen in atherosclerosis, hypertension and coarctation of aorta).
The strength of the pulse can also be reported:[4][5]
- 0 = Absent
- 1 = Barely palpable
- 2 = Easily palpable
- 3 = Full
- 4 = Aneurysmal or Bounding pulse
Force[edit]
Also known as compressibility of pulse. It is a rough measure of systolic blood pressure.
Tension[edit]
It corresponds to diastolic blood pressure. A low tension pulse (pulsus mollis), the vessel is soft or impalpable between beats. In high tension pulse (pulsus durus), vessels feels rigid even between pulse beats.
Form[edit]
A form or contour of a pulse is palpatiory estimation of arteriogram. A quickly rising and quickly falling pulse (pulsus celer) is seen in aortic regurgitation. A slow rising and slowly falling pulse (pulsus tardus) is seen in aortic stenosis.
Equality[edit]
Comparing pulses and different places gives valuable clinical information.
A discrepant or unequal pulse between left and right radial artery is observed in anomalous or aberrant course of artery, coarctation of aorta, aortitis, dissecting aneurysm, peripheral embolism etc. An unequal pulse between upper and lower extremities is seen in coarctation to aorta, aortitis, block at bifurcation of aorta, dissection of aorta, iatrogenic trauma and arteriosclerotic obstruction.
Condition of arterial wall[edit]
A normal artery is not palpable after flattening by digital pressure. A thick radial artery which is palpable 7.5-10 cm up the forearm is suggestive of arteriosclerosis.
Radio-femoral delay[edit]
In coarctation of aorta, femoral pulse may be significantly delayed as compared to radial pulse (unless there is coexisting aortic regurgitation). The delay can also be observed in supravalvar aortic stenosis.
Patterns[edit]
Several pulse patterns can be of clinical significance. These include:
- Pulsus alternans: an ominous medical sign that indicates progressive systolic heart failure. To trained fingertips, the examiner notes a pattern of a strong pulse followed by a weak pulse over and over again. This pulse signals a flagging effort of the heart to sustain itself in systole.
- Pulsus bigeminus: indicates a pair of hoofbeats within each heartbeat. Concurrent auscultation of the heart may reveal a gallop rhythm of the native heartbeat.
- Pulsus bisferiens: an unusual physical finding typically seen in patients with aortic valve diseases. If the aortic valve does not normally open and close, trained fingertips will observe two pulses to each heartbeat instead of one.
- Pulsus tardus et parvus or anacrotic pulse: a slower than normal rise in the tactile pulse caused by an increasingly stiff aortic valve. Loss of compliance in the aortic valve makes it progressively harder to open, thus requiring increased generation of blood pressure in the left ventricle.
- Pulsus paradoxus: a condition in which some heartbeats cannot be detected at the radial artery during the inspiration phase of respiration. It is caused by an exaggerated decrease in blood pressure during this phase, and is diagnostic of a variety of cardiac and respiratory conditions of varying urgency.
- Tachycardia: an elevated resting heart rate. In general an electrocardiogram (ECG) is required to identify the type of tachycardia.
- Pulsatile This description of the pulse implies the intrinsic physiology of Systole and Diastole. Scientifically, Systole and Diastole are Forces that expand and contract the pulmonary and systemic circulations.
- A collapsing pulse is a sign of hyperdynamic circulation.
Common palpable sites[edit]
Upper limb[edit]
Front of right upper extremity
- Axillary pulse: located inferiorly of the lateral wall of the axilla
- Brachial pulse: located on the inside of the upper arm near the elbow, frequently used in place of carotid pulse in infants (brachial artery)
- Radial pulse: located on the lateral of the wrist (radial artery). It can also be found in the anatomical snuff box.
- Ulnar pulse: located on the medial of the wrist (ulnar artery).
Chinese medicine has focused on the pulse in the upper limbs for several centuries. The concept of pulse diagnosis is essentially a treatise based upon palpation and observations of the radial and ulnar volar pulses at the readily accessible wrist.
Lower limb[edit]
- Femoral pulse: located in the inner thigh, at the mid-inguinal point, halfway between the pubic symphysis and anterior superior iliac spine (femoral artery).
- Popliteal pulse: Above the knee in the popliteal fossa, found by holding the bent knee. The patient bends the knee at approximately 124°, and the physician holds it in both hands to find the popliteal artery in the pit behind the knee (Popliteal artery).
- Dorsalis pedis pulse: located on top of the foot, immediately lateral to the extensor of hallucis longus (dorsalis pedis artery).
- Tibialis posterior pulse: located on the medial side of the ankle, 2 cm inferior and 2 cm posterior to the medial malleolus (posterior tibial artery). It is easily palpable over Pimenta's Point.
Head and neck[edit]
- Carotid pulse: located in the neck (carotid artery). The carotid artery should be palpated gently and while the patient is sitting or lying down. Stimulating its baroreceptors with low palpitation can provoke severe bradycardia or even stop the heart in some sensitive persons. Also, a person's two carotid arteries should not be palpated at the same time. Doing so may limit the flow of blood to the head, possibly leading to fainting or brain ischemia. It can be felt between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage.
