character of pulse so the first thing is the character of pulse is best felt in carotid arteries except in case of pulses bispherians and pulses alternates in which the radial artery is preferred and the normal pulse character is of cataclytic type and the basic concept that you need to know while discussing about the character is that is the pulse is the pressure waveform of the left ventricle contraction that is any pressure changes in the left ventricle which can be palpated over the Carotid is known as pulse so what happens normally is when the left ventricle contracts first thing what happens is the pressure from the left ventricular walls transmit along to the aortic walls and from there transmit to the carotid walls and this produces the first wave in the pressure waveform that is the percussion wave then as the electronical contraction proceeds the blood from the left ventricle now goes to the Iota which then goes to the Carotid that is the blood from here within the left ventricular cavity goes to the Iota which then goes to the Carotid and now it will also produce a pressure waveform that is a second wave that is the tidal wave okay so due to left ventricle contraction the first wave is due to pressure transmission through the vessels whereas the second tidal wave is due to transmission of blood from left ventricle to the Carotid then as the blood transfers from carotid to the peripheries and the left ventricle starts relaxing the pressure within the Carotid will start to decrease but as the relaxation starts and the Blood start coming back to the heart from the peripheries there will be a sudden stoppage of the aortic valve that is the aortic valve will shut suddenly which will lead to hitting of the blood forcefully onto the aortic valve and this will increase the pressure transiently and this will be producing the next wave that is the dichrotic Notch and followed by as a lead ventricle relaxation progresses there will be the progressive decrease in the pressure so initially is the percussion wave that occurs due to the pressure transmission across the walls followed by there is a tidal wave which occurs due to left ventricular blood going through the carotides then there is a decrease in the pressure which is occurring due to blood going to the paraphrase and starting of the left integral relaxation but then there is increase in the dichrotic notch present which occurs due to AV valve shutting and also due to the blood being squeezed from the peripheries back to the heart and then the blood is decreasing within the carotids and the following left ventricular pressures decrease and so on so the Carotid pressures so this is the normal ketocratic pulse and normally what happens is what we feel when we keep the finger of the Carotid is we feel a single elevation and this single elevation is a combination of the percussion and the tidal wave why single elevation because there is a very decreased time gap between the percussion and the tidal wave so we palpate it as a single wave so now we'll be discussing about the different pathological pulse characters so the first is the pulses powers in which the amplitude of the tidal wave decreases like in this case this is the normal waveform the blue one and this is the decrease amplitude and now when will there be a decrease amplitude Whenever there is decreased blood to the carotids which can occur either Whenever there is a decreased blood within the left ventricle cavity which can occur in case of shock or in it can occur in case of metal stenosis or it can occur when there is a decreased force of contraction of the left ventricle which can occur in case of heart failure or it can occur in case of dilated cardiomyopathy or it can occur in case of aortic stenosis in which there will be obstruction in the left ventricle outflow so there will be decrease amplitude as the less blood will be going to the carotids the next is the Pulsar Stardust which means that the time duration of the wave is increasing so the blue one here is the normal wave and due to the obstruction the left ventricular outflow which can occur in the eotechnosis or if there is a delayed contraction of the myocardium like in case of left bundle branch block all the myocardial fibers cannot be depolated once so there is a delayed contraction of the left ventricle as a whole so the time duration of the wave will increase and this is Pulsar Stardust and pulses parvis etardus is the third one which is a combination of one and two that is the pulver's parvis and Pulsar Stardust and it occurs in case of aortic stenosis in which there will be decreased amplitude as the less blood is going and also there will be increased time taken as there will be obstruction present so third is the pulses parvis at Tardis now the fourth and the one of the most confusing one is the pulses bispherins so the best here means to normally what happens is we feel a single pulse due to both tidal and percussion wave occurring together but in case of pulses best friends there are two peaks palpable and both the Peaks are palpable before S2 that is both the Peaks are occurring in systole normally what happens is this is percussion wave this is tidal wave and we palpated as together because it is less time Gap but if let's say there is a increased time gap between percussion wave and tidal wave in that case both the percussion wave and the tidal wave will be palpated as a single wave and the these will be present before S2 occurs so this is known as pulses bispherins so now when will it occur it will occur when either there is a increased time gap between the percussion and the tidal wave and it can occur in case of hocm severe aortic regurgitation and severequotic regurgitation plus aortic stenosis what happens is hocm is due to hypertrophic muscle there will be increased contraction of the percussion left ventricle and this will lead to increased