This week we’re covering pulse checks during CPR. Detecting a patient’s pulse is critical when assessing for ROSC, but it is fraught with inaccuracy.
A Review Of: Zengin S et al. Comparison of Manual Pulse Palpation, Cardiac Ultrasonography and Doppler Ultrasonography to Check the Pulse in Cardiopulmonary Arrest Patients. Resus 2018. PMID: 30253230
What: A single-center, prospective observational study of 137 patients older than 16 years of age undergoing CPR. Patients were evaluated by EM physicians for ROSC via manual palpation, cardiac ultrasonography (subxiphoid view), and doppler ultrasonography. The study compared the respective efficiency of these modalities in detecting ROSC. Interestingly, a special curtain system was used to blind evaluators from each other during pulse checks.
1. Our very own Dr. Tarlan Hedayati has a fantastic 10 min presentation from Rebellion in EM covering Pseudo-PEA and using echo in cardiac arrest: https://rebelem.com/rebellion-in-em-2019-all-pea-is-not-the-same-via-tarlan-hedayati-md/
2. Critical Care Now has a digestible overview of the different modalities of assessing for ROSC: https://criticalcarenow.com/2020/08/25/pulse-checks-in-cardiac-arrest/
3. For a more in-depth discussion, EM Cases has a great episode+write-up on PEA/Pseudo-PEA arrest: https://emergencymedicinecases.com/pea-arrest-pseudopea-prem/
4. SMACC has a great short video on ETCO2 in cardiac arrest: https://www.youtube.com/watch?v=Nwzsj6qQZ9U
Why: The study results showed that of 37 patients judged to be in PEA (via manual palpation), 7 had significant cardiac activity on bedside echo. Interestingly, of the 7 patients with “false PEA” 2 did not have detectable pulses on doppler US. The rates of false positive and false negative detection of manual pulse decreased as the cardiac arrest progressed to 15 min and onwards. Ultimately, the study suggests that manual palpation of pulse alone may lead to incorrect assessments of ROSC vs PEA. In the study, they were notably able to implement ultrasound effectively within the 10 second window of pulse checks.
The study adds to a growing body of literature demonstrating that healthcare providers are not accurate at detecting a pulse manually, let alone finding one within 10 seconds during a high-stress situation. We might falsely detect a pulse and stop CPR prematurely or miss the pulse, resuming CPR when the patient is actually in a state of profound shock. Therefore, when available, we should be using adjuncts to assist our inaccurate fingers in their assessment. This study and others have argued for the implementation of POCUS pulse checks with a linear probe on the carotid/femoral or a cardiac echo to assess for organized activity. There have been many proposed approaches that you can find via the resources above, but it’s important to emphasize that compression pauses should be kept under 10 seconds. Don’t let adjuncts get in the way of good compressions. Have your US probe ready before the pulse-check to make it seamless, use the video record function, and don’t leave ultrasound gel right on the chest where people are doing compressions.
It’s worth noting that other adjuncts can be similarly useful for detecting ROSC, including arterial lines, quantitative End Tidal CO2, and even TEE. Arterial lines and TEE maybe difficult to find in our Resus bay, but any cardiac arrest patient with an airway should ideally have ETCO2 hooked up to the monitor.
Lots of FOAMed resources this week, but I recommend you take a look. Nothing is perfect and everything has its limitations, but using these adjuncts may drastically affect our patient outcomes (stopping a code vs detecting ROSC).
As always, read through it and talk with your attendings.
Written by:
Jorge Aceves, MD
Twitter: @joaceve91
Peer Reviewed by:
Neeraj Chhabra MD, MSCR
Division of Medical Toxicology, Department of Emergency Medicine
Cook County Health
Assistant Professor, Rush Medical College
Twitter: @NeerajBC