Water –Hummer (collapsing ) pulse or Corrigan pulse or Pulsus Celer

Written By:Dr.Nabil Paktin,MD.
For further reading , please click “read  the rest of the article “

Thomas Watsan (1844) , an English physician , named this term after a Victorian toy , which refers to the rapid and forceful ascending limb of the arterial pulse . water-hammer consisted of a sealed glass tube containing water in a vacuum . As solids and liquids fall at the same rate in vacuum , so when this glass tube is quickly inverted , water column falls abruptly from one end of the tube to the other and inger tip holding the inverted end senses a sudden impact or jolt . 

 

 

It is characterized by rapid upstroke ( percussion wave) followed by rapid descent ( collapse) of the pulse wave without dicrotic notch , which reflects low systemic vascular resistance.

– Rapid upstroke is due to the rapid ejection of greatly increased stroke volume .
– the rapid descent or collapsing character is due to :
a) diastolic “run-off” ( back flow) into the left ventricle
b) reflex vasodilation mediated by carotid baroreceptors secondary to large stroke volume .
c) the rapid run-off to the periphery due to decreased systemic vascular resistance .

Detection: It is best appreciated at the radial pulse with the palmer side of the patient’s wrist held in the examiner’s hand and with the patient’s arm suddenly elevated above the shoulder. This may be related to the artery becoming more in line with the central aorta, allowing direct systolic ejection and diastolic backward flow . 

The descending limb of the peripheral pulse is very difficult to palpate such that special maneuver is needed to appreciate this abnormality.   The good news is that there is only one type of pulse that has this abnormal descending limb: the collapsing pulse.

The rate of decline of the collapsing pulse is fastest at the beginning of diastole – when the left ventricular pressure is lowest. Moreover, the larger the stroke volume of that beat, the faster will be the rate.  This rate of decline can be further accentuated by elevating the arm above patient’s shoulder such that the column of blood can fall by gravity.  Therefore, a 3-step maneuver has been designed to detect the collapsing pulse:

To occlude a radial pulse by finger is not easy because the systolic pressure in aortic regurgitation is typically very high.  Therefore, it would be wiser to occluding the radial pulse by your hand – wrapping it around the wrist of the patient.

There are three other advantages of doing this.  The first advantage is you can fine tune you pressure easily by tightening or loosening the grip such that it is just above the systolic pressure.  Secondly, the pressure can be remained unchanged when you elevate the arm above patient’s shoulder later on. Thirdly, the run-off of the column of blood can be appreciated vividly when it fall across the palm of your grip.  Actually, this is what the original fun the Victoria toy “water-hammer” designed to produce:

Again, as a self-learner now, you have to correlates it with objective measures.  The objective measure for collapsing pulse is the pulse pressure.  It is present when the pulse pressure is wide.  But how wide is wide?  A pulse pressure is wide whenever it is larger than the diastolic pressure. To maintain a constant grip throughout the procedure, I will advise you not to elevate the arm by your gripping hand. The arm is elevated by putting you right hand under patient’s elbow.

Causes

1) conditions with aortic run-off: AR, PDA, AP widnow, rupture of sinus of vasalva into the right chambers and arteriovenous fistula .

2) cyanotic congenital heart disease: truncus arteriosis with truncal “run-off into PA or truncal insufficiency , pulmonary atresia with bronchopulmonoray collaterals , TOF with bronchopulmonary collaterals/associated PDA/associated AR or after Blalock Taussig (BT) shunt ( systemic artery to pulmonary artery ) .

3) Hyperkinetic circulatory states: Pregnancy , anemia , thyrotoxicosis, Beriberi, fever, and Paget’s disease of the bone.