VII. PULSES AND HYPOVOLEMIC SHOCK

CHAPTER 14 — PULSE RATE AND CONTOUR   107



EBM BOX 14-3



Pulses and Hypovolemic Shock*70

Sensitivity

(%)



Finding



Specificity

(%)



Likelihood Ratio†

if Finding Is

Present



Absent



NS

2.9

NS



NS

0.1

0.5



Detecting Systolic Blood Pressure ≥60 mm Hg

Carotid pulse present

95

22

Femoral pulse present

95

67

Radial pulse present

52

89



*Diagnostic standard: For systolic blood pressure, invasive arterial blood pressure

measurements.

†Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.

NS, not significant.

Click here to access calculator.

SYSTOLIC BLOOD PRESSURE > 60 mm Hg (IF HYPOVOLEMIC SHOCK)

Probability

Decrease

Increase

–45% –30% –15%

+15% +30% +45%

LRs



0.1



0.2



0.5



Femoral pulse absent

Radial pulse absent



1



2



5



10



LRs



Femoral pulse present



The references for this chapter can be found on www.expertconsult.com.



REFERENCES    107.e1



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CHAPTER



15



Abnormalities of Pulse

Rhythm

I.  INTRODUCTION

In the late 19th and early 20th centuries, before the introduction of electrocardiography, clinicians could examine the patient’s arterial pulse, heart

tones, and jugular venous waveforms and, from these observations alone,

diagnose atrial and ventricular premature contractions, atrial flutter, atrial

fibrillation, complete heart block, Mobitz type 1 and 2 atrioventricular blocks,

and sinoatrial block.1–3 In fact, clinicians were familiar enough with the bedside findings of these arrhythmias that early textbooks of electrocardiography

included tracings of the arterial and venous pulses to help explain the electrocardiogram (ECG) (Fig. 15-1).4

The bedside diagnosis of arrhythmias today is probably little more than

an intellectual game because all significant arrhythmias require electrocardiography for confirmation and monitoring. Nonetheless, bedside diagnosis

of arrhythmias is still possible, using the principles discovered 100 years

ago by Mackenzie, Wenckebach, and Lewis. These principles, based on

extensive investigation and many polygraph recordings of the arterial and

venous pulses,1–4 allow diagnosis of simple arrhythmias when the electrocardiograph is not immediately nearby.



II.  TECHNIQUE

The first step in diagnosing arrhythmias is to determine the basic rhythm

of the patient’s radial pulse. Most arrhythmias can be classified as one of

five basic abnormalities: (1) the pause, (2) regular bradycardia, (3) regular tachycardia, (4) irregular rhythm that varies with respiration, and

(5) irregularly irregular (or chaotic) rhythm (Fig. 15-2).

The radial pulse may not correspond to the ventricular pulse (or apical

pulse), as determined by auscultation of the heart tones or palpation of

the cardiac impulse, because some ventricular contractions are too weak

to propel blood to the radial artery. Although the clinician must compare the radial pulse with the ventricular pulse to diagnose arrhythmias,

the difference in rate between the two by itself indicates no particular

diagnosis.

After the basic rhythm of the radial pulse is identified, analysis of the

jugular venous waveforms, heart tones, and response of the heart rhythm to

vagal maneuvers may further distinguish the various causes.

108



CHAPTER 15 — ABNORMALITIES OF PULSE RHYTHM   109



Normal sinus rhythm



Venous waveform



Arterial waveform



Electrocardiogram



Complete heart block



Atrial fibrillation



FIGURE 15-1  Simultaneous venous, arterial, and electrocardiographic curves. To help clinicians

understand the P, QRS, and T waves of the newly introduced electrocardiogram, early textbooks

displayed simultaneous venous and arterial waveforms with the electrocardiogram. These examples, reproduced from Sir Thomas Lewis’s 1925 work Mechanism and Graphic Registration of the

Heart Beat, 3rd ed. (London: Shaw and Sons Ltd.), depict normal sinus rhythm (top), complete

heart block (middle), and atrial fibrillation (bottom). See text.



110   PART 4 — VITAL SIGNS



Pause



1 sec

Regular bradycardia



Regular tachycardia



Irregular variation with respiration

In



Out



In



Out



Chaotic



FIGURE 15-2  Basic abnormalities of pulse rhythm are (1) the pause, (2) regular bradycardia,

(3) regular tachycardia, (4) irregular rhythm that varies with respiration (“in” depicts inspiration and

“out” depicts expiration), and (5) irregularly irregular (or chaotic) rhythm. See text.



III.  FINDINGS AND THEIR CLINICAL

SIGNIFICANCE

A.  THE PAUSE

The pause has two important causes: premature contractions (common)

and heart block (uncommon).

1.  Terminology

When the radial pulse consists of the regular repetition of two beats followed by a pause, the term bigeminal pulse or bigeminal rhythm is used.

When there are three radial pulse beats between each pause, the appropriate term is trigeminal pulse or trigeminal rhythm. The finding of several

beats between each pause is usually called group beating, and much longer periods of regular rhythm interrupted by the rare pause is sometimes

referred to as pulse intermissions. The basic mechanism for all of these

rhythm disturbances is the same; only the frequency of premature beats or

heart block differs among them.

Because the cadence of these rhythms becomes predictable after short

periods of observation, the term regularly irregular is sometimes used. This

term, however, inaccurately conveys to others what actually is going on

and is best discarded.



CHAPTER 15 — ABNORMALITIES OF PULSE RHYTHM   111



2.  Basic Mechanism of the Pause

The pause has three basic mechanisms, illustrated in Figure 15-3. The two

most important questions that distinguish these mechanisms are the following: (1) Is there a premature radial pulse immediately preceding the

pause? (2) Do additional ventricular beats (identified by listening to the

heart tones or palpating the apical pulse) occur during the pause?

a.  Premature Beat

Patients with premature contractions (the first two examples in Fig. 15-3)

have evidence of a premature ventricular beat during or immediately preceding the pause in the radial pulse. This early beat is always evident in the

Premature beat opens aortic valve:

a



b



Arterial

pulse

Heart

tones

S1 S2



S1 S2



S1 S2 S1 S2



S1 S2



lub dup



lub dup



lub dup lub dup



lub dup



Premature beat fails to open aortic valve:



S1 S2



S1 S2



S1 S2 S1



S1 S2



lub dup



lub dup



lub dup lub



lub dup



Heart block:



S1 S2



S1 S2



S1 S2



S1 S2



lub dup



lub dup



lub dup



lub dup



FIGURE 15-3  Mechanism of the pause. The radial pulse tracing and heart tones are presented,

illustrating the three mechanisms for the pause: (1) premature contraction that opens the aortic

valve, (2) premature contraction that fails to open the aortic valve, and (3) heart block. Onomatopoeia of the heart tones appears below each tracing. (Lub is the first heart sound, dup is the second

heart sound.) See text.