STUDY - Technical - New Dacian's Medicine
Pulsus
paradoxus (Classical / Allopathic Medicine)
Pulsus
paradoxus, or paradoxical pulse, is an exaggerated decline
in blood pressure during inspiration. Normally, systolic
pressure falls less than 10 mm Hg during inspiration. With
a paradoxical pulse, however, it falls more than 10 mm Hg.
When systolic pressure falls more than 20 mm Hg, the
peripheral pulses may be barely palpable or may disappear
during inspiration.
Pulsus
paradoxus is thought to result from an exaggerated
inspirational increase in negative intrathoracic pressure.
Normally, systolic pressure drops during inspiration
because of blood pooling in the pulmonary system. This, in
turn, reduces left ventricular filling and stroke volume
and transmits negative intrathoracic pressure to the
aorta. Conditions associated with large intrapleural
pressure swings (such as asthma) or those that reduce
left-sided heart filling (such as pericardial tamponade)
produce a paradoxical pulse.
To
accurately detect and measure paradoxical pulse, use a
sphygmomanometer or an intra-arterial monitoring device.
Inflate the blood pressure cuff 10 to 20 mm Hg beyond the
peak systolic pressure. Then deflate the cuff at a rate of
2 mm Hg per second until you hear the first Korotkoff
sound during expiration. Note the systolic pressure. As
you continue to slowly deflate the cuff, observe the
patient's respiratory pattern. If a paradoxical pulse is
present, Korotkoff's sounds will disappear with
inspiration and return with expiration. Continue to
deflate the cuff until you hear Korotkoff's sounds during
both inspiration and expiration and, again, note the
systolic pressure. Subtract this reading from the first
one to determine the degree of the paradoxical pulse. A
difference of more than 10 mm Hg is abnormal.
You
can also detect paradoxical pulse by palpating the radial
pulse over several cycles of slow inspiration and
expiration. Marked pulse diminution during inspiration
indicates a paradoxical pulse. When you check for a
paradoxical pulse, remember that irregular heart rhythms
and tachycardia cause variations in pulse amplitude and
must be ruled out before a true paradoxical pulse can be
identified.
ALERT:
When you detect a paradoxical pulse:
- quickly assess all vital signs
- check for additional signs and symptoms of cardiac tamponades, such as dyspnea, tachypnea, diaphoresis, jugular vein distention, tachycardia, narrowed pulse pressure, and hypotension
- institute emergency measures, if necessary.
If the patient's condition permits, perform a focused assessment.
When you detect a paradoxical pulse:
- quickly assess all vital signs
- check for additional signs and symptoms of cardiac tamponades, such as dyspnea, tachypnea, diaphoresis, jugular vein distention, tachycardia, narrowed pulse pressure, and hypotension
- institute emergency measures, if necessary.
If the patient's condition permits, perform a focused assessment.
HISTORY:
Review the patient's medical history for chronic cardiac or pulmonary disease.
Ask the patient about associated signs and symptoms, such as cough or chest pain.
Review the patient's medical history for chronic cardiac or pulmonary disease.
Ask the patient about associated signs and symptoms, such as cough or chest pain.
PHYSICAL
ASSESSMENT:
Take the patient's vital signs.
Auscultate for abnormal breath sounds.
Take the patient's vital signs.
Auscultate for abnormal breath sounds.
SPECIAL
CONSIDERATIONS:
An increase in the degree of paradox may indicate recurring or worsening cardiac tamponade or impending respiratory arrest in severe chronic obstructive pulmonary disease. Vigorous respiratory treatment, such as chest physiotherapy, may avert the need for endotracheal intubation.
An increase in the degree of paradox may indicate recurring or worsening cardiac tamponade or impending respiratory arrest in severe chronic obstructive pulmonary disease. Vigorous respiratory treatment, such as chest physiotherapy, may avert the need for endotracheal intubation.
PEDIATRIC
POINTERS:
Paradoxical pulse commonly occurs in children with chronic pulmonary disease, especially during an acute asthma attack.
Children with pericarditis may develop paradoxical pulse due to cardiac tamponade; however, this disorder more commonly affects adults. A paradoxical pulse greater than 20 mm Hg is a reliable indicator of cardiac tamponade in children; a change of 10 to 20 mm Hg is equivocal.
Paradoxical pulse commonly occurs in children with chronic pulmonary disease, especially during an acute asthma attack.
Children with pericarditis may develop paradoxical pulse due to cardiac tamponade; however, this disorder more commonly affects adults. A paradoxical pulse greater than 20 mm Hg is a reliable indicator of cardiac tamponade in children; a change of 10 to 20 mm Hg is equivocal.
PATIENT
COUNSELING:
Instruct the patient on what to expect from diagnostic testing, which may include an echocardiogram and electrocardiogram.
Instruct the patient on what to expect from diagnostic testing, which may include an echocardiogram and electrocardiogram.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common symptoms,
Edition V, McGraw - Hill, 2002.