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 above 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.

Watch this video to learn how we teach pulsus paradoxus with straws.

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).

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