The following highlights some of the special pulses and the pathologies with which they are associated.

Normal carotid pulse

  • Upon palpation, a normal carotid pulse should feel like a sharp knock, while an abnormal carotid pulse will feel like a weak nudge, followed by a slight pulsation or push
  • Normal carotid volume should be easy to feel with light palpation

Pulsus alternans

  • Alternating strong and weak pulses palpable at radial or femoral arteries
  • Almost always indicates left-sided heart failure

Brachioradial delay

  • Palpate right brachial artery with right thumb while simultaneously using the left index and middle finger to palpate the right radial artery
  • Use light pressure to avoid distorting or compressing the normal arterial pulsation
  • A noticeable delay between the brachial and radial pulsations is considered abnormal and indicative of aortic stenosis

Apical-carotid delay

  • Palpate the precordial apical impulse (point of maximal impulse), typically located in the 5th interspace (left side) with fingerpads of right hand while at the same time palpating the right carotid artery
  • A noticeable delay indicates an abnormality and suggestive of aortic stenosis

Water-hammer pulse

  • Due to large stroke volume and backflow of blood from the aorta into the left ventricle and indicative of aortic regurgitation
  • Palpate the radial pulse while the patient lies on the exam table, applying pressure until the pulse is obscured
  • Raise the arm straight over the patient’s head, perpendicular to the exam table
  • Palpate pulse for a sudden rise and collapse of radial pulse that feels "jumpy""

Radio-femoral delay

  • Palpate the radial pulse while the patient lies on the exam table while simultaneously palpating the femoral pulse on the ipsilateral side of patient
  • Palpate for a delay in pulsations between the radial and femoral pulse locations
  • A delay between the two pulses may indicate coarctation of the aorta

Paradoxical pulse

  • Perform if pulse varies in strength and amplitude when patient breathes or if percarditis or tamponade are suspected
  • While the patient breathes quietly, inflate the blood pressure cuff to 40 mm Hg above previously measured level
  • Deflate the cuff slowly while the patient is at the end of expiration. Note the systolic pressure. Repeat the process noting the systolic pressure at peak of inspiration. A difference of greater than 20mm Hg is positive for paradoxical pulse.
  • Paradoxical pulse suggests cardiac tamponade but may also be present in pericarditis
  • It is important to note that deep inspiration and the Valsalva maneuver accentuate the drop in systolic pressure during inspiration so paradoxical pulse should be assessed during normal respiration

Kussmaul's sign

  • Normally when inspecting the JVP, it declines during inspiration but the amplitude of the a wave increased. If there is an increase in the JVP or even a stable JVP on inspiration this is a positive Kussmaul’s sign.
  • Paradoxical drop in systolic blood pressure > 20/10 mmHg with inspiration (pericardial tamponade, constrictive pericarditis, pulmonary etiologies)
  • positive test indicates impaired venous return to the right heart


  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.