# He has no pulse!



## snaketooth10k (May 29, 2008)

No matter how hard I search, I cannot find a posterior tibial pulse. Is the pulse mythical or does it really exist? How do you locate it?


----------



## PapaBear434 (May 29, 2008)

I had a lot, and I mean a LOT, of trouble finding that pulse.  It's just something that you eventually find and then you'll be able to find it most every other time.

Sorry, I can't really tell you how to find it.  I just grabbed my wife's foot for an hour and poked at the back of her ankle until I found it.  

Truthfully, though, I can't see any real reason to need it anyway.  Pedal pulse is normally enough for our purposes.


----------



## stonez (May 29, 2008)

It can be a real tough one....grab your friends,partner,family members or anyone else and keep trying. The more you practice the easier it will get. and yes it DOES exist!!!


----------



## mikeylikesit (May 29, 2008)

Depends on the pt, it is found under the lateral maleolus though bottom side on the soft tissue, when you find it or the dorsal pedis always mark it with your pen so that the ER can find it if they need it.


----------



## Jeremy89 (May 29, 2008)

That happened to me last week on my ride along.  I was taking vitals and the pt actually had to show me where it was.  Embarassing, I know.


----------



## Airwaygoddess (May 29, 2008)

*Patient teaching...*

Sometimes your can learn a lot from your patients......


----------



## snaketooth10k (May 29, 2008)

*Eureka!*

Thanks a *TON* guys! I thought it was posterior to the malleolus rather than inferior to it. Just to get a good shot at finding it, I laid down for a bit and then jumped up and down a couple times before checking. I nearly passed out, but I found the pulse!


----------



## mikeylikesit (May 29, 2008)

did i say lateral...i meant medial...sorry.:sad:


----------



## BruceD (May 29, 2008)

Also, in some patients, if the knee is bent or bent too much, it can reduce the pulse pressure in the posterior tibial.

-B


----------



## yay4stress (Jun 2, 2008)

this used to be a huge problem for me too.  I could never find a pedal pulses, so when I needed to check a pulse in the inferior extremities, I tended to just grab a look at cap refill.

Then I reached down my own foot and managed to find a dorsal and posterior pulse.  I don't know which one people mean when they talk about pedal pulses, but I know where at least two of them are now


----------



## mikie (Jun 4, 2008)

Is the femoral artery palatable?  I have never found my own...


----------



## BruceD (Jun 4, 2008)

Should be palpable, but you are really 'getting fresh' with yourself to locate it.

I believe this link is helpful.

http://student.bmj.com/issues/03/09/education/318.php


----------



## PapaBear434 (Jun 5, 2008)

Yeah, the femoral is easily felt unless there is a BIG issue, but keep in mind you aren't likely to want to go for this one unless the person is unconscious.  Someone is likely to slap you stupid if you don't warn them first.


----------



## mikeylikesit (Jun 7, 2008)

the femoral is inside the thigh. it is big and relatively easy to find if the patient doesn't think your trying to feel them up. here is a little tip for anyone trying to find the dorsal pedis. on the tarsal for the Haulex(Big Toe) where the the leg begins to curve dramatically into the foot, put your index finger on the tibia and space the middle finger next to it. you should now be with in a few millimeters of the dorsal pedis. it helps of coarse if your not on the bone but between the tarsal of the big toe and the toe next to it. P.S if thier foot is flexed like they were standing it is extremely difficult to find. if you can have them point thier toe downward, it's a cake walk then.


----------



## mikie (Jun 7, 2008)

BruceD said:


> Should be palpable, but you are really 'getting fresh' with yourself to locate it.



I must have no pulse from my femoral down...i tried locating and as 'fresh' as i got, no luck.

So what are the palpable, arteries?

Radial, Brachial, Carotid, Femoral (except for me :sad: ), Pedal (dorsal, forgot the name) (those are the ones I learned (or at least remembered) from the basic curriculum) 

could someone continue the list?  

This is I guess more for personal knowledge.  I'm not going to try to locate every single artery to confirm a pulse on my patient


----------



## rhan101277 (Jul 1, 2008)

In the field are these pulses check by a stethoscope or by hand?

