Where can you feel a pulse?
In general, it is easiest to detect a pulse at the wrist (radial pulse), neck (carotid pulse), bend in the arm (brachial pulse) and at the groin (femoral pulse). A strong pulse detected in the abdomen may suggest the presence of an aneurysm. When peripheral pulses are not detectable, such as pulses at the wrists or ankles, vascular disease may be inhibiting proper blood flow.
Which pulse is best?
The radial pulse (at the wrist) is most easily accessible, and is often the first pulse used to gauge heart rate and rhythm. If the radial pulse is faint or absent, a more central pulse, such as a carotid or femoral pulse, may be used.
How should a pulse be felt for?
A pulse should be felt with the tips of the index and middle fingers, as these fingertips are highly sensitive. You should not press too hard as this may stop blood flow and the pulse itself. Do not use your thumb as it has its own pulse. When feeling a pulse, noting the rate, rhythm and character can provide improtant information.
- A normal pulse rate for adults is between 60 and 100 beats per minute (bpm). Pulses are usually faster in children than adults. Bradycardia is less than 60bpm and tachycardia is greater than 100bpm.
- Bradycardia may be normal in athletes even after retirement.
- Rate is best measured over at least 30 seconds
- The rhythm can be regular, regularly irregular or irregularly irregular. Essentially the last two terms indicate whether an irregular pulse has a repeating pattern or not. These could indicate different conditions such as heart block or atrial fibrillation.
- A doctor will look at how the pulse changes with breathing. Abnormal changes may be present in pericarditis, severe COPD or a pneumothorax. (air or gas in the cavity between the lungs and the chest wall)
- An ECG can provide a more reliable distinction.
- Bounding pulses may indicate carbon dioxide retention (common with COPD or emphysema), sepsis (advanced infection) or liver failure.
- Thready, small volume pulses may be present in aortic stenosis (a blockage of the aortic valve), shock and pericardial effusions (fluid around the heart).
- Collapsing pulses may occur in arteriovenous malformations (a tangle of blood vessels) or a patent ductus arteriosus (a small hole in the heart that uaually closes a few days after birth).
- Slow rising pulses are characteristic of aortic stenosis
- Alternating strong and weak beats may indicate left ventricular failure, or aortic stenosis
- Jerky pulses may be present in hypertrophic obstructive cardiomyopathy (HOCM) which is essentially excess or enlarged tissue where blood exits the heart.
- A radio-radial delay (delay between the pulses in either arm) may suggest there is a cervical (extra) rib, aortic dissection/coarctation or embolism
- A radio-femoral delay (delay between the pulse in the wrist and groin) may indicate dissection or pulmonary embolism.
- The head can jerk with each pulse in the case of severe aortic regurgitation.
- Pulsation of the capillary nail bed can also occur in aortic regurgitation.
Overview and next steps
A doctor will usually take a history, perform necessary examinations and investigations for each condition. Pulse examination is a very useful tool which can reveal a lot regarding heart function and vascular health. Rate, rhythm and character are the main aspects assessed with a pulse. Combined with other observations and tests such as an ECG for example, more reliable conclusions can be drawn about your health. Your doctor will take this into account during a visit to suggest the next best steps for you.
Hope, R. A., et al. Oxford Handbook of Clinical Medicine. Oxford University Press, 1994.
Ruthven, Alasdair K. B. Essential Examination, Third Edition - Step-by-Step Guides to Clinical Exam. Scion Publishing Ltd, 2015.
Tidy, Colin. “Pulse Examination. Cardiovascular (CVS) Examination. Patient.” Patient.info, 8 May 2015, patient.info/doctor/pulse-examination.