Cardiac Pulse Assessment Explained - Clinical Skills - Dr Gill

[music] Hello and welcome back to the channel. My name's Dr. James Gil and you join me today for a video on how to examine a pulse. Now, on the surface of it, that seems like a very straightforward assessment, but there's actually quite a lot of background to understand about what it is that you're finding when you're checking a person's pulse. Let's start off with the demonstration of how we're going to check the radial pulse, the brachial pulse, and the corroted pulse, and also have a look at a collapsing pulse as well. Hello, my name's Dr. Gil. Um, one of my colleagues has asked me to come and check your pulses. Uh, before I start, can I please confirm your name and date of birth? >> It's Harvis Alvie, 4th of January, 2000. >> Super. Thank you. So, before I start, do you have any problems with your heart that you're aware of? None that I'm aware of, but I do feel slightly short of breath recently. >> Okay, thank you. Can I get you to put your hands up briefly for me? So, I can't see any obvious issues to the palm. Turn your hands over for me. There's no obvious issues there. I'm just going to take both wrists at the same time. So, we've got a normal rhythm there. >> And we're going to time for 15 seconds. Okay. So, that's a normal pulse. It's your hands. It's coming through to both hands at the same time. Just going to go a little bit higher up there. Just relax your arm for me. And just contract your bicep. Pull your arm up. Super. Thank you. And relax for me. Okay. So, we've checked the rate and now I'm checking the strength of your pulse. So, here I can feel a good pulse. So I've not got any concerns at that point. Okay. So that cons that pulse seems normal. Um so I'll feed this back. Do you have any questions for myself? >> No. >> Super. Thank you. >> Thanks. >> So given we've seen what goes on with the examination. Let's actually just dig into a little bit about how to do it. So starting off with the radial pulse, I want to find flexor carp radiialis. And I'm going to come about two finger breaths across towards the radial side. And I'm pressing with the pulp of my two fingers. And I'm going to hold here for about 15 seconds. And then multiply that by four. That's going to give me the cardiac rate or the pulse rate. Now, I'd actually argue we need to check the pulse at both wrists at the same time because this allows us to detect something called a radial radial delay. If for example we've got something like co-actation of the aorta narrowing a set of blood vessels meaning the movement of the blood down the arms is different. However a much better reason for doing it is that it doubles my chance of finding the pulse in a high stress situation such as a medical oski for examination. Once we've found that rate we need to work out is this of significance. So what I meaning by that is it a uh normal pulse rate is it a tachicardia or is it a bradicardia? So most textbooks will have the normal uh cardiac rate between about 50 to 60 beats a minute on the low end and about 95 on the top end. Conversely below 50 is always going to be a braticardia and over 95 particularly 100 beats a minute is a tachicardia. Now the bottom end is quite important because different people a slow pulse rate will have different implications. So for example if I have a young fit athletic individual who has a heart rate of 40 I'm going to assume that this is not a medical problem and this is due to the cardiac adaptations to their athleticism. Conversely, if I've got a 90-year-old with a heart rate of 40, I'm going to be very concerned there's maybe a problem with medications or perhaps an issue with the heart itself. So, the numbers that we are going to get for heart rate need to be read in conjunction with what um we're seeing with the patient. Now almost to contradict myself there, a tacic cardia a pulse of 100 beats a minute is always going to be a case of tell me more. Is it that that patient has a low blood pressure? So they're tachocardic because they're compensating there. Is it that they have a sepsis? They've got a fever. They are have an infection. So they're fighting it from that perspective. Do they perhaps have a cardiac problem whereby they've got a a tacic cardia um that's causing issues coming from the heart itself? Do they have a problem that's coming from the heart for example due to stimulation from the thyroid? Have we got a thyrotoxyosis causing a tacic cardia? Whatever it is, if we're seeing a heart rate over 100, it's always very much a case of tell me more. At the same time as checking the rate, we also want to pay attention to the rhythm of the pulse. What's the pattern? So, is it one of two things? Is it a regular rhythm or is it an irregular rhythm? And in terms of that, we can split it a little bit further. Is it a regularly irregular rhythm or is it an irregularly irregular rhythm? So, a sinus rhythm is a normal rhythm. So one, two, one, two. An irregular uh rhythm would be something that is outside of that one, two. So perhaps one, two, pause, one, two, pause. That is still a regular rhythm, but we have an irregularity to it. Conversely, we can have uh irregularly irregular rhythms. one one one two two one one one one two two two one one one one literally all over the place and that would be an example of atrial fibrillation. Now atrial fibrillation is going to come up quite a lot in this video because of how it changes other aspects of the pulse examination. So that's going to be very much a top tip for revision making sure that you're very aware of all the facets of atrial fibrillation. So one of the commonest arrhythmias that you're going to find is that of a sinus tacicardia. Conversely, we can have other arrhythmias that are to do with increase in the heart rate. The waveform on the ECG tells us it's a much more significance. So for example, a ventricular tachicardia