Pulse pressure, widened
Pulse pressure, widened: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Pulse pressure is the difference between systolic and diastolic blood pressures. Normally, systolic pressure is about 40 mm Hg higher than diastolic pressure. Widened pulse pressure—a difference of more than 50 mm Hg—commonly occurs as a physiologic response to fever, hot weather, exercise, anxiety, anemia, or pregnancy. However, it can also result from certain neurologic disorders—especially life-threatening increased intracranial pressure (ICP)—or from cardiovascular disorders that cause backflow of blood into the heart with each contraction, such as aortic insufficiency. Widened pulse pressure can easily be identified by monitoring of arterial blood pressure and is commonly detected during routine sphygmomanometric recordings.
Emergency Interventions
Ifthe patient’s level of consciousness (LOC) is decreased, and you suspect that his widened pulse pressure results from increased ICP, check his vital signs and oxygen saturation. Maintain a patent airway. Provide supplemental oxygen and ventilatory support to keep the patient’s partial pressure of arterial oxygen above 90 mm Hg or his oxygen saturation above 95%. Give osmotic diuretics, such as mannitol, by I.V. infusion to decrease ICP. Insert an indwelling urinary catheter; monitor intake and output during mannitol therapy. Start ICP monitoring. Administer analgesics as ordered. Hyperventilation therapy to decrease the patient’s partial pressure of arterial carbon dioxide and to treat ICP remains controversial but may be needed for short intervals when ICP and neurologic deterioration increase. Perform a neurologic examination. Use the Glasgow Coma Scale (see page 480) to evaluate LOC. Check cranial nerve function—especially cranial nerves III, IV, and VI—and assess papillary reactions, reflexes, and muscle tone. Continue ICP monitoring. If you don’t suspect increased ICP, ask about associated symptoms, such as chest pain, shortness of breath, weakness, fatigue, or syncope. Check for edema and auscultate for murmurs.
Medical causes
Aortic insufficiency
With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial gallop or ventricular gallop develop. These signs may be accompanied by chest pain; palpitations; pallor; strong, abrupt carotid pulsations; pulsus bisferiens; and signs of heart failure, such as crackles, dyspnea, and jugular vein distention. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).
Arteriosclerosis
With this disorder, reduced arterial compliance causes progressive widening of pulse pressure, which becomes permanent without treatment of the underlying disorder. This sign is preceded by moderate hypertension and accompanied by signs of vascular insufficiency, such as claudication, angina, and speech and vision disturbances.
Febrile disorders
Fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder.
Increased intracranial pressure
Widening pulse pressure is an intermediate to late sign of increased ICP. Although decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (Even a gap of only 50 mm Hg can signal a rapid deterioration in the patient’s condition.) Assessment reveals Cushing’s triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.
Special considerations
If the patient displays increased ICP, continually reevaluate his neurologic status and compare your findings carefully with those of previous evaluations. Be alert for restlessness, confusion, unresponsiveness, or decreased LOC. Keep in mind, however, that increasing ICP is commonly signaled by subtle changes in the patient’scondition, rather than the abrupt development of any one sign or symptom.
Pediatric pointers
Increased ICP causes widened pulse pressure in children. Patent ductus arteriosus (PDA) can also cause it, but this sign may not be evident at birth. The older child with PDA experiences exertional dyspnea, with pulse pressure that widens even further on exertion.
Geriatric pointers
Recently, widened pulse pressure has been found to be a more powerful predictor of cardiovascular events in elderly patients than either increased systolic or diastolic blood pressure.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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