Pulseless

Introduction The pulse of the limb is obviously weakened or absent, and the blood pressure is obviously reduced or undetectable. It is called pulsless disease as an abnormal arterial pulsation, which is a common clinical sign, especially in cardiovascular disease. It can be seen in non-cardiovascular diseases, such as external or adjacent blood vessel tissue and other factors such that the arteries are compressed and the tissue covering the blood vessels is thickened. Avascular disease provides a reliable clue and basis for the diagnosis of most arterial diseases. Common clinical sites are mainly caused by obstruction and stenosis of the subclavian artery or radial artery.

Cause

Avascular disease, mainly seen in the heart, arterial system lesions, arterial stenosis, stenosis, obstruction, etc. can affect arterial pulsation and blood pressure, external factors can also cause arterial compression to partially block blood flow, or intravascular wall fibrous tissue hyperplasia , causes blood flow reduction and other reasons can form a pulseless disease. The common causes are:

(1) Severe shock caused by various reasons.

(B) peripheral arterial occlusive disease: including multiple arteritis, thromboangiitis obliterans, arteriosclerotic occlusive disease, abdominal aortic aneurysm, limb aneurysm. Subclavian artery stealing syndrome, acute arterial embolism, etc.

(C) peripheral arterial dysfunction diseases: including hand and foot hair disease, vascular rickets after injury, reticular bluish, war sacral foot syndrome.

(D) non-vascular factors: including thoracic outlet syndrome, scleroderma and so on.

mechanism

The rhythmic contraction and relaxation of the heart of the pump organ causes a regular change in the pressure and blood volume within the artery, thereby causing corresponding expansion and retraction of the vessel wall to complete the blood circulation. The pulsation of the artery can be recorded on the body surface or can be recorded by the instrument, called the arterial pulse. The occurrence of pulse is affected by many factors, such as left ventricular contraction intensity, heart rate and rhythm, stroke volume and blood volume, blood vessel wall elasticity, blood viscosity, peripheral vascular resistance, and vascular neuromodulation. Among them, any one or more factors are abnormal, and no pulse can occur. Such as severe shock without pulse, it is an acute circulatory insufficiency, resulting in insufficient blood perfusion of the whole body tissue, the formation of blood pressure is significantly reduced and the pulse is significantly reduced. Studies have shown that in peripheral vascular disease, arteries are occluded and narrowed. It is the cause of avascular disease, which is caused by arteriosclerosis (AS). Arteriosclerosis is a non-inflammatory, degenerative, and proliferative lesion of the arteries that causes thickening and hardening of the arterial wall, thereby depriving the arteries of elasticity and narrowing the lumen, and reducing blood flow. As for the pathogenesis of arteriosclerosis, the theory is not completely clear. The generalizations include: theory of fat infiltration, theory of damage response, theory of thrombosis and platelet aggregation, theory of viral infection, autoimmune theory, etc. Recently, independent factors such as Apo-A, Apo-B, etc. have been discovered. . In fact, each doctrine cannot satisfactorily explain the whole process of arteriosclerosis. It shows that the mechanism of arteriosclerosis is a very complicated evolution process in which various factors are related to each other and interact.

Defects in small arteries and/or venules, causing arterial dysfunction, are also one of the causes of avascular disease. Arterial blood vessels are compressed by adjacent tissues and the skin covering the arteries becomes hard and too thick to produce veins.

an examination

Related inspection

Dynamic electrocardiogram (Holter monitoring)

First, medical history

Avascular disease is a common sign of clinical peripheral vascular disease. When you are in the consultation, you should pay attention to the history of cardiovascular disease. Due to the insufficiency of the arteries, stenosis, sputum and external pressure on the blood vessels, it will inevitably affect blood patency. The symptoms of the blood supply to the distal end are reduced, and the pulse of the artery, especially the superficial artery, is significantly weakened or disappears. The patient complains that it is more accurate to say the time of occurrence. Therefore, detailed questions about symptoms such as limb pain, decreased skin temperature, pale skin, dryness, and dystrophic dysfunction of the extremities. These symptoms are also the main cause of patient visits. If there is sudden limb pain, skin temperature drop, pale, and even numbness, it often indicates acute blockage of the limb arteries, mostly arterial embolism or acute thrombosis. When the patient has intermittent breaks, it often indicates lower extremity arterial insufficiency and chronic arterial occlusion. Should also pay attention to ask patients with or without resting pain, when there is resting pain, suggesting that arterial ischemia is aggravated. Also pay attention to the relationship between pain and the environment. Such as a temperature difference, a sudden change in temperature difference will make the pain worse. Changes in body temperature can also stimulate or relieve pain. Patients with pulselessness often feel cold and wear more clothes than others but do not feel warm. In addition, when the nerve trunk is deficient in nutrition when the artery is embolized, numbness, acupuncture or anthill sensation may occur.