or a super ventricular tachicardia. In both of those, we're going to see a massively elevated heart rate. In terms of uh the irregularity, it's often that there are changes um in the uh the pattern of the uh the rhythm. So for example, we may have a a Mobitz type one um arhythmia whereby we're seeing dropped beats potentially getting longer and longer and longer duration between the beats until finally we end up missing that beat. We can also have irregular rhythms where we're getting extra systols, added beats applied um randomly or at a particular order to uh the pulse. Ultimately, it's very important that when we're checking the pulse, we know the rate, but we also if we notice any issues with the rhythm, we carry on palpating here long enough in order for us to determine what's going on. and in reality then organized for an ECG so we can measure and formally diagnose what the arhythmia is. Now it's possible when you're assessing the rhythm that you might notice some changes in the pulse that might make you think it's not a sinus rhythm but as long as those changes are related to breathing we don't have an issue and we can still say it's a sinus rhythm. So for clarification there, when we breathe in, we have a reduction in parasympathetic tone, our rest and digest. And as a direct result of this, the heart rate increases ever so slightly. If we flip things around, when the patient breathes out again, we get an increase in parasympathetic tone. As a result, we've got a higher rest and digest effect going on. Thus, the heart rate will decrease on expiration. Now that's something that we can actually use in the A&E department. If we have a um an arrhythmia such as a super ventricular tachicardia that we want to try and bring into control, we can have the patient do breathing exercises where they're breathing out forcefully. So for example, into a syringe or against their thumb. In doing so, that increases the pressure in the chest causing an increased parasympathetic drive which will take the heart rate down. Now, assuming we have a patient who's not able to do that, we can do a corroted sinus massage putting strong pressure over the corroted um pulse. In doing so that will stimulate the vagus nerve and again reduce the um the heart rate due to increased parasympathetic drive potentially terminating one of these very serious arhythmias such as the super ventricular tachicardia. The atrial fibrillation is also incredibly important from a global health of the patient because when the heart is fibrillating, when we're not getting a nice contraction to eject all of the blood from the heart, we end up keeping some of the blood mixed within the heart. And if that shaking of the atria or the ventricles is meaning that we get some blood caught in a turbulent eddy there, that can then begin to form a clot. And if that clot should break off, we can end up with an emolic stroke. Now, for clarification, an emolic stroke is catastrophic in 50% of patients. So the big question when we found a patient with an irregular irregular pulse and we believe that they've got um atrial fibrillation, the question is if we can get an ECG that day, why should that patient not be started on a blood thinning medication which could potentially save their lives from this potential risk of a catastrophic stroke. So we can take the rate and rhythm from the wrist. Another part of the pulse that we're going to assess for of the wrist is a collapsing pulse. Now, here we're going to make sure that the patient has no problems with their shoulder. And we're going to quickly raise the arm up. In doing so, we cause there to be a column of blood which is going to have greater pressure at the bottom. If we have a collapsing pulse, this pressure from the column actually causes a defect in the aortic valve to become an apparent if there is an aortic valve regurgitation and thus that pulse will collapse down. In technical terms, what this is going to show is that we have a widened pulse pressure, which we'll talk about in a little bit. So our rate and rhythm are going to be um measured at the uh radius. However, we have to move up to the brachial artery to check the character. Actually, that's not quite correct. We simply need to move to a larger bore artery to check the character. So that could be the brachial pulse or potentially the corroted. Personally, I like to avoid checking the corroted pulse for the reasons that you're going to see here. When we check for um the corroted, we want to look between the trachea and the anterior border of sternocllyamastoid muscle. And [clears throat] we need to apply gentle pressure because if we apply excess pressure then we can cause a a veagal reflux and potentially result in the patient fainting having a sinkable episode. Similarly, unlike a radial radial delay, we never want to check the corroteds on both sides at the same time. The reason being is if we have a narrowing, if we've got blockages to one corroted or the other, which we are not aware of, potentially applying pressure to both could briefly um impair the blood supply to the brain and again result in uh the patient collapsing. There is a low-level worry that if somebody has corroted plaques and things like that and you're particularly rough in checking their corroted pulse, maybe it could cause a an embolism to go off, but I think that's probably more of a theoretical concern than actual concern. So, they're the reasons why I would tend to avoid the corroteds initially. There may be reasons to go there as we'll discuss in a moment, but my preference is to try and get the character from the brachial pulse. In terms of finding the brachial pulse, we can get the patient to slightly contract um uh their bicep. So, getting them to move uh their arm up and in doing so, we can find the bicep tendon. And we're going to just drop down ever so slightly with two fingers medial to the bicep tendon. And