Part 1: The Pulse
There are few things that EMT’s should claim as their domain. There are certain skills that the EMT provider should simple dominate. Vital signs are one such skill. No medical provider anywhere should be able to hold a candle to the EMT when vitals signs are the name of the game.
Vital signs are, to the EMT, what sharp shooting is to the sniper; what the fast ball is to the closing pitcher; what swordsmanship is to Zorro. It’s the EMT bread-and-butter skill. And yet…so many EMTs fumble through vital signs like it’s amateur hour. No more. Over the next few weeks we’re going to break down vital signs here at The Spot and make every one of our trusted and loyal readers a vital sign virtuoso.
Are you ready? Carnegie Hall awaits. Let’s start with the pulse check.
Some EMT’s can take 30 seconds to a minute to check a pulse. When they’re done they have one single piece of clinical information to pass on, the heart rate. Others can feel a pulse for 3 seconds and tell you much, much more about the patient’s cardiovascular status. What’s the difference? Practice and focus. If you’d like to be the second EMT, here’s how.
1) Know where to check for a pulse. (And why)
There are a bunch of places to obtain a pulse and good reasons to use each one. Here, our collapsed young runner shows us the seven primary pulse points that every EMT should know.
Recall that the pulse is felt when we trap an artery between our finger (or fingers) and a bone lying beneath the vessel. There is some technique to this. It requires a firm, gentle, accurate touch. There’s only one way to develop this skill. Take a lot of pulses. Let’s look at each one of these pulse points in a little more detail.
We’ll start at the top and work our way down.
The Carotid Pulse
The carotid pulse is found by palpating the external carotid artery on the side of the neck on either side of the trachea. The carotid is a very central pulse and should be easily palpated with somewhat deep pressure. Feel for the side of the trachea and then press posterior into the neck.
This is the classic CPR pulse check site and well known to the lay public. It is often used by runners and athletes to assess their own heart rate. A palpable carotid is the current tipping point for rapidly deciding if external chest compressions are indicated. Until a more definitive measure of cardiac output is available, in the absence of a carotid pulse, CPR is indicated. (Presuming the patient is unresponsive.) This site can also be used to assess the effectiveness of CPR. During adequate chest compressions, a carotid pulse should be palpable. If not, it might be time to switch rescuers.
The Brachial Pulse
Felt on the inner aspect of the arm on babies and small children and commonly found on the medial aspect of the antecubital fossa in adults, the brachial pulse should be the starting point for each blood pressure check you perform. Find the brachial pulse and line the artery arrow on the BP cuff up with the pulse point about one inch above the elbow joint.
The brachial is the primary pulse check point for infant CPR, it’s also often overlooked as an easily accessible pulse point when the radial pulse is inconvenient or painful to use. Feeling a brachial pulse requires a bit more pressure than the average radial pulse. Brachial pulses are often present even when a radial pulse is not discernible. If you are ever unable to palpate a radial pulse, the brachial should be your next stop.
The Radial Pulse
Conveniently located and easy to palpate on the anterior / lateral portion of the wrist (thumb side), the radial pulse tends to be the classic point for checking heart rate and rhythm in the conscious patient. More convenient than a carotid, less personal than a femoral, the radial pulse is far and away the most common pulse location in use.
The absence of a radial pulse is a fairly reliable indicator that the systolic blood pressure has fallen below the 80 mmHg mark. Unequal radial pulses can signify a variety of conditions, including aortic abnormalities, vascular compromise, atherosclerosis and compartment syndrome. In the presence of shoulder or upper arm injuries, an accurate blood pressure can still be auscultated at the radial artery, providing that the cuff is properly fit to the forearm and applied correctly over the artery.
The Femoral Pulse
After the aorta passes through the retroperitoneal cavity of the abdomen it branches into the left and right femoral arteries. These arteries can be palpated in the crease between the upper thigh and the lower pelvic area, where the lower abdominal quadrant joins the leg. Palpate deeply in the crease about midway between the iliac crest and the groin.