When you understand your medical history, you should also pay attention to the consultation of systemic diseases. Learn about possible sources of emboli, such as rheumatic heart disease, acute myocardial infarction, infective endocarditis, especially with atrial fibrillation. Whether the patient has diabetes, hyperlipoproteinemia, arteriosclerosis. Some also need to ask about the type of work, whether to use the tremor tool for a long time or to hit with a finger. The above information can provide a basis for diagnosis.

Second, physical examination

Avascular disease is the same as other arterial pulsations, mostly caused by cardiovascular and systemic diseases. In addition to routine physical examination during physical examination, the heart and blood vessels should be checked. The site where the blood vessels are separated and the superficial artery is located should be carefully examined. Such as the neck roots on both sides, the upper clavicle, the middle and upper abdomen, and the bilateral thighs. For the pulsation of superficial arteries, it is more convenient and easy to obtain. Generally, you only need to use the index finger, middle finger and anonymous finger to touch the artery you want to check. The superficial arteries of the whole body include the radial artery and the ulnar artery. The arterial artery, the anterior ear artery, the mandibular artery, the carotid artery, the radial artery, the cerebral artery, the femoral artery, and the dorsal artery of the foot. The above superficial artery may have a positional variation or absence in some patients, such as the radial artery is not accessible in the normal position, but is touched on the dorsal side of the base of the thumb metacarpal, which is called the anti-guana pulse. Sometimes the position is too deep, the artery is too thin, and it is easy to mistakenly believe that there is no pulse. According to anatomical statistics, 10% of normal people have congenital absence of the dorsal artery of the foot, mostly bilateral, 5% of normal people have a posterior iliac artery absent, and often bilateral, so the pulsation disappears when touched. . Under physiological conditions, the bilateral pulse strength and limb rhythm are small in the limbs. However, in the case of aortitis (head-arm type), the pulse of the upper limbs is different, one side even disappears, and some diseases, the upper and lower limbs have abnormal pulse strength, and the lower limb pulse is obviously weaker or even disappears than the upper limb pulse. Can be seen in the aortic constriction. Therefore, when checking the pulse, you should compare the two sides, the upper and lower controls, so as not to miss the diagnosis. Arterial auscultation of murmurs can indicate the extent of arterial stenosis and the vessel segment. Normally, two sounds corresponding to the first heart sound and the second heart sound can be heard at the carotid artery and the subclavian artery. In patients with multiple arteritis, systolic murmurs can be heard in the bilateral supracons and in the posterior triangle of the neck. When the aorta is narrowed, systolic murmurs can be heard on the left side of the back spine.

When measuring blood pressure, it is generally based on the upper limbs. It should be measured three times and the lowest value is taken as the blood pressure reading. The blood pressure of the upper limbs of healthy people may not be equal, and the left and right sides are different. Skin color, temperature and nutrition, repeated and persistent local arterial blood supply, can make the skin tarnish, thin, and reduce skin temperature. Measuring the skin temperature can estimate the condition of the blood circulation in this section. If the temperature difference of the skin of both limbs is above 2 °C, it indicates the blood flow disorder of the limb. Due to insufficient blood supply, muscle atrophy can also occur, and the nails grow slowly, and the limbs can also have ulcers or gangrene.

Third, laboratory inspection

Clinically, no pulse disease can be seen in many diseases of the cardiovascular system. Laboratory tests include: angiography, digital subtraction angiography (DSA) continuous wave Doppler ultrasound.

Differential diagnosis

The diagnosis should be differentiated from the following symptoms:

1. Micro-pulse: The pulse is very thin and soft, and it seems to be like it. A kind of pulse. Very fine and soft, just like it, if there are none, the number is unknown. Caused by qi and blood deficiency. More common in shock, collapse, chronic weakness and so on.

2. The pulse is weak and can not be clearly touched: obstetric shock is divided into shock compensation period, shock inhibition period, and shock failure period. A weak pulse or even a clear failure is a symptom of the shock inhibition period.

3. Heart sound and pulse disappearance is a manifestation of ventricular fibrillation: the pulse can not be touched, the heart sound disappears, and the blood pressure (systolic blood pressure) is often below 60 mm Hg? or the signs of deterioration of the blood circulation are not detected. Clinical manifestations of ventricular fibrillation indicate that the patient has had a cardiac arrest, the main clinical manifestations are loss of consciousness, heart sounds and pulse disappear, breathing stops after tens of seconds, skin, mucous membranes are blemishes or pale, some patients have short convulsions and bowel movements Incontinence, most patients have dilated pupils.

4. The forearm artery mainly consists of the radial artery, the ulnar artery and the common interosseous artery, and the palmar arch and the deep palm of the hand that are subdivided into the hand. Forearm arterial injury mainly manifests as partial obstruction of blood supply to the hand, including weakening and disappearance of ulnar artery or radial artery pulsation, cold finger sensation, skin irritation and numbness.

5. Pulse leakage: atrial fibrillation (atrial fibrillation), this arrhythmia may have "three inconsistencies", that is, the heart sounds are inconsistent, the speed is inconsistent, and the pulse is inconsistent.

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