II. Exam: Locations

  1. Peripheral arterial pulsation
    1. Arm
      1. Radial pulse (wrist)
      2. Ulnar pulse (wrist)
      3. Brachial pulse (antecubital)
    2. Foot
      1. Posterior tibial pulse
      2. Dorsalis pedis pulse
  2. Central arterial pulsation
    1. Carotid pulse (Neck)
    2. Femoral pulse (Groin)

III. Exam: Pulse loss in Hypotension

  1. In Hypotension, radial pulse is lost first, then femoral and then carotid
    1. Systolic Blood Pressure at which each Blood Pressure is lost is variable per patient
    2. Old ATLS guidelines (see below) appeared to overestimate the systolic Blood Pressure at which pulse was lost by at least 10 mmHg
  2. Old ATLS estimates - deprecated from current ATLS guidelines (cutoff was overestimated by at least 10 mmHg)
    1. Radial pulse present if systolic Blood Pressure >80 mmHg
    2. Femoral pulse present if systolic Blood Pressure >70 mmHg
    3. Carotid pulse present if systolic Blood Pressure >60 mmHg
  3. References
    1. Deakin (2000) BMJ 16:321(7262): 673-4 [PubMed]

IV. Findings: Abnormal

  1. See Arrhythmia for abnormal rate or rhythm
  2. Water-Hammer Pulse: Large amplitude, rapidly rising (Abrupt Pulse)
    1. Hypertrophic Cardiomyopathy
    2. Aortic Regurgitation
    3. Mitral Regurgitation (severe)
    4. Patent Ductus Arteriosus
  3. Pulsus parvus et tardus (Small amplitude, slow rising)
    1. Definitions
      1. Parvus: Low volume pulse
      2. Tardus: Slow rate of rise to carotid or brachial pulse - nudge instead of a strong tap
    2. Causes
      1. Aortic Stenosis
      2. Diminished Cardiac Output
  4. Pulsus Alternans (alternating strong and weak pulse)
    1. Left Ventricular Systolic Dysfunction
  5. Pulsus Paradoxus (Diminished pulse on inspiration)
    1. Cardiac Tamponade
    2. Congestive Heart Failure (severe)
    3. Chronic Obstructive Pulmonary Disease (severe)
    4. Asthma
    5. Constrictive Pericarditis
  6. Pulsus Bisferiens (Double-peak pulse)
    1. Aortic Regurgitation
    2. Hypertrophic Cardiomyopathy
  7. Asymmetric Pulse
    1. Central Causes
      1. Aortic Dissection
      2. Aortic Coarctation
      3. Subclavian Steal Syndrome
      4. Takayasu Arteritis
    2. Peripheral Causes
      1. Peripheral Arterial Disease (to the point of Critical Limb Ischemia)
      2. Compartment Syndrome (or other acute peripheral vascular compromise)
  8. References
    1. Chizner (2002) Dis Mon 48:7-98 [PubMed]
    2. Giese (2007) Am Fam Physician 75:1008-14 [PubMed]

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Related Studies

Ontology: Double pulse (C0232120)

Concepts Finding (T033)
SnomedCT 50234002, 415216000
English Pulsus Bisferiens, pulsus bisferiens (physical finding), pulsus bisferiens, bisferiens arterial pulses were present, Bisferiens pulse, Double pulse, Pulse bisferiens, Double pulse (finding), Pulsus bisferiens, Bisferious pulse, Pulsus bisferiens (finding)
Dutch bisferische pols, pulsus bisferiens
French Pulsus bisferiens
German doppelgipfliger Puls, Pulsus bisferiens
Italian Polso bisferiens, Pulsus bisferiens
Portuguese Pulso biférico, Pulso dícroto
Spanish Pulso bisferiens, Pulso en mitra, pulso bífero (hallazgo), pulso bífero, pulso bisferiens, pulso de doble latido (hallazgo), pulso de doble latido
Japanese 二峰性脈, ニホウセイミャク
Czech Časný dvouvrcholový pulz
Hungarian Bisferius pulzus, Pulzus biszferiens

Ontology: Pulsus alternans (C0232121)

Concepts Finding (T033)
SnomedCT 389358001, 248628005, 390089000, 195099005, 42807005
English Pulsus Alternans, pulsus alternans (physical finding), pulsus alternans, pulsus alternans was appreciated, alternan pulsus, Pulsus alternans, Pulsus alternans (finding)
Dutch pulsus alternans
French Pouls alternant
German Pulsus alternans
Italian Polso alternante
Portuguese Pulso alternante
Spanish Pulso alternante, pulso alternante (hallazgo), pulso alternante
Japanese 脈交代, ミャクコウタイ
Czech Alternující pulz
Hungarian Pulzus alternáló

Ontology: Abrupt pulse (C0232126)

Concepts Sign or Symptom (T184)
SnomedCT 52147007
English Abrupt pulse, Abrupt pulse (finding)
Spanish pulso abrupto (hallazgo), pulso abrupto

Ontology: Abnormal pulse (C0235472)

Concepts Finding (T033)
SnomedCT 67683007
LNC LA17269-4
English PULSE ABNORMAL, Pulse abnormal NOS, Pulse abnormalities, abnormal pulse, Pulse-abnormal, Pulse abnormal, Abnormal pulse, Abnormal pulse (finding)
Italian Polso anormale, Alterazioni del polso, Polso anormale NAS
Dutch pols abnormaal NAO, pols abnormaliteiten, pols abnormaal
French Pouls anormal SAI, Anomalies du pouls, POULS ANORMAL, Pouls anormal
German Puls anomal NNB, Pulsanomalien, PULSANOMALIE, Puls anomal
Portuguese Anomalias do pulso, Pulso anormal NE, PULSO ANORMAL, Pulso anormal
Spanish Anormalidades del pulso, Pulso anormal NEOM, PULSO ANORMAL, pulso anormal (hallazgo), pulso anormal, Pulso anormal
Japanese 脈拍異常NOS, 脈拍異常, ミャクハクイジョウ, ミャクハクイジョウNOS
Czech Abnormální pulz, Abnormality pulzu, Pulz abnormální NOS
Hungarian Pulzus kóros, Pulzus eltérések, Pulzus kóros k.m.n.

Ontology: Pulsus parvus et tardus (C0240843)

Concepts Finding (T033)
SnomedCT 308531000009104
English Pulsus parvus et tardus, Pulsus parvus et tardus (finding)

Ontology: Physiologic pulse (C0391850)

Definition (NCI) The rhythmic wave within the arteries occurring with each contraction of the left ventricle.
Concepts Physiologic Function (T039)
SnomedCT 8499008
English Pulse Rate, Pulse, function, Physiologic pulse, pulse, Pulse, Pulse, function (observable entity), Pulse, NOS, Pulse (function)
Spanish pulso (entidad observable), pulso (función), pulso

Ontology: arterial pulse (C0392683)

Concepts Organ or Tissue Function (T042)
SnomedCT 87179004
English Arterial Pulse, arterial pulse, Arterial pulse, Pulse (Arterial)
Spanish pulso arterial (entidad observable), pulso arterial