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.
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?
b) Radial
c) Femoral
d) Popliteal
(Answer: b) Radial
Pulsus paradoxus is characteristic of which condition?
b) Cardiac tamponade
c) Atrial fibrillation
d) Mitral regurgitation
(Answer: b) Cardiac tamponade
A bounding pulse is seen in which of the following conditions?
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.