- Wash Hands
- Introduce self, intended purpose - I've been asked to assess your pulse and blood pressure today. Is that alright?
- Confirm Age, Date of birth
- Do you have any questions?
- Would you mind lifting your sleeve for me please? Make sure it doesnt compress the arm at all.
Palpate radial pulse for 15 seconds, comment on:
- Rate (BPM)
- Regularity (Regular/Irregular)
- Character(strong, weak, thready)
Im just going to press on your neck briefly. Let me know if it's uncomfortable
- Palpate carotid pulse = decribe character (waveform)
- Aortic valve stenosis - slow rise
- Aortic regurgitation/incompetence = collapse
Assess both radial pulses simultaneouly, assessing synchrony.
- Delay = coarctation
- Right radial and left carotid dysynchrony = coarctation between braciocephalic and left carotid
- Right radial and left radial dysynchrony = coarctation between left carotid and left subclavian
- Right radial and femoral dysynchrony = coarctation after left subclavian
Auscultate carotid pulse checking for bruits. Expect to hear nothing if flow is normal = laminar flow
- Narrowing = bruits = turbulent flow
Systolic BP estimate via palpation
- Check to ensure sphygmomanometer is properly calibrated, working properly
- At this point I would allow the patient to relax for 2 minutes
- I'm now going to assess your blood pressure quickly. Just relax and breathe normally.
- Apply cuff, midpoint of cuff over brachial artery
- Estimate systolic bp by palpation (to detect auscultatory gap - venous congestion, arterial stiffness)
- Take pulse with tip of distal and middle fingers at radial point
- Inflate cuff until pulse vanishes
- Inflate cuff for an additional 20mmhg
- Release pressure slowly until pulse is felt again
- This is estimated systolic bp
Auscultatory Systolic and Diastolic Pressure
- Place stethoscope head over brachial artery
- Close valve and inflate rapidly, 20mmhg after pulse ceases to be heard
- Slowly release pressure, watching mercury column
- Record the value of systolic, diastolic and patient position
We have John, a x year old patient. Heart Rate is x beats per minute, regular and strong. Patient is normo/hypo/hypertensive with a bp of xx/xx seated. If bp was high, I would reassess bp in the left arm, and proceed with a full cardiovascular examination.
Korotkoff actually described five types of sounds:
- The first Korotkoff sound is the snapping sound first heard at the systolic pressure. Clear tapping, repetitive sounds for at least two consecutive beats is considered the systolic pressure.
- The second sounds are the murmurs heard for most of the area between the systolic and diastolic pressures.
- The third = A loud, crisp tapping sound.
- The fourth sound, at pressures within 10 mmHg above the diastolic blood pressure, were described as "thumping" and "muting".
- The fifth Korotkoff sound is silence as the cuff pressure drops below the diastolic blood pressure. The disappearance of sound is considered diastolic blood pressure -- two mm Hg above the last sound heard.
The second and third Korotkoff sounds have no known clinical significance.
|If blood pressure is high in both arms and there is a radio femoral delay, what would you suspect?
|Coarctation of the aorta after the left subclavian artery. Secondary hypertension.
|Name major arterial pulse points of the limbs when assesing peripheral aterial circulation
| Temporal, facial, carotid, brachial, radial, femoral, polpliteal, posterior tibial, dorsalis pedis
|What is a pulse deficit?
| Difference between the HR and pulse rate. Occurs in atrial fibrillation, with fast irregular beats, some of which aren't strong enough to open the aortic valve.
|What is sinus arrhythmia?
| Regular variation in hr occuring during breathing cycle (increases during inspiration, decreases in expiration) due to stimulation of nucleus ambiguus
|What is sinus tachycardia?
| HR over 100 bpm originating from SA node, fever, anxiety, exercise, anxiety, hypovolemia
|What is sinus bradycardia? What might cause it?
| HR under 60 from Sa node. Sleep, hypothermia, hypothyroidism
|What can cause an Irregularly Irregular Heart rate
| Heart block, conduction block, normal breathing.
|What is pulse pressure? What condition can cause a decrease?
| The difference between systolic and diastolic, reflects stroke volume, inversely proportional to aortic compliance. Usually under 40 mmHg. Can drop with blood loss, aortic stenosis,
|What is Pulsus paradoxus? What can cause it?
| Exxageration of the normal variation in pulse during inspiration. The paradox is the associated pulse deficit, due to accentuated decrease in blood pressure. Cardiac tamponade, pericarditis, apnea, COPD
|What can cause systolic hypertension?
|Raised systemic resistance
|What can cause wide pulse pressure?
|Athersclerosis, thyrotoxicosis, anaemia, pregnancy. Increases normally with exercise (systolic increases, diastolic remains the same)