- Facial pulse: located on the mandible (lower jawbone) on a line with the corners of the mouth (facial artery).
- Temporal pulse: located on the temple directly in front of the ear (superficial temporal artery).
Torso[edit]
- Apical pulse: located in the 4.5th or 5th left intercostal space, just outside the mid-clavicular line. In contrast with other pulse sites, the apical pulse site is unilateral, and measured not under an artery, but below the heart itself (more specifically, the apex of the heart).
See also[edit]
- Heart rate
- Pulse meter
- Tempo
References[edit]
- ^ Temkin 165;BBC[a]
- ^ U.S. Department of Health and Human Services - National Institutes of Health Pulse
- ^ "Pulse Rate Measurement". Healthwise. WebMD. Retrieved 14 March 2011.
- ^ "www.meddean.luc.edu". Retrieved 2009-05-20.
- ^ "Vascular Surgery, University of Kansas School of Medicine". Retrieved 2009-05-20.
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Medical examination and history taking
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| Medical history |
- Chief complaint
- History of the present illness
- Systems review
- Allergies
- Past medical history
- Family history
- Social history
- Psychiatric history
- Progress notes
- Mnemonics
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| Physical examination |
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General/IPPA
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- Inspection
- Auscultation
- Palpation
- Percussion
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Vital signs
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- Temperature
- Heart rate
- Blood pressure
- Respiratory rate
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HEENT
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Oral mucosa · TM · Eyes (Ophthalmoscopy, Swinging-flashlight test) · Hearing (Weber, Rinne)
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Respiratory
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- Respiratory signs and symptoms
- Respiratory sounds
- Cyanosis
- Clubbing
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Cardiovascular
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- Precordial examination
- Peripheral vascular examination
- Cardiovascular signs and symptoms
- Other
- Jugular venous pressure
- Abdominojugular test
- Carotid bruit
- Ankle brachial pressure index
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Abdominal
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Digestive
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Liver span · Rectal · Murphy's sign · Bowel sounds
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Urinary
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Murphy's punch sign
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Extremities/Joint
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Back (Straight leg raise) · Knee (McMurray test) · Hip · Wrist (Tinel sign, Phalen maneuver) · Shoulder (Adson's sign) · GALS screen
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Neurological
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- Mental state
- Mini–mental state examination
- Cranial nerve examination
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Neonatal
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- Apgar score
- Ballard Maturational Assessment
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Gynecological
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- Intimate examination
- Well-woman examination
- Vaginal examination
- Breast examination
- Cervical motion tenderness
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| L/I |
Labs (Electrolytes, ABG, LFT) · Medical imaging (EKG, CXR, CT, MRI)
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| A/P |
Medical diagnosis · Differential diagnosis
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Cardiovascular system, physiology: cardiovascular physiology
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| Heart |
| Volumes |
- Stroke volume = End-diastolic volume – End-systolic volume
- Cardiac output = Heart rate × Stroke volume
- Frank–Starling law of the heart
- Cardiac function curve
- Venous return curve
- Aortic valve area calculation
- Ejection fraction
- Cardiac index
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| Dimensions |
- Fractional shortening = (End-diastolic dimension – End-systolic dimension) / End-diastolic dimension
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| Interaction diagrams |
- Cardiac cycle
- Wiggers diagram
- Pressure volume diagram
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| Tropism |
- Chronotropic (Heart rate)
- Dromotropic (Conduction velocity)
- Inotropic (Contractility)
- Bathmotropic (Excitability)
- Lusitropic (Relaxation)
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Conduction system /
Cardiac electrophysiology |
- Cardiac action potential
- Atrial action potential
- Ventricular action potential
- Effective refractory period
- Pacemaker potential
- EKG
- P wave
- PR interval
- QRS complex
- QT interval
- ST segment
- T wave
- U wave
- Hexaxial reference system
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| Chamber pressure |
Central venous pressure/right atrial pressure → Right ventricular pressure → Pulmonary artery pressure → Pulmonary wedge pressure/left atrial pressure → Left ventricular pressure → Aortic pressure
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| Other |
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Vascular system/
Hemodynamics |
| Blood flow |
- Compliance
- Vascular resistance
- Total peripheral resistance
- Pulse
- Perfusion
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| Blood pressure |
- Pulse pressure
- Mean arterial pressure
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| Regulation of BP |
- Baroreflex
- Kinin–kallikrein system
- Renin–angiotensin system
- Vasoconstrictors/Vasodilators
- Autoregulation
- Myogenic mechanism
- Tubuloglomerular feedback
- Cerebral autoregulation
- Paraganglia
- Aortic body
- Carotid body
- Glomus cell
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noco/cong/tumr, sysi/epon, injr
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proc, drug (C1A/1B/1C/1D), blte
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anat (a:h/u/t/a/l,v:h/u/t/a/l)/phys/devp/cell/prot
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noco/syva/cong/lyvd/tumr, sysi/epon, injr
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proc, drug (C2s+n/3/4/5/7/8/9)
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