“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.
Explore This IssueACEP Now: Vol 41 – No 08 – August 2022
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.”