Also if you suspect internal injuries to arteries, how often are distal pulses checked to see if there is a problem.

If there is a problem, shouldn't the blood pressure drop?


----------



## Ridryder911 (Jul 1, 2008)

rhan101277 said:


> In the field are these pulses check by a stethoscope or by hand?
> 
> Also if you suspect internal injuries to arteries, how often are distal pulses checked to see if there is a problem.
> 
> If there is a problem, shouldn't the blood pressure drop?



Most pulses are checked by palpation (pads of the fingertips) by slight pressure of pushing the artery against a bone or hard surface (this is how pulses are produced). 

Distal pulses (radial-wrists, femoral-groin, feet) on all critically ill or severely traumatized patients. One should always check for an apical pulse (stethoscope listening for heart beat) on all patients that do not have peripheral (in the limbs-arms-legs) pulses. As well, apical pulses should be assessed on children and infants. 

R/r 911


----------



## apagea99 (Sep 11, 2008)

We just started pulse checks at the end of class last night. We didn't check them all in class, but we were walked through the how's and where's of the radial, ulnar, brachial, femoral, carotid, dorsalis pedis, and tibialis posterior pulses. He also gave us 1 "hard" one to find: the popliteal. Luckily, my wife has offered to let me use her as my test patient as long as the feet get rubbed from time to time  

For the most part, all of the pulse points were easy for me to find except for the tibial, femoral, and the popliteal. Her tibial pulse was impossible for me to find. I can find my own, but hers seems to be hidden. She was too ticklish for the femoral check. I did find it on one side, but not the other (she mentioned that I would probably get slapped for that one in the field ). And the popliteal is just something I couldn't find to save my life, either on her or myself.

Also, it took me a bit to figure out that I needed to push the bicep back a bit to get a good feel for the brachial, but now I think I've got it down.

Anyone have any tricks for the popliteal? I'd like some extra credit lol. I have a Dr. appointment this afternoon, so I may ask him about it.


----------



## BruceD (Sep 11, 2008)

With the patient laying on their back, bend the knee such that the foot is planted flat on the ground.

Take a hand on each side of the knee and press the fingers into the back of the knee, aim each hand as if you were trying to palpate the patella from underneath.  The pulse is located 'deep' inside, but you should be able to feel it, if not, move the tips of your fingers a little closer together and you'll often feel it pulsating between them.


----------



## mycrofft (Sep 11, 2008)

*I had trouble, then I remembered avocados.*

Well, actually nectarines, but "avocados" is so much more exotic sounding.

First remove footgear. The patient's, that is.

I would place my entire index finger along the side of the foot inferior to the malleolus and _*feel*_. You don't crush a nectarine (or an alligator pear) to check if it's ripe, you gently palpate and concentrate. Maybe shut your eyes. This may "scout out" the pulse point, which you can then try to "concentrate" on. If it eludes you, retrace your technique, mark location, then try a few other spots nearby (due to idosyncratic relocation, such as due to old trauma, or "just being made that way" as my own MD says). Anyway, many folks are taught or teach you to mash down, and if you are excited you will tend to mash down, but that is not always gonna get 'er done.

Also, if you are worried about an artery, consider that there's damn little you can do about it except splint treat for shock and boogey, and it will quickly create a "downstream" condition of relative pallor and coolness. (Take off BOTH shoes and socks). If there is a breach of an artery, too, that blood's going somewhere that's going to get swollen and tight eventually (although in the glutes or thighs that can take far too long, the location of trauma will suggest that injury). Finally, if something hits an artery hard enough to injure it, there's going to be PAIN; if the pt can tell you where it hurts most, and mech of injury suggests vascular damage at that location, there's your clue.

Oh, and by the way, there's a case for protecting your wrists from repetitive motion injury...carpal tunnel injury often affects the nerves going to the first three digits, which means you have to re-learn how to palpate using other digits. Back off the Gameboy.


----------



## mycrofft (Sep 11, 2008)

*PS: the helpfulness in these replies is EXCELLENT!*

..............


----------

