Understanding pulsus paradoxus
Pulsus paradoxus is an exaggeration of the normal drop in blood pressure that occurs during inspiration. It’s seen in disease states such as cardiac tamponade and less commonly constrictive pericarditis. Watch the video below or visit our website to learn more!
Today’s Stanford Medicine 25 session was about pulsus paradoxus. Thanks to Dr. Ronald Witteles for leading this discussion! Breathing through straws, our residents and students were able to reproduce pulsus paradoxus and teach each other how to detect this important finding.
The History of Pulsus Paradoxus
According to this article, cardiac tamponade was first noted by the Cornish physician Richard Lower in the following quote: “The envelope becomes ﬁlled in hydrops of the heart; the walls of the heart are compressed by the ﬂuid settling everywhere so that the heart cannot dilate sufﬁciently to receive the blood; then the pulse becomes exceedingly small, until ﬁnally it becomes utterly suppressed by the great inundation of ﬂuid whence succeed syncope and death itself.”
In 1761 Joseph Auenbrugger described physical signs of a pericardial effusion: protrusion of the sternum, bulging of the epigastrium and decreased resonance in Traube’s space. In 1873 the German physician Adolf Kussmaul described pulsus paradoxus in three patients when he noted their pulse disappeared completely during inspiration while their heartbeat remain regular. Finally another German physician, Edmund Rose, in 1884 coined the term cardiac tamponade in a description of fatal heart wounds which caused death by constricting the filling of the heart through compression. It is interesting to note that it is the same Kussmaul of Kussmaul’s sign who first noted pulsus paradoxus, while Kussmaul’s sign (increase of lack of decrease of the JVP during inspiration) is usually absent in cardiac tamponade (although can be seen occasionally).
In this video, we show how to use a patient’s arm veins to estimate the central venous pressure.
Here is video showing an actual patient from Stanford Hospital describing the fixed split second heart sound and a loud pulmonic valve (P2).
Pulsus paradoxus is an exaggeration of the normal drop in blood pressure during inspiration. Learn the history of pulsus paradoxus and how to measure it.