Pulsus Paradoxus - Measurement

 For patients without an indwelling arterial access, pulsus paradoxus is best measured with a manual sphygmomanometer and stethescope. Automatic blood pressure cuffs cannot accurately measure pulsus paradoxus. 

Assessment is made by inflating the cuff until all Korotkoff are absent, then very slowly releasing pressure from the cuff. The first sounds auscultated will be heard only during expiration, and this pressure should be noted. Next, as cuff pressure is dropped further, the pressure should be noted when Korotkoff sounds are heard during both inspiration and expiration. The variation between these 2 systolic pressure is what quantifies pulsus paradoxus.