amplitude of the percussion wave followed by as the blood is going through the left ventricle Outlet due to Dynamic obstruction present in hocm there will be obstruction which will lead to delay in the blood going from the left ventricle to the carotides and this delay will lead to gap between the percussion wave and the type idle wave so these two will be palpated as two different pulses but before S2 so this is pulses best friends whereas in case of severe AR there will be increased amount of blood in the left ventricle at the endosterone so again due to Frank Starling load there will be increased force of contraction so there will be again increased percussion wave followed by as the blood is flowing through the left ventricle Outlet through High Velocity what will happen is due to venture effect there will be negative pressure created between the walls of Iota which will lead to collapse of the aorta and this will lead to again delaying the blood going from the left ventricle to the Carotid and this Gap will now again lead to palpable of palpation of tidal in the percussion wave separately so there will be a pulse's best friend since severe AR and what happens in severe AR plus Nas in severe AR again there will be increased force of contraction and producing increased percussion wave and the as will be acting as obstruction here and this will increase the gap between the percussion and the tidal wave so there will be pulses bispherians present okay the next is the pulses dichroticus dichroticus again there will be two peak spell people in this type of pulse character but one occurs before S2 and one occurs after this two that is one will be in systole and one will be in diastole normally what happens is this combination of tidal and percussion wave is palpable whereas the amplitude of dichrotic pulse occurring after S2 diagnotic wave is normally very less which cannot be palpable but if there is increased amplitude of the dichrotic notch in that case this combination will also be palpable and this dichrotic Notch will also now being become palpable and so there will be two palpable Peaks one before S2 and one after S2 and this is known as pulses dicloticus and it will occur when there will be increased amplitude of the dichrotic Notch and we know that the dichrotic notch occurs one due to blood coming back from vessels to the Heart Another due to shutting of the aortic valve so increase his blood will coming be coming back to the heart if there is increased peripheral vascal resistance which occurs in case of shock what happens in case of shock is like the patient is hypovolemic shock so in that case there is peripheral vasoconstriction occurring so that more of the blood goes to the vital organs but as this peripheral vasoconstriction occurs more blood is being pushed back to the heart and this will lead to increased amplitude of the dichrotic notch so this is the pulses dichroticus and the last one is the pulses alterance in which there is a alternating amplitude of pulse present in each cycle like in this case let's say there is this amplitude even in the first pulse but there will be a different decrease amplitude A2 in the second pulse and again amplitude even in the pulse first pulse and again the amplitude A2 in the next pulse and it occurs in case of severe heart failure now the mechanism is let's say the patient is systolic heart failure and there is decreased level identical contraction present so there will be less cardiac output present and there will be weak pulse but as a there will be less cardiac output so more blood will be accumulated in the left ventricle this will lead to stretching of The myocardium and there will be increased contraction in the less next cycle as per the Frank styling low so now there will be more con cardiac output and there will be a strong pulse so let's say this is strong pulse followed by as it will be less blood now in the LV there will be A2 but now after A2 again there will be increased blood in LV so there will be a strong contraction increased amplitude followed by there will be decreased blood in LV so there will be decreased atom root so there is a alternating amplitude of pulse present so this is known as pulses alterance but important thing is you should never confuse it with electrical alternates which is a different phenomena in electrical alternates what happens is there is a alternating amplitude of voltage in each cycle of the ECG like this is the ECG so this is a amplitude of QRS followed by decrease amplitude again normal again decreased increased then decrease so this is alternating voltage within the ECG and in it occurs in case of cardiac tamponade white occurs in case of cardiac tamponade is let's say this is the heart this is the pericardium and this pericardium is full of fluid so as there is increased fluid present the heart will be floating within this fluid so due to floating what will happen is with each cycle the heart will come towards the chest wall let's say this is the chest wall as the heart is floating in this fluid the heart will come close to the chest hole then it will go away from the chest hole it will again come close to the chest Sole and then it will go again away from the stone due to floating into the fluid so as the heart comes towards the chest wall the voltage amplitude will increase followed by as the heart moves away from the chest wall the voltage amplitude will decrease so what will happen in this case the river is a alternating amplitude of the QRS but the important thing is the amplitude of the pulse palpable of the Carotid will be normal in this patient because the depolarization occurring is normal so the left ventricle contraction is normal in each cycle so there will be normal amplitude of the pulse whereas there will be alternating amplitude of the voltage so this is the pulses alternates and these are the different characters of pulse