Cummins RO, Hazinski MF. Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med. 1999;34(6):780–784.
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One thought on “Pulse Checks During Cardiopulmonary Resuscitation”
Daniel Zajarias-Fainsod
Hi Lauren,
Thanks for another great episode of FOAMcast. I tend to agree that there is a significant misunderstanding regarding guidelines recommending for pulse checks rather than simply recommending avoiding pauses except when absolutely necessary. The question that is probably on many of the listeners minds is how to determine ROSC if and when it happens. I think one of the underreported findings during ROSC are signs of life. In my experience, these tend to be new gasping, swallowing, etc. Which may be evident to the person managing the airway. As you correctly mention, rhythm checks every two minutes —which require no more than five seconds pauses— are paramount particularly looking for shockable rhythms but also for any change in rhythm with close attention to organised rhythms like the (inaptly named) PEA. As you mention in your podcast, PEA is oftentimes a state of profound shock rather than absolute pulselessness, and hence the treatment should focus on vasopressors and ionotropic agents primarily. This leads me to ultrasound which, although has become mainstream in diagnosing and differentiating shock and hypotension, is not used as often used in cardiopulmonary resuscitation except for, as you mention, looking for reversible causes such as pulmonary embolism or pericardial effusion. It has been my practice to use ultrasound not only for the aforementioned potential diagnoses, but also for other procedures such as placement of femoral lines such as high flow IV catheters or insertion of ECMO cannulae. Ultrasound is also a great adjunct for looking at the heart and determining the adequacy of cardiac output when a new rhythm —organised enough to be compatible with a pulse— is shown on the monitor. This, as you say, can be acquired in brief pauses and cine loops reviewed when resuming compressions or using a subxiphoid window during compressions; although the latter may require significant more user experience. Moreover, since the ultrasound probe is already literally in hand, another useful trick is to place it in the groin (potentially during the insertion of a venous line) to determine the presence of a central pulse using colour Doppler. Although anecdotal, I strongly believe that the sensitivity for detecting the presence of a central pulse is much bound to be higher than 80% mentioned in the studies you quoted. It is useful to note, that when performing CPR, a pulse check —or as I propose a Doppler pulse check— is meant to be used only to rule in the presence of a pulse. In the event that a pulsatile flow in synchrony with the rhythm present on the monitor is not clearly seen, chest compressions should be resumed immediately.
Hi Lauren,
Thanks for another great episode of FOAMcast. I tend to agree that there is a significant misunderstanding regarding guidelines recommending for pulse checks rather than simply recommending avoiding pauses except when absolutely necessary. The question that is probably on many of the listeners minds is how to determine ROSC if and when it happens. I think one of the underreported findings during ROSC are signs of life. In my experience, these tend to be new gasping, swallowing, etc. Which may be evident to the person managing the airway. As you correctly mention, rhythm checks every two minutes —which require no more than five seconds pauses— are paramount particularly looking for shockable rhythms but also for any change in rhythm with close attention to organised rhythms like the (inaptly named) PEA. As you mention in your podcast, PEA is oftentimes a state of profound shock rather than absolute pulselessness, and hence the treatment should focus on vasopressors and ionotropic agents primarily. This leads me to ultrasound which, although has become mainstream in diagnosing and differentiating shock and hypotension, is not used as often used in cardiopulmonary resuscitation except for, as you mention, looking for reversible causes such as pulmonary embolism or pericardial effusion. It has been my practice to use ultrasound not only for the aforementioned potential diagnoses, but also for other procedures such as placement of femoral lines such as high flow IV catheters or insertion of ECMO cannulae. Ultrasound is also a great adjunct for looking at the heart and determining the adequacy of cardiac output when a new rhythm —organised enough to be compatible with a pulse— is shown on the monitor. This, as you say, can be acquired in brief pauses and cine loops reviewed when resuming compressions or using a subxiphoid window during compressions; although the latter may require significant more user experience. Moreover, since the ultrasound probe is already literally in hand, another useful trick is to place it in the groin (potentially during the insertion of a venous line) to determine the presence of a central pulse using colour Doppler. Although anecdotal, I strongly believe that the sensitivity for detecting the presence of a central pulse is much bound to be higher than 80% mentioned in the studies you quoted. It is useful to note, that when performing CPR, a pulse check —or as I propose a Doppler pulse check— is meant to be used only to rule in the presence of a pulse. In the event that a pulsatile flow in synchrony with the rhythm present on the monitor is not clearly seen, chest compressions should be resumed immediately.