“Time to pause for a pulse check.”

Although this refrain is uttered during cardiac arrests across the United States each day, we are overdue to stop this practice. Interruptions in chest compressions are associated with decreased survival.^1–3 As a result, focus has increasingly shifted to finding ways to ensure minimal interruptions in chest compressions during cardiopulmonary resuscitation (CPR). This has resulted in the de-emphasis on advanced airways and the introduction of mechanical chest compression devices. Traditional point of care ultrasound during cardiac arrest has faced scrutiny as data has demonstrated pauses of more than 10 seconds are common, leading some institutions to introduce transesophageal echocardiography.^4,5 Some have even suggested hands-on defibrillation to reduce interruptions.⁶ However, there is a far easier way to improve the quality of CPR—stop routinely performing pulse checks during CPR.

Pulse Checks Are Hard

Despite the ubiquity of pulse checks, few people can accurately determine whether a patient is pulseless in under 10 seconds. In a 1996 study of patients on cardiopulmonary bypass, study participants were blinded to whether the flow was pulsatile or non-pulsatile and asked to perform a carotid pulse check. Only 16.5 percent of the 206 first responder participants were able to determine that a patient was pulseless in under 10 seconds. Further, only two percent correctly recognized truly pulseless patients.⁷

A similar study by Tibballs et al., in 2010 evaluated pulse palpation by 154 nurses and physicians on individuals on extracorporeal devices. They found pulse palpation was only 78 percent accurate. The mean time to a decision about the presence of a pulse was 20 seconds and was slightly longer in the physician cohort (24 seconds) compared with the nursing cohort (17 seconds). One of the most worrisome findings of this study was that participants reported the presence of a pulse in 14 percent of cases when it did not. Participants took an average of 30 seconds to diagnose cardiac arrest. By comparison, participants were able to diagnose the absence of cardiac arrest in an average of 13 seconds.⁸

The Guidelines Dropped Routine Pulse Checks Over a Decade Ago

In response to these studies demonstrating the complexity to pulse palpation, the American Heart Association (AHA) guidelines in 2010 began discouraging routine pulse checks during CPR: “Because of difficulties with pulse assessments, interruptions in chest compressions for a pulse check should be minimized during the resuscitation, even to determine if ROSC has occurred.”

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

1. Talikowska M, Tohira H, Finn J. Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2015;96:66–77.
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.
4. Clattenburg EJ, Wroe P, Brown S, et al. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018;122:65–68.
5. Fair J 3rd, Mallin MP, Adler A, et al. Transesophageal echocardiography during cardiopulmonary resuscitation is associated with shorter compression pauses compared with transthoracic echocardiography. Ann Emerg Med. 2019;73(6):610–616.
6. Brady W, Berlat JA. Hands-on defibrillation during active chest compressions: Eliminating another interruption. Am J Emerg Med. 2016;34(11):2172–2176.
7. Dick WF, Eberle B, Wisser G, Schneider T. The carotid pulse check revisited: What if there is no pulse? Crit Care Med. 2000;28(11 Suppl):N183–5.
8. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 2010;81(6):671–675.
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.