Pulse Monitoring and Management

Pulse Monitoring

Pulse monitoring is a fundamental clinical skill in medicine, used to assess the cardiovascular status of a patient. This guide covers all essential aspects of pulse examination and management for medical students, helping them prepare for practical and theoretical exams.

Pulse rate monitoring

1. Definition of Pulse

Pulse is the rhythmic expansion and recoil of arteries due to the contraction of the heart, specifically the left ventricle. It provides crucial information about heart rate, rhythm, and vascular health.

2. Physiological Basis of Pulse

  • Cardiac Cycle: Systole and diastole create pressure waves in arteries.
  • Stroke Volume: The amount of blood ejected per beat influences pulse strength.
  • Arterial Elasticity: Determines the nature of the pulse wave.

3. Normal Pulse Characteristics

  • Rate: 60-100 beats per minute (bpm) in adults.
  • Rhythm: Regular or irregular.
  • Volume: Weak, normal, or bounding.
  • Character: Fast-rising, slow-rising, dicrotic, collapsing, etc.
  • Tension: Hard (high BP) or soft (low BP).
  • Equality: Same on both sides or different.
  • Condition of Arterial Wall: Hard (atherosclerosis) or soft.

Normal Pulse rate by Age

Age Group Normal PR
(BPM)
Pulse Rhythm Pulse Strength
Newborn
(0-1 month)
100-180 Regular but
can be irregular
Strong and
easily palpable
Infant
(1-12 months)
100-160 Regular Strong
Toddler
(1-3 years)
80-130 Regular Moderate
Preschooler
 (3-5 years)
80-120 Regular Moderate
School-age
(6-12 years)
70-110 Regular Moderate
Adolescent
(13-18 years)
60-100 Regular Strong
Adult
(18+ years)
60-100 Regular Strong
Older Adult
(65+ years)
60-100 Regular but may
have slight variations
May be weaker
due to aging

4. Sites for Pulse Examination

  • Radial artery (wrist) - Most commonly used.
  • Brachial artery (antecubital fossa)
  • Carotid artery (neck)
  • Femoral artery (groin)
  • Popliteal artery (behind the knee)
  • Dorsalis pedis artery (foot)
  • Posterior tibial artery (ankle)

Clinical Tip: Always compare both sides to detect abnormalities.

5. Methods of Pulse Examination

A. Manual Palpation

  • Use the index and middle fingers (not the thumb).
  • Count for 60 seconds or 15 seconds x 4 for an estimate.

B. Electronic Monitoring

  • Pulse oximeter
  • ECG (Electrocardiogram)
  • Doppler ultrasound for weak pulses

Type Description Clinical Conditions
Normal Pulse Regular, 60-100 bpm Healthy individual
Tachycardia >100 bpm Fever, anxiety,
hyperthyroidism,
hypovolemia
Bradycardia <60 bpm Athletes, heart block,
 hypothyroidism
Bounding Pulse Strong, full Fever, anemia,
hyperthyroidism
Weak (Thready)
Pulse
Low volume, hard to feel Shock, heart failure
Irregular Pulse Varying rhythm Atrial fibrillation,
arrhythmia
Pulsus Paradoxus Drop >10 mmHg
in BP during inspiration
Cardiac tamponade,
asthma
Pulsus Alternans Alternating strong
and weak beats
Left ventricular failure
Collapsing Pulse
(Water Hammer Pulse)
Forceful upstroke,
sudden collapse
Aortic regurgitation,
PDA

7. Factors Affecting Pulse Rate

  • Physiological Factors: Age, gender, emotions, exercise, fever.
  • Pathological Factors: Heart disease, blood loss, electrolyte imbalances, infections.
  • Medications: Beta-blockers (↓ pulse), adrenaline (↑ pulse).

8. Clinical Importance

  • Detecting Arrhythmias: Irregular pulse in atrial fibrillation.
  • Assessing Shock: Weak, rapid pulse in hypovolemia.
  • Evaluating Peripheral Circulation: Absent pulses in peripheral arterial disease.
  • Monitoring Response to Treatment: Changes in pulse after fluid resuscitation or drug therapy.

9. Practical Examination Tips

  • Wash hands before and after examination.
  • Explain the procedure to the patient.
  • Use a calm environment to prevent external influences.
  • Count the pulse for a full minute for accuracy.
  • Always compare both sides for abnormalities.
  • Document findings correctly: Rate, Rhythm, Volume, Condition of arterial wall, and any special pulse characteristics.

Medicine of abnormal Pulse Rate

Medications for Bradycardia (Low Pulse Rate < 60 bpm)

  • 1. Sympathomimetics (Adrenergic Agonists):
    • Atropine – Blocks vagal tone, increases SA node firing
    • Isoproterenol – Increases heart rate and contractility
    • Adrenaline (Epinephrine) – Used in severe bradycardia, cardiac arrest, anaphylaxis)
    • Dopamine – At moderate doses, increases HR
  • 2.  Stopping Bradycardia-Inducing Drugs: β-blockers (Metoprolol, Propranolol), Calcium Channel Blockers (Verapamil, Diltiazem)
  • 3.  Pacemaker Therapy: If drug therapy fails

Medications for Tachycardia (High Pulse Rate > 100 bpm)

  • 1. Beta-Blockers (Reduce Sympathetic Activity):
    • Metoprolol, Atenolol – Reduce HR by blocking β1 receptors
    • Propranolol – Also used for anxiety-induced tachycardia
    • Esmolol – Short-acting, used in acute settings
  • 2. Calcium Channel Blockers (Reduce AV Node Conduction): Verapamil, Diltiazem – Used for atrial fibrillation & SVT
  • 3. Antiarrhythmics:
    • Class Ia: Quinidine, Procainamide
    • Class Ib: Lidocaine, Mexiletine
    • Class Ic: Flecainide, Propafenone
    • Class III: Amiodarone, Sotalol
  • 4. Other Medications:
    • Digoxin – Increases parasympathetic tone, used in atrial fibrillation
    • Adenosine – For paroxysmal SVT
    • Ivabradine – Selective SA node blocker

Summary Table

Condition Drugs
Bradycardia (HR < 60 bpm) Atropine, Isoproterenol, Epinephrine, Dopamine
Sinus Tachycardia (HR > 100 bpm) β-blockers (Metoprolol, Propranolol), Calcium Channel Blockers (Verapamil, Diltiazem)
Atrial Fibrillation (AF) β-blockers, Digoxin, Amiodarone
Supraventricular Tachycardia (SVT) Adenosine, Verapamil
Ventricular Tachycardia (VT) Lidocaine, Amiodarone, Procainamide

Adrenaline vs Noradrenaline

Parameter Adrenaline (Epinephrine) Noradrenaline (Norepinephrine)
Primary Receptor Action β1 (Heart) & β2 (Vasodilation), α1 (High dose) α1 (Vasoconstriction), Mild β1 effect
Effect on Heart Rate (Pulse Rate) ↑ Increases HR (Positive Chronotropic Effect) Minimal HR increase, may cause reflex bradycardia
Effect on Blood Pressure Moderate ↑ (Low dose), High ↑ (High dose) Marked ↑ BP due to vasoconstriction
Vasoconstriction Mild (β2-mediated vasodilation at low doses) Strong Vasoconstriction (α1 effect)
Use in Bradycardia? Yes, used for severe bradycardia No significant role
Use in Tachycardia? Can worsen tachycardia May cause reflex bradycardia
Use in Hypotension/Shock? Yes, used in anaphylaxis & cardiac arrest First-line for hypotension & septic shock
Clinical Applications Bradycardia, Anaphylaxis, Cardiac Arrest, Asthma Septic Shock, Hypotension, Cardiogenic Shock
Route of Administration IV, IM, SC, Nebulization IV Infusion (Titrated based on BP response)

10. MCQs about pulse monitoring

Which artery is most commonly used for pulse examination?

a) Carotid
b) Radial
c) Femoral
d) Popliteal

(Answer: b) Radial

Pulsus paradoxus is characteristic of which condition?

a) Aortic stenosis
b) Cardiac tamponade
c) Atrial fibrillation
d) Mitral regurgitation

(Answer: b) Cardiac tamponade

A bounding pulse is seen in which of the following conditions?

a) Severe dehydration
b) Aortic regurgitation
c) Hypothyroidism
d) Heart block

(Answer: b) Aortic regurgitation

Conclusion

Pulse monitoring is an essential clinical skill for medical students. A systematic approach to pulse examination helps in early diagnosis and management of various cardiovascular conditions. By mastering pulse assessment, students can enhance their clinical competence and improve patient outcomes.

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