we can often feel the pulse there. However, there is an alternative way. Still having the patient flex their arm, but cupping the elbow and checking with the thumb for the pulse here. Now, it's actually a little bit easier to find the brachial pulse with your thumb. But one of the reasons why some people don't like to teach it like so is to make sure there's no confusion with the radial pulse. If you were to check the radial pulse with your thumb, because the thumb has its own pulse, it's possible that you could accidentally miss a weak pulse and end up recording your own pulse. So for clarification, fingers for the radial pulse and you can do a thumb for the brachial pulse. Having looked at our rate and rhythm, we need to go to a larger bore artery such as the brachial or the corroted um to look at the volume and character of the pulse. The volume of the pulse is the investigator's perceived level of pulsation and the character of the pulse is to do with the waveform of the pulse. So one is more about perception and one is about how the pulse feels in terms of its nature. For example, in terms of the volume of the pulse, we're looking at two things. A high volume pulse or a low volume pulse. I.e. Is the pulse very easily palpable or is it quite weak and barely palpable? A high volume [snorts] pulse is going to be due to fluid overload. So somebody having been given a lot of fluid literally pushing the uh the blood pressure and the pulse up. It could be due to recently having exercise because again blood vessel dilation and the heart going very forcefully. Staying with the idea of forceful contractions, it could be due to thyotoxyosis where everything has been cranked to volume 10 and the person is having a higher heart rate, higher volume load uh like that. And it can also be due to issues with anemia where a person's got less blood cells within the blood volume, thus they're having to work harder to move the oxygen around the body. We may also see a high volume or large volume pulse in pregnant patients. Now a low volume pulse is a little bit more significant. So we may have issues with hypoalmia. So patient having low blood pressure. Is that because they've potentially um had an injury, they've lost blood. Have they not had enough to drink? Have they got a problem with sepsis and that's caused a a crash in their blood pressure? Other issues tend to be more structural in nature. So for example, do we have a mital stenosis? Do we have a problem with the valves in the heart such as aotic stenosis? Do we have issues whereby we've got a cardiac tamponard? So the heart is restricted from fully expanding and taking in the blood to then pump out to uh the body. To that same end, is there a problem with the heart muscle? So for example, a cardiac failure would result in a reduced pulse volume because literally the heart has a reduced ejection systolic fraction. So it can't move as much blood as it should do, thus giving us a low volume pulse. Moving on to the character again, thinking about this being related to the waveform, let's go back to um aotic regurgitation as a really good example. So here we're going to get a much larger waveform and that may give us also a large larger pulse volume. So with the collapsing pulse we're going to get a normal um beat normal contraction which will move the pulse up. However, because of the column and pressure causing the aortic uh valve to fail and go backwards, regurgitating, the pulse pressure [snorts] is seen to fall lower back than it did, giving us a a much bigger um uh range in the pulse from the high to low, which we'd see on a a graph of the pulse character showing this very broad um pulse volume. If we take the idea of aotic regurgitation and run with it, but add an aotic stenosis into the mix, we get a very um rare pulse form called a pulsus biferian. And on this we get two [clears throat] peaks on the waveform. So the aotic stenosis is making it harder [snorts] for the heart to push uh the blood out. So we get a slow rising pulse. But then the aortic regurgitation results in us having a second peak to that wave following the aotic regurgitation. So the two classic waveforms that we get with regard to the character are a slow rising pulse. This is often seen in aotic stenosis where the narrowing of that valve means that the heart can't force blood as quickly as it should do. So the pulse takes longer to reach the peak. Conversely, we can have issues whereby we've got a collapsing pulse as we've seen due to aotic regurgitation giving us a much greater pulse um wave on uh the uh on the graphs because of the regurgitation taking uh the floor of the pulse wave below the normal on initial contraction. I've mentioned that atrial fibrillation is a very important um rhythm to pay attention to. One of the reasons being is the heart is no longer contracting as we'd expect it to and that could give us a low volume pulse because as I say it's not contracting. The heart muscle is now shaking for want of a better word. As a result the stroke volume can be impaired. we can get a low volume pulse to the degree that we may not even get each pulse um transmitted through to the radius. As a result, we can find that we may sometimes have a a difference between the radial pulse and the apical pulse that you'd listen to with the stethoscope. This again is very important because it's indicating how many inadequate beats the patient is getting and thus may explain some of the symptoms that patients with uh atrial fibrillation get such as fatigue and shortness of breath. So I hope that's been a good overview of how to examine the pulse and crucially what we're looking at it uh with regard to the rate, the rhythm, the volume and the character. If you've got any questions, please put them down in the comments below and we'll see what we can do to help. With that in mind, take care and we'll see you in the next one. Cheerio.