Peripheral Pulse

Issues of Concern

Practical Approaches to Common Pitfalls

Accurate assessment of peripheral pulses requires both technical skill and clinical judgment. Applying excessive pressure during palpation may obliterate a weak pulse, while using too light a touch can result in missing a subtle one. In patients with obesity or edema, deeper palpation or repositioning of the limb may be necessary to locate the pulse effectively.

Distinguishing arteries from tendons is also important.[8] Rolling the structure under the fingertips can help, as tendons tend to move, while arteries remain stationary. When pulses are difficult to detect, warming the limb or encouraging the patient to relax may improve palpability.

Arteries in young children are smaller and more superficial than in older children and adults, making them easier to compress and harder to detect.[9] Clinicians should use the pads of the index and middle fingers to prevent interference from the examiner's pulse and to apply gentle pressure that does not occlude the small arteries of infants and children. Additionally, ensuring that the child is calm is crucial, as crying or movement can alter heart rate and make pulse detection more challenging.

The Role of Adjunctive Technologies

Palpation of peripheral pulses in patients with a strong systolic blood pressure, performed under controlled conditions by experienced clinicians, remains a valuable and reliable component of the physical examination. However, evidence indicates that the reliability of this maneuver diminishes when ideal conditions are compromised, such as in the presence of underlying pathology, time constraints, environmental challenges, or limited clinical experience. In such scenarios, adjunctive technologies, as described above, can support the assessment of peripheral pulses and aid in the identification of underlying vascular pathology.

Clinical Significance

The heart rate may be obtained through various devices routinely applied in most medical encounters, from the prehospital setting to the intensive care unit. While measuring heart rate provides valuable information, recording the peripheral pulse often enhances patient care by offering additional clinical insight. Peripheral pulse assessment aids in identifying specific vascular pathologies, including peripheral arterial disease (PAD), vasculitis, and congenital abnormalities.

Lower extremity peripheral pulses serve as an effective screening tool for PAD. The traditional screening method, the ankle-brachial index (ABI), compares systolic blood pressure in the ankle to that in the arm. Although reliable, ABI testing is relatively time-consuming and requires specialized equipment and training. A study demonstrated that when pedal pulses are palpable bilaterally, the likelihood of PAD is less than 3.5%, giving clinicians the option to forgo ABI testing in such cases.[10] Additional intrinsic arterial pathologies that affect peripheral pulses include thrombosis and vasculitis, such as Takayasu arteritis.

Peripheral pulse assessment is also critical during cardiopulmonary resuscitation (CPR) as part of evaluating return of spontaneous circulation (ROSC). The presence of a palpable pulse indicates ROSC and guides the decision to cease CPR. However, evidence shows clinicians frequently struggle to detect pulse return accurately. This limitation has prompted interest in supplementing manual palpation with adjunctive methods such as Doppler waveform analysis, arterial line monitoring, and end-tidal carbon dioxide (EtCO2) measurement to improve ROSC determination.[11] 

The strength or presence of a peripheral pulse correlates with blood pressure in trauma, but traditional estimations of specific systolic pressure thresholds for pulse palpation have been disproven. Historically, estimates placed the radial pulse as nonpalpable below 80 mm Hg systolic, the femoral pulse below 70 mm Hg, and the carotid pulse below 60 mm Hg. However, a large study of battlefield casualties found that only 15% of patients with systolic pressures below 80 mm Hg lacked a palpable radial pulse. Despite this finding, the study confirmed a correlation between blood pressure and both the strength and presence of pulses. The radial artery was palpated as strong at an average blood pressure of 130 mm Hg, weak at 107 mm Hg, and absent at 85 mm Hg.[12]

Loss of palpable pulses at specific anatomical sites likely correlates with blood pressure, although exact thresholds remain undefined. Larger and more central arteries exhibit lower pressure thresholds at which pulses remain palpable.

Clinicians should recognize that any vessel impingement can reduce peripheral pulses. Such impingements may result from chronic processes, such as tumors adjacent to vessels, or acute trauma. After extremity trauma, distal pulses require assessment to confirm adequate blood flow and to evaluate for anatomical disruptions. Pulse checks are also essential in suspected compartment syndrome, where elevated pressure within a fascial compartment may compress vessels. However, pulselessness is an unreliable indicator of compartment syndrome despite common clinical reliance on this sign.[13]

Other pathologies affecting peripheral pulses include vasospasm, as seen in Raynaud phenomenon, and congenital anatomical abnormalities. Peripheral pulses are a critical part of the physical examination for detecting coarctation of the aorta. Since 60% to 80% of affected infants leave the hospital undiagnosed, emphasis on peripheral pulse assessment in neonates is proposed to improve early detection and patient outcomes.[14]

Other Applications of Peripheral Pulse Assessment

Peripheral pulse quality and location help differentiate between types of shock. Hypovolemic shock typically presents with weak or absent peripheral pulses due to low circulating volume and compensatory vasoconstriction. In contrast, distributive shock, such as septic shock, may feature bounding pulses early on due to peripheral vasodilation.[15]

Pulse checks, performed before interventions such as arterial line placement or fracture reduction, establish a baseline for distal perfusion. Postprocedure assessments help identify complications such as thromboembolism or vascular injury. Any change in pulse strength or symmetry should prompt immediate evaluation.

Special Populations

Pediatric patients require gentle palpation with smaller fingers and a calm environment for accurate pulse assessment. In older adults, arterial stiffness can obscure pulse quality, making interpretation more complex.[16] Athletes may have naturally strong pulses at baseline, so any deviation postinjury should be closely evaluated.[17]

Nursing, Allied Health, and Interprofessional Team Interventions

Peripheral pulse observation and recording provide a valuable assessment due to their speed, ease, and the absence of specialized equipment or additional costs. This evaluation is commonly used to monitor patients with trauma, sepsis, or other forms of shock, and as a screening tool for conditions such as PAD. Many healthcare providers, including nurses, physicians, and personnel trained in CPR, are skilled in pulse assessment. Clear documentation is essential, noting the pulse’s location, laterality, findings, and any changes from prior assessments. Occasionally, peripheral pulses are marked with an “X” on the skin to promote continuity of care as different clinicians assess the patient over time.

Nursing, Allied Health, and Interprofessional Team Monitoring

Peripheral pulses are routinely monitored in various clinical settings, especially when frequent “limb checks” are necessary. Conditions such as compartment syndrome, critical limb ischemia, and severe fractures require regular pulse assessment to ensure adequate vascular supply. Additionally, peripheral pulses are among the fundamental vital signs regularly measured and documented.