What is paradoxical pulse

New Word List Word List. Save This Word! An exaggeration of the normal variation in the pulse during respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales; it is characteristic of constrictive pericarditis or pericardial effusion. We could talk until we're blue in the face about this quiz on words for the color "blue," but we think you should take the quiz and find out if you're a whiz at these colorful terms.

Words nearby paradoxical pulse paradoxical contraction , paradoxical diaphragm phenomenon , paradoxical embolism , paradoxical intention , paradoxically , paradoxical pulse , paradoxical reflex , paradoxical respiration , paradoxical sleep , paradrop , paraesthesia. Published by Houghton Mifflin Company. On physical examination, he appeared comfortable and in no distress.

His cardiac exam was notable only for flat neck veins, an irregularly irregular rhythm, a well-healed pacer site, and no peripheral edema. Laboratory studies revealed a stable hemoglobin level, a negative troponin, and an INR of 2.

An electrocardiogram showed atrial fibrillation but no evidence of ischemia. Imaging studies included a chest x-ray, which was normal, and a computed tomography CT scan of the abdomen, which revealed a pericardial effusion but no hepatobiliary pathology. The ED physician discussed the case and CT findings with the on-call cardiologist who recommended admission but no need for an urgent echocardiogram given the normal vital signs and the patient's clinical stability.

The following day, the patient's echocardiogram confirmed a large pericardial effusion "without tamponade" physiology. Providers continued to remark about the patient's clinical stability based on vital signs and appearance. Later that day, the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures, including large drainage of a pericardial effusion to relieve his cardiac tamponade.

While surviving the emergent resuscitation, the patient ultimately suffered additional complications and passed away after a prolonged hospital course. Clinicians are often reassured by the general appearance of a patient, "stable" vital signs, and a benign physical exam. In some clinical scenarios, however, this heuristic fails: patients "look fine," and by the time the patient does not "look fine," it is too late.

Thus knowing the limitations of the clinical examination is often important. In this case, an elderly gentleman on warfarin had a pacemaker implanted and subsequently developed cardiac tamponade. His large pericardial effusion, which was presumably the result of the "post-pericardiotomy syndrome" reported with transvenous procedures 1 , was likely exacerbated by his anticoagulation therapy.

The pericardial effusion was discovered, but the patient's clinical appearance, vital signs, and echocardiogram reassured his physicians. Unfortunately, his effusion progressed to cause hemodynamic compromise from which he ultimately succumbed.

The clinical examination of the cardiovascular system is challenging to trainees and experienced clinicians alike.

Cardiac tamponade occurs when fluid or gas trapped in the pericardial space compresses the heart and causes hemodynamic compromise Figure. This syndrome exists on a continuum, from barely perceptible hemodynamic effects to overt collapse.

The clinical examination of cardiac tamponade starts with a history. In this case the key points were recent pacemaker placement, anticoagulation therapy, and symptoms of chest discomfort, dyspnea, and nausea.

The symptoms are fairly non-specific, but in the context of the recent procedure and anticoagulation, the clinicians should have had a high suspicion that the patient was at risk for a progressive pericardial effusion.

However, when they discovered the pericardial effusion on a CT done for another reason, they were not willing to attribute his symptoms to this finding. Perhaps this was because he did not "look ill," or because their primary motivation to obtain the CT was to investigate his abnormal liver enzymes, not his heart. In this scenario, a small pericardial effusion might be considered an "incidentaloma," and perhaps might even have been considered to be "normal" after pacemaker placement.

It was probably a combination of all these lines of reasoning, in addition to over-the-phone reassurance by the on-call cardiologist, that led them to not seriously consider tamponade in their differential diagnosis.

The clinicians were also falsely reassured by negative physical exam findings. Pulsus paradoxus is an exaggeration of the physiologic drop in blood pressure with inspiration.

Originally described in by Adolf Kussmaul as a palpable diminution of the radial pulse with inspiration, this finding is typically elicited with a sphygmomanometer. The cuff is deflated slowly while listening for the first Korotkoff sounds, which are intermittent and disappear with inspiration.

The cuff is then deflated further until the sounds become constant with each cardiac cycle. The difference between these two pressures is the pulsus paradoxus. A pulsus paradoxus is considered abnormal if it is greater than 10 mm Hg. In one study a pulsus paradoxus of greater than 10 mm Hg had a LR- of 0. Echocardiography is the non-invasive test of choice for the diagnosis of cardiac tamponade; it has largely replaced cardiac catheterization and direct measurement of intracardiac pressures.

Echocardiographic findings of right atrial and right ventricular collapse and inferior vena cava plethora are consistent with cardiac tamponade. In this case, the initial echo was reassuring, as was the clinical appearance of the patient. However, pericardial fluid was likely continuing to accumulate as the patient bled into the closed pericardial space.

Knowing that this patient had a large pericardial effusion that was at risk of progressing, the clinicians should have been looking for early evidence of frank hemodynamic collapse by regular checks for pulsus paradoxus with a sphygmomanometer. They also might have followed for pulsus paradoxus by using an arterial line tracing, or even by using continuous pulse oximetry, which will pick up respirophasic changes in the pulse waveform.

Postpericardiotomy syndrome and cardiac tamponade following transvenous pacemaker placement. Clin Cardiol. The Rational Clinical Examination. Does this patient have abnormal central venous pressure? Joshi N. The third heart sound. South Med J. We explain the symptoms, diagnosis, and treatment of arrhythmia. Implantable pacemakers can be a valuable tool to keep your heart in rhythm. Learn more about under-the-skin pacemaker implantation in women. Certain arrhythmias, especially atrial fibrillation, are major risk factors for stroke.

Learn more about this connection, symptoms, and treatments. Arrhythmia is sometimes inherited. We explain the genetics of inherited cardiac arrhythmia, including causes, diagnosis, treatment, and more. Health Conditions Discover Plan Connect.

Understanding Pulsus Paradoxus. Medically reviewed by Elaine K. Luo, M. Asthma Other causes Measurement Takeaway What is pulsus paradoxus? Several things can cause pulsus paradoxus, especially conditions related to the heart or lungs. Does asthma cause pulsus paradoxus? What else causes pulsus paradoxus? How is pulsus paradoxus measured? The bottom line. Sinus Arrhythmia. Sinus Tachycardia. Sick Sinus Syndrome. Read this next.

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