The femoral artery is a very central section of vasculature which makes it a popular point of access for insertion of cardiac stents and other invasive procedures that require surgeons to operate within the vasculature. It is also a great spot to check the effectiveness of CPR compressions. Due to its location, femoral pulse checks are reserved for unconscious patients. Like its centrally located brother, the carotid, femoral pulses can sometimes be felt at systolic pressures as low as 50 mmHg.
The Popliteal Pulse
Possibly the hardest to locate of the bunch, the popliteal pulse is useful in assessing vascular compromise in the presence of a knee or femur injury. In significant leg injury it can assist in determining the location of vascular compromise and is a good secondary location for distal circulation checks when using a traction splint, which covers both of the primary pedal pulse locations.
The popliteal artery can be felt behind the knee and is easiest to reference when the knee is slightly bent. Place both of your thumbs on the knee cap and feel in the pit behind the knee at the mid-point with the fingers of both hands.
The Dorsalis Pedis Pulse
While its location can vary considerably, the dorsalis pedis pulse can often be felt on the dorsal (top) region of the foot just medial to the bony prominence above the instep.
The dorsalis pedis is the most commonly used pulse when assessing for distal circulation in lower limb injury. Once you find it, mark it with a pen for future reference. (Note the “X marks the spot” markings on the feet of the patient at left.)
The Posterior Tibial Pulse
Due to the infinite variations of splinting options in lower limb injuries, it’s often helpful to have an alternate spot for distal circulation checks. The posterior tibial pulse is located behind the bony prominence on the distal end of the tibia. (The medial ankle bone.)
It’s also a handy location to check is the sometimes elusive dorsalis pedis pulse cannot be located. Often patients with a difficult to locate dorsalis pedis pulse will have a strong posterior tibial pulse and vice-versa.
2) Know what you’re checking
As previously stated, there’s a lot more to that pulse check than heart rate. Circulation compromise, cardiovascular status as well as acute and chronic conditions can all be assessed if you’re paying attention to the rate, quality, rhythm and equality of the pulses.
An exact heart rate is actually pretty low on my pulse check priority list. Before that, I primarily want to know if it is fast or slow, strong or weak, regular or irregular. Most of the really important stuff can be figured out in the first three seconds of your pulse check.
3) Put the pulse in context for the patient
This is often overlooked and one of the harder things to grasp for newer EMTs. The pulse, just like everything else you assess, needs to be placed in the context of the overall clinical picture.
An EMT student might ask, “What if I can’t find a radial pulse?” Hoping for some definitive response to the “no pulse” situation. The answer is always the same. “What’s the patient’s mental status? What does their skin look like? Do they have a brachial pulse? Do they have a radial on the opposite side?” The answers to these questions and a bunch more will determine the proper next step.
A friend of mine recently assisted a dentist who was doing CPR on a conscious combative male who had collapsed at a local pool. The fact that he couldn’t feel a carotid pulse was the only thing that mattered to him. The rest of the clinical presentation, including the victim’s cries of protest, didn’t matter to the dentist. He insisted bystanders help restrain the patient while he continued CPR. Sometimes, even people with advanced medical training have a hard time considering the whole clinical picture.
The presence or absence, rate and rhythm, equality or inequality, strength or weakness all need to be put into the greater context of the patient presentation. They don’t stand alone.
4) Really take a pulse
I don’t mean take a long time. I mean focus. Pay attention to that pressure wave beneath the skin we call a pulse. We check pulses so routinely, we often fall into the habit of not paying attention to other stuff while we check a pulse. Allow me to elaborate.
Have you ever checked your watch and had someone else who saw you checking ask, “Hey, what time is it?” …and you have no idea? That’s because you were performing a routine. You weren’t really focusing on the time, you were just checking because that’s what you do.
We do the same thing with pulses. We check it, we find it, we hold it for a few seconds and then we move on. If someone sees us check and asks, “What was the pulse like?” we might know, we might not.
Don’t get stuck in that rut. Feel the wave. Visualize the heart beating withing the patient, sending a wave of pressure through the vessels. Feel for its regularity, equality, strength and rate. Ask yourself what it means. Now you’re on your way to becoming a virtuoso.
Now it’s your turn: What’s your favorite pulse check trick?
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