Pulse Deficit

[Sublime]

I was doing a ride out today and had a patient who had chronic A-Fib. His pulse on the ECG was 120-155 or so, and when I palpated a pulse it was much slower. It was hard to calculate due to it being a bumpy ride (every 6-7 beats I'd count we would hit a bump and I would lose it for a couple secs), not to mention the irregularity, but it was around 65-75. I looked this up when I got home and it says its a normal finding in a-fib and just means each ventricular contraction is not producing enough of a pulsation to reach the peripheral points. From what I read its not a significant clinical finding.... but nowhere could I find anything that says which pulse to go off of? To I tell the ED in my radio report his ecg pulse or the palpable one, or just tell them both? Which one is more clinically significant?

Thanks

[DwayneEMTP]

Great question! Let me answer it with a couple of other questions.

What is the monitor telling you?

What is more important to end organ perfusion, the monitors findings, or what you feel peripherally?

Why?

Dwayne

[Sublime]

The monitor is telling me 120-155 (went up and down during the short transport). I believe what I palpate would be more significant, but am unsure of myself. Just because each of those ventricular contractions is not producing enough ejection to produce a palpable pulse, does not mean those beats are putting out nothing. So to me it seems both are significant, but the peripheral pulse would be more important because obviously what you feel is the beats that are producing more blood flow.

[entity]

I'm not 100% on this, and maybe I'm being a bit picky on semantics.

When you say "each ventricular contraction is not producing enough of a pulsation to reach the peripheral points", I assume you refer to each QRS wave not corresponding to a pulse felt peripherally. My understanding though is that while you may very well see a QRS wave that looks like a normal one, it MAY correspond with zero ventricular contraction. The wave just tells us that there is some conduction through the heart. It tell us nothing about contractility (although it is a safe bet that an asystolic waveform likely points to a heart muscle without contractility). This is similar to pulse deficit where you hear one of the heart sounds but don't feel a pulse because the valve may not open.

"Just because each of those ventricular contractions is not producing enough ejection to produce a palpable pulse, does not mean those beats are putting out nothing."

I think what you said there is a possibility (ie. QRS wave with the heart putting out nothing). PEA's are a good example of this. But yes, it may very well be pushing out SOME blood, but thats hard to confirm. Maybe you would feel those pulses at the carotid but not the radial point?

Not sure about your last question because I'm still learning about that in my rideouts

[DwayneEMTP]

Man, good logic from both. And major Kudos for not Googling your answers but answering from your head instead...really strong.

The monitor gets really confused with Afib. It's picking up electrical activity from all over the heart and isn't always really sure what to report as a pulse rate. We have atrial contractions and ventricular contractions, right? They most often are in sync, but, as in this case, they're not. So you have the ventricles beating at a slower rate then the atria.

It's the ventricular contractions that you feel in the peripheral pulses as the ventricles are the big boys, they swing the big hammers...the left ventricle in particular.

Very often we can have the atria doing very little yet still have a viable, even thriving patient, as the ventricles are still getting enough blood to be able to cram it through the rest of the body, at least temporarily.

So to answer your question, at least in the way that I would do it, you would report to the hospital that "I am showing Afib on the monitor with a ventricular rate of 68/full/irregular." The reason being is that your monitor is just giving you shit right now where pulse rate is concerned. Your SPO2 would likely report more accurately, but it's a wuss move to use that instead of your own fingers.

You're not missing 'weak' vent contractions, it's just that each electrical signal that's creating a contraction on top isn't being transmitted all the way to the bottom.

What I truly love most about this post, besides you showing that you have the balls to not only ask your question but also define your logic, is that it shows your innate distrust of the machines. And this should always, always, always, be the case. They are amazing and useful tools, but they will not take the place of your own touch/smell/hearing and logic....at least not in our careers. They are always your partner, never your instructor.

Each time that you choose to use one try and get a really good idea of what it's going to tell you before you do. Then compare what you thought to what you see. If the information that it gives you is far off from what you expected, but makes better sense, then your assessments need to be stronger. If what your assessment shows, as in this case, makes more sense that what the machine is telling you, then it's off in the ditch for some reason. And they are often going to be off in the ditch. Particularly in the prehospital environment.

When you get a peripheral pulse, that is an excellent sign in the 'average' patient that you're getting end organ perfusion. Combine that with your patients respiration, mentation, (How focused are they, how quickly and clearly do they answer questions?), and their skin color and you're on pretty solid ground.

Good on you for participating man...thanks for doing it.

Dwayne

[mobey]

Just to add my 2cents.

Also remember your monitor's numerical readout is just grabbing a few seconds of data from the strip and formulating a rate., That is why we see rates jumping from 30-200 in patients with a-fib.

To accuratly count the electrical rate you see on the monitor, you need to print off a 1min strip and count the QRS complex's.

Good question! Nice to see some critical thinking at work!