Pulse – rate, rhythm, strength

Stiffness of the body's largest artery, the aorta, is the leading cause of increased pulse pressure in older adults. High blood pressure or fatty deposits on the walls of the arteries (atherosclerosis) can make your arteries stiff. The greater your pulse pressure, the stiffer. “Feeling of the pulse at different locations in the body can be completely normal,” says Chester M. Hedgepeth, III, MD, PhD, Executive Chief of Cardiology at Care New England. “Importantly, all the arteries in the heart conduct the pulse wave started in the heart.

We all know that the pulse represents heart beats but probably don’t give it much thought about how that pulsating sensation comes about. It is when the left ventricle of the heart contracts, blood is suddenly pushed away from the ventricle to the main artery called the aorta.

Two things happen due to the sudden forcing of blood from the heart into the arteries:

1. Expansion of the artery.

Think of the arteries as thin rubber walled tubes, when that sudden rush of blood adds to the volume of blood already in the arteries they need to expand. When they quickly contract or squeeze, they go back to their normal size and blood is then forced from those arteries, into the capillaries, and through the veins.

2. Pulse.

Whilst this expansion of the arteries is happening, what is best described as a “wave” travels through the arteries. This is the pulse. It isn’t just a few spots like radial (wrist), carotid (throat), and brachial (inside of elbow), all arteries have this pulse, but it is easier to feel (palpate) when it is nearer the surface of the body such as wrist, groin, neck etc.

The pulse rate is the number of times that wave passes a point in one minute.

It is important to understand that other than counting the pulse rate we need to note certain other factors; the strength of the pulse, and the regularity of the pulse.

Pulse Sites

The three most common sites are:

• Radial (wrist)
• Carotid (throat)
• Brachial (inside of elbow).

The site you take the pulse may vary depending upon the condition of the patient.

Let’s take a scenario: You are treating a casualty who is bleeding severely from a wound in their thigh and have successfully stopped the bleeding.

Check the patient’s pulse at a point below the injury to ensure the bandage has not cut off the blood circulation to the lower leg.

You have a number of options for pulse sites:

Popliteal (behind the knee) site,
Dorsalis pedis (top of the foot) site
Posterior tibial (back of the ankle) site.

The above will provide information as to circulation or lack of it but for a measure of the pulse in general, use the following:

• Radial. This is taken at a point where the radial artery crosses the bones of the wrist.

  If the patient’s hand is facing palm up, the radial pulse is taken on the thumb side of top of the wrist.

• Carotid. This is taken on either side of the trachea (windpipe).

  Ideally the grooves to the right and left of the larynx (Adam’s apple).

• This is taken in the soft dip located about one-half inch above the crease on the inside of the elbow (not the bony side).

  This is where blood pressure is taken.

Pulse Rate.

An ‘average’ adult has a pulse rate of about 72 beats each minute.
Infants have a much higher pulse rate than an adult.

Below are the normal pulse rate ranges based upon age in beats per minute (BPM).

• Adults: 60 to 100 BPM.
• Children: 70 to 120 BPM.
• Toddlers: 90 to 150 BPM.
• Newborn: 120 to 160 BPM.

Pulse rates that are outside the normal range are classified as tachycardia (fast) or bradycardia (slow).

• Tachycardia. If the patient’s pulse rate is over 100 beats per minute, the patient is said to have tachycardia.
• Bradycardia. If the patient’s pulse rate is below 50 beats per minute, the patient is said to have bradycardia.

Strength.

The strength of the pulse is measured by the amount of blood forced into the artery.

• Bounding. Think of “leaps and bounds” .The heart is pumping a large amount of blood with each heartbeat and the pulse feels very strong.

  A bounding pulse is generally caused by exercise, anxiety, or even alcohol consumption.

• Weak. When the heart is pumps only a small amount of blood with each heartbeat, it will be much harder to detect. This type of pulse could be described as weak, feeble, or thread (feeling like a small cord or thread under the finger). If the pulse is weak it may be difficult to find.
• Strong. A strong pulse is stronger than a normal pulse, although less than a bounding pulse.

  Shock and haemorrhage can cause a strong pulse.

Rhythm.

Rhythm is, as it implies, the pattern of the beat. In a regular pulse, the time between beats is constantly the same and of the same strength.

• Without trying to state the obvious, a pulse is irregular when the rhythm does not have a regular pattern. Count the time between beats, does it change? or does the strength of the beats change? does the pulse vary in both time and strength between beats?
• An intermittent pulse misses a beat. The strength does not vary, but a beat is skipped and this can be at regular or irregular interval.

When taking a casualty’s radial pulse, place their arm across their chest to allow you to count their breaths after taking their pulse. The casualty’s breathing pattern could change if they are aware you are watching their breathing.

A bounding pulse is a strong throbbing felt over one of the arteries in the body. It is due to a forceful heartbeat.

A bounding pulse and rapid heart rate both occur in the following conditions or events:

• Abnormal or rapid heart rhythms
• Anemia
• Anxiety
• Long-term (chronic) kidney disease
• Fever
• Heart failure
• Heart valve problem called aortic regurgitation
• Heavy exercise
• Overactive thyroid (hyperthyroidism)
• Pregnancy, because of increased fluid and blood in the body

Call your health care provider if the intensity or rate of your pulse increases suddenly and does not go away. This is very important when:

• You have other symptoms along with increased pulse, such as chest pain, shortness of breath, feeling faint, or loss of consciousness.
• The change in your pulse does not go away when you rest for a few minutes.
• You already have been diagnosed with a heart problem.

Your provider will do a physical exam that includes checking your temperature, pulse, rate of breathing, and blood pressure. Your heart and circulation will also be checked.

Strong Pulse Feeling

Your provider will ask questions such as:

• Is this the first time you have felt a bounding pulse?
• Did it develop suddenly or gradually? Is it always present, or does it come and go?
• Does it only happen along with other symptoms, such as palpitations? What other symptoms do you have?
• Does it get better if you rest?
• Are you pregnant?
• Have you had a fever?
• Have you been very anxious or stressed?
• Do you have other heart problems, such as heart valve disease, high blood pressure, or congestive heart failure?
• Do you have kidney failure?

The following diagnostic tests may be performed:

• Blood studies (CBC or blood count)
• ECG (electrocardiogram)

Fang JC, O'Gara PT. The history and physical examination: an evidence-based approach. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 10.

McGrath JL, Bachmann DJ. Vital signs measurement. In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia, PA: Elsevier; 2019:chap 1.

Mills NL, Japp AG, Robson J. The cardiovascular system. In: Innes JA, Dover AR, Fairhurst K, eds. Macleod's Clinical Examination. 14th ed. Philadelphia, PA: Elsevier; 2018:chap 4.

Strong Pulse In Neck

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. How to determine back focus. Editorial team.