In fact, pulse checks only arise four times in the body of the AHA 2020 guidelines—all in reference to initial identification of cardiac arrest.⁹

Rhythm Checks Are “In”

During CPR, advanced cardiac life support (ACLS) guidelines advocate for rhythm checks every two minutes. Rhythm checks allow rescuers to identify rhythms amenable to defibrillation. Unlike a pulse check, rhythm checks take a few seconds. The goal of the rhythm check is to ascertain whether the patient has an intervenable rhythm—one that is amenable to defibrillation (ventricular fibrillation or ventricular tachycardia) or a potentially perfusing rhythm. If a patient is in asystole, there is no need to check for a pulse—there will not be one. If a patient is in ventricular fibrillation or ventricular tachycardia, there is no need to feel for a pulse—the treatment is defibrillation. In both cases, prolonging the pause in chest compressions may have deleterious effects on organ perfusion.

Although the AHA guidelines have specified rhythm checks rather than pulse checks for over 10 years, clinicians have been slow to change practice. In fact, research continues to focus on “pulse checks.”10A 1999 article in Annals of Emergency Medicine urged clinicians to pay close attention to pivotal shifts in evidence behind common CPR practices as AHA guidelines would certainly change. The authors highlighted pulse checks and summarized the 1996 data, “rescuers will hallucinate a pulse when one is absent about once every 10 arrests. They will hallucinate death (no pulse) four times as frequently—about four out of 10 times.”¹¹ Despite the authors’ urging, first responders and physicians continue with pulse checks.

Perhaps some may resist the pivot to rhythm checks, arguing this is only a semantic change. However, the pulse palpation literature is clear—assessing for a pulse is cognitively taxing. A shift in our language and personnel to tasks that are actionable, creates a simpler and more efficient resuscitation environment that has a better chance of reducing “hands off” time. It is more likely that we believe we have overconfidence in our ability to do simple things well and have difficulty unlearning our fundamental practices. Before we debate antiarrhythmics or double sequential defibrillation, let’s get the fundamentals right and stop routinely checking pulses during CPR cycles.

Dr. Westafer (@LWestafer) is assistant professor of emergency medicine and emergency medicine research fellowship director at the University of Massachusetts Medical School–Baystate and co-host of FOAMcast.

References

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2. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120(13):1241–1247.
3. Vaillancourt C, Everson-Stewart S, Christenson J, et al. The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation. Resuscitation. 2011;82(12):1501–1507.
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9. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult basic and advanced life support: 2020 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S366–S468.
10. Yamane D, McCarville P, Sullivan N, et al. Minimizing pulse check duration through educational video review. West J Emerg Med. 2020;21(6):276–283.
11. Cummins RO, Hazinski MF. Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med. 1999;34(6):780–784.