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Walker HK, room WD, Hurst JW, editors. Clinical Methods: The History, Physical, and also Laboratory Examinations. Third edition. Boston: Butterworths; 1990.


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Definition

The carotid pulse is defined by a smooth, relatively rapid upstroke and a smooth, more gradual downstroke, interrupted only briefly in ~ the pulse peak. These palpable pulsatile changes in the carotid arterial diameter room virtually identical to the intraluminal press pulse.

Abnormalities the the carotid pulse may involve an change in the amplitude the the pulse peak, a distortion of the upstroke or downstroke, or any mix of this changes.


Technique

The carotid arterial pulses are usually examined through the patient supine and the tribe of the patient"s body slightly elevated. The patient"s chin must be elevated to enable easy palpation and also yet not sufficient to tighten the neck muscles.

During palpation that the pulse, the examiner provides the tactile or mechanoreceptors in the fingertips to sense activity of the arterial wall surface associated with the pressure pulse as it overcome by the site of palpation. The fingers need to be positioned between the larynx and also the anterior border of the sternocleidomastoid muscle in ~ the level of the cricoid cartilage. In palpating the pulse, the level of pressure applied to the artery should be varied till the best pulsation is appreciated.

Opinions vary as to how many and which fingers should be used and also as to the proper positional relationship between patient and also examiner. Part physicians believe that tactile economic stimulation is accentuated by making use of a single finger and may even prefer to use the thumb. Rather absolutely forbid use of the thumb for palpation and favor usage of 2 or 3 fingers. Whichever finger or mix of fingers is used, it is essential that the examiner ascertain the he is no perceiving his very own fingertip pulse. This potential error can be recognize by pressing down through a finger in ~ an adjacent body website not overlying the patient"s artery. That is an ext likely the the examiner will certainly perceive his own pulse if he offers his thumb. Generally, the carotid artery is palpated through the examiner sitting or was standing comfortably in ~ the patient"s ideal side. Some clinicians, however, favor to research the carotid pulsations when standing at the head of the patient"s bed. Due to the fact that simultaneous palpation that the carotid artery and also auscultation that the heart is sometimes beneficial, the examiner positioning himself in ~ the patient"s ideal side seems preferable.

Palpation of one arterial pulse might be directed towards assessing cardiac performance, determining cardiac rate and also rhythm, establishing the verity of the peripheral arterial blood supply, or localizing peripheral lesions. Check of the carotid pulse is typically directed toward analyzing the status of the heart. While palpation the the carotid pulse is the most crucial component, the examination should additionally include inspection and auscultation. The absence of visible carotid pulsations suggest significant decrease in carotid pulse amplitude. The existence of a bruit might be a clue to partial carotid obstruction or may be a sound sent indigenous a cardiac murmur.

Generally, the brachial artery is the preferable website for analyzing the problem of the patient"s arterial walls. The hardness and tortuosity the the arterial wall can finest be assessed at this site. The love rate and also rhythm space usually assessed by palpating the brachial or radial pulse.

Palpation the the carotid artery generally detects a smooth, reasonably rapid external movement beginning shortly ~ the an initial heart sound and cardiac apical impulse. The pulse peaks about one-third that the method through systole. This peak is sustained momentarily and is adhered to by a downstroke that is somewhat less rapid than the upstroke. Variations native this pattern may be noted during the upstroke, summit, or downstroke. The examiner"s time of the carotid pulse events may be improved by coincided auscultation the the heart. Palpation of the carotid pulse ~ a premature beat might be very helpful because details pulse abnormalities are accentuated adhering to a premature contraction.


Basic Science

The arterial pulse mirrors the interaction in between a control force and impedance come blood flow. The driving force is dependency on the intrinsic contractility of the left ventricle, the size and shape the the heart, and also the heart rate. The impedance is related mostly to peripheral resistance and also arterial compliance associated with the distensibility of the courage wall.

The arterial pulse wave begins with opening of the aortic valve and also ejection of blood native the left ventricle. The press pulse boosts sharply as the blood enters the aorta faster than it flows to the periphery. The left ventricle ejects most of its punch volume fairly rapidly. A major portion the this swiftly ejected volume is transiently organized in the proximal aorta and also other large central arteries the are generally quite distensible. This swiftly rising part of the carotid push curve is termed the anacrotic limb (anacrotic from the Greek "upbeat").

The elevation of pulse push is approximately proportional come the proportion of the punch volume to arterial distensibility. Arterial distensibility, however, decreases together the distending press within the artery increases. Consequently, a provided stroke volume will produce a bigger pulse pressure if the median arterial press is elevated. Arterial distensibility is additionally inversely regarded the price of rise of intraluminal pressure. As the rate of ventricular ejection accelerates, the arterial wall stiffens and the pulse push increases. The amplitude that the pulse pressure can additionally be modification by the "peripheral runoff." An sped up runoff will reduced the diastolic press and an outcome in higher amplitude of the pulse pressure.

While the upstroke that the carotid pulse shows the steering force and also vessel compliance, the downstroke shows the distensibility the vessels and the peripheral resistance. After ~ the aortic push curve peaks, it starts a decline as ventricular ejection slows and also blood continues to circulation to the periphery. Throughout the initial step of ventricular relaxation, over there is a momentary reversal of blood flow from the compliant central arteries earlier toward the ventricle. With this reversal the flow, the aortic valves close. A notch top top the descending body of the aortic pressure curve is associated with this transient reversal of blood flow. The succeeding smaller an additional positive wave, or dicrotic height (dicrotic indigenous the Greek "double beat"), has been attributed come the elastic recoil of the aorta and also aortic valve. Adhering to this tiny wave, the aortic pressure decreases as peripheral runoff continues.


Clinical Significance

An inequality in between the pulse amplitude in the two carotid arteries usually reflects atherosclerosis. Other feasible explanations include aortic dissection, arteritis, or embolus. Kinking the the carotid artery is periodically seen in a hypertensive patient and also may simulate one aneurysm.

The hyperkinetic pulse (Figure 20.1A) is identified by boost in the velocity of the upstroke and amplitude. The water-hammer, or Corrigan"s, pulse is characterized by a very brisk upstroke, big amplitude, and rapid collapse; that is an extreme type of the hyperkinetic pulse. Hyperkinetic pulses may be connected with anxiety, exercise, fever, thyrotoxicosis, hypertension, aortic regurgitation, arterio-venous fistula, and patent ductus arteriosus. Patients with significant bradycardia might compensate with a big stroke volume clinically manifest by a hyperkinetic pulse. The water-hammer pulse is usually linked with aortic regurgitation.


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Figure 20.1

Carotid pulses: A, hyperkinetic pulse; B, bifid pulse; C, bifid pulse characteristics of IHSS; D, hypokinetic pulse; E, pulsus parvus et tardus.


The pulsus bisferiens (cf. Latin, "twice beating"), or bifid, arterial pulse is viewed as two narrowly separated hopeful waves during systole (Figure 20. 1B and 1C). The bifid pulse frequently occurs in patients v aortic regurgitation and also is typical in patients with linked aortic stenosis and aortic regurgitation. A comparable pattern might occasionally be provided in other conditions characterized by a hyperkinetic pulse. The bifid pulse, as shown in number 20.1C, is properties of idiopathic hypertrophic subaortic stenosis.

The hypokinetic arterial pulse (Figure 20.1D) is found in patients with a diminished stroke volume. This group has patients v hypovolemia, left ventricular failure, and mitral stenosis.

A small and delay arterial pulse, pulsus parvus et tardus (Figure 20.1E), is properties of significant valvular aortic stenosis. It need to be recognized, however, the the lack of this finding, an especially in an elderly patient with noncompliant vasculature, does no exclude serious aortic stenosis.

Pulsus paradoxus is a characteristic pulse pattern in which there is significant attentuation in the amplitude that the pulse during the inspiratory phase of normal respiration. A paradoxical pulse must be measured v the sphygmomanometer and should be higher than 10 mm Hg to it is in significant. Pulsus paradoxus is usual in pericardial tamponade but can also be seen v asthma, chronic obstructive airway disease, and also superior vena cava obstruction.

Pulsus alternans is a beat-to-beat sports in the amplitude the the pressure pulse. It might be accentuated adhering to a premature birth contraction. This pulse abnormality is usually best appreciated in distal arteries that have actually a more comprehensive pulse pressure than the carotid artery. Pulsus alternans is a manifestation of serious depression in left ventricular systolic function.


O"Rourke RA. Physics examination of the arteries and veins. In: Hurst JW, ed. The heart. Brand-new York: McGraw-Hill, 1982;188–93.

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Tavel ME. Clinical phonocardiology and external pulse recording, 2d ed. Chicago: Year publication Medical Publishers